The inclusion of fathers in investigations of autistic spectrum disorders

The inclusion of fathers in investigations of autistic spectrum disorders

Research in Autism Spectrum Disorders 7 (2013) 858–865 Contents lists available at SciVerse ScienceDirect Research in Autism Spectrum Disorders Jour...

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Research in Autism Spectrum Disorders 7 (2013) 858–865

Contents lists available at SciVerse ScienceDirect

Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp

The inclusion of fathers in investigations of autistic spectrum disorders Valerie L. Braunstein, Nicole Peniston, Andrea Perelman, Michael C. Cassano * Widener University, One University Place, Chester, PA 19013, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 12 November 2012 Received in revised form 15 March 2013 Accepted 17 March 2013

Recent reviews indicate an underrepresentation of fathers in empirical investigations of child development and psychopathology (Cassano, Adrian, Veits, & Zeman, 2006; Phares, Fields, Kamboukos, & Lopez, 2005). The purpose of the current study was to examine the nature of parental involvement in research on children with autistic spectrum disorders (ASD). Articles published over the last decade from journals with the highest impact factors in disciplines relevant to the study of ASD were reviewed, including areas of psychiatry, developmental psychopathology, and developmental disabilities. A total of 404 articles were included in the review and were coded to determine if parental inclusion and method of statistical analysis varied as a function of child age, journal type, year of publication, and parent gender. Results were consistent with findings from recent reviews and indicated that fathers are widely underrepresented in the literature on ASD, even more so than rates of inclusion in investigations of developmental and child clinical psychology. In contrast to findings from broad reviews of parental inclusion in studies of child psychopathology, fathers’ involvement was not higher in older versus younger age of child participant. Clinical implications and recommendations to improve inclusion rates of fathers in research on children with ASDs are discussed. ß 2013 Elsevier Ltd. All rights reserved.

Keywords: Autism spectrum disorder Father Parent

1. Introduction and review of the literature Over the past two decades, research has increasingly highlighted the importance of understanding the role of parents in the identification and care of children with an autistic spectrum disorder (ASD) (McConachie & Diggle, 2007). Empirical investigations consistently find that parents of children with ASDs play critical roles in the detection, treatment, and course of a wide range of psychosocial and educational challenges encountered throughout development (Al Anbar, Dardennes, Prado-Netto, Kaye, & Contejean, 2010; Dardennes et al., 2011; Manning et al., 2011; Reed & Makrygianni, 2010). Unfortunately, few investigations have evaluated whether these roles differ for mothers and fathers (Flippin & Crais, 2011). Several systematic reviews of the literature on parents of children with psychopathology indicated that there is an underrepresentation of fathers in research across broad domains of clinical and developmental psychology (Cassano et al., 2006; Fabiano, 2007; Phares et al., 2005). The purpose of the current study was to examine recent rates and type of parental inclusion in empirical investigations of ASD. There is clear evidence that parents are a significant source of environmental influence on outcomes for children with ASD. Specifically, parents are integral to detection and diagnosis of ASD by being the first to notice symptoms, select and initiate interventions, and connect with educational systems (Miller, Schreck, Mulik, & Butter, 2011). In addition, parental

* Corresponding author at: Institute for Graduate Clinical Psychology, 225 Bruce Hall, Widener University, One University Place, Chester, PA, 19013, United States. Tel.: +1 610 499 1385. E-mail address: [email protected] (M.C. Cassano). 1750-9467/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rasd.2013.03.005

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involvement in interventions for ASD is highly associated with child and parent treatment-related outcomes (Laugeson, Frankel, Mogil, & Dillon, 2009; Makrygianni & Reed, 2010; Matson et al., 2012). Not surprisingly, mothers and fathers of children with ASD experience increased parental stress and difficulty managing their child’s behavior compared to parents of children without ASD (Brobst, Clopton, & Hendrick, 2009; Epstein, SaltzmanBenaiah, O’Hare, Goll, & Tuck, 2008; Hayes & Watson, 2012). Parents of children with ASD have been found to report higher levels of aggravation than parents of children with other developmental disabilities and parents of children without special health care needs (Schieve, Blumberg, Rice, Visser, & Boyle, 2007). Specifically, compared to parents of children without significant psychosocial concerns, mothers of children with ASD have been found to exhibit higher rates of life stress and depression (Quintero & McIntyre, 2010) and sleep problems (Lopez-Wagner, Hoffman, Sweeney, & Hodge, 2008). In addition, caregivers of children with ASD reported exerting more effort to identify and receive services for their children, compared to parents of children with other disabilities (Bitterman, Daley, Misra, Carlson, & Markowitz, 2008). Recent investigations of parents of children with ASD suggest the experience of mothers and fathers of children with ASD differ in important ways. Epstein and colleagues (2008) examined stress levels of parents of children with Asperger’s Syndrome and found a positive correlation between the children’s level of impairment and mothers’ reported parenting stress. However, there was no correlation between the stress levels of fathers and the degree of impairment of their children. Davis and Carter (2008) suggested that the stress of both mothers and fathers are correlated with severity of children’s behavioral problems, but this association differed between mothers and fathers as a function of the type of psychosocial concern. Specifically, among parents of toddlers with ASDs, maternal stress increased when child regulatory problems increased, whereas paternal stress rose when the children exhibited more externalizing behaviors. Further, Pisula and Kossakowska (2010) found that mothers of children with autism self-reported spending almost twice the amount of time per day on direct care (9.5 h) for their child compared with fathers (4.9 h). Hartley, Barker, Seltzer, Greenberg, and Floyd (2011) compared the experiences of mothers and fathers of children with autism and found that, compared to mothers, fathers were more sensitive to the characteristics of the child. Relatedly, Kayfitz, Gragg, and Orr (2009) found that mothers of children with autism reported more positive experiences compared to fathers of children with autism. Papageorgiou and Kalyva (2010) found that mothers were more likely to disclose to their colleagues at work that they had a child with an ASD compared to fathers who did not, suggesting this lack of disclosure of emotions might contribute to lower support for fathers from work colleagues. Investigations of parent management training programs highlight the importance paternal inclusion while also indicating different experiences and outcomes for mothers vs. fathers. For example, Lundahl, Tollefson, Risser, and Lovejoy (2008) found that parent training studies that included fathers yielded larger effect sizes regarding children’s behaviors. However, father’s reported fewer personal gains from the intervention compared to mothers, possibly because parenttraining programs are typically geared toward mothers and as a result may be less effective and/or acceptable for fathers. Sofronoff and Farbotko (2002) studied parental self-efficacy after parent training of parents of children with Asperger’s syndrome. Findings indicated parent self-efficacy differed by parent gender, with mothers reporting a significant increase in self-efficacy and fathers reporting no change in self-efficacy at post-treatment. Despite these documented differences, many research studies on parents of children with ASD include only mothers or fail to specify the gender of the parent studied. Therefore there is considerably less known about the unique experience of fathers, prompting a recent call for the inclusion of gender in research on parents of children with ASD (Hayes & Watson, 2012). There is a growing body of evidence that indicates that fathers are significantly underrepresented in investigations of children with psychopathology. However, it is only recently that researchers have begun to systematically examine the involvement of fathers in specific areas of inquiry (Cassano et al., 2006; Fabiano, 2007; Phares & Compas, 1992; Phares et al., 2005). Phares and Compas (1992) were the first to conduct a systematic review of fathers’ involvement in research related to abnormal child development. Results highlighted a clear under-representation of fathers within broad fields of behavioral research. A similar finding was reported 13 years later when Phares and colleagues (2005) conducted a review of more recent research that revealed that fathers were still largely underrepresented within the research. Cassano and colleagues (2006) conducted a similar review of clinical and developmental literature between 1992 and 2005, with an emphasis on identifying differences in paternal inclusion by demographic variables, type of journal, child age, parental race, parent gender, and year of journal publication. The review was limited to empirical articles that included an explicit focus on the relationship between at least one parent variable and child outcomes; studies that relied on child report of parent variables were excluded. Articles from nine clinical and developmental journals with the highest impact factor ratings were included. Results revealed fathers were more likely to be involved in research with older children and within clinical rather than developmental journals. In addition, fathers were more likely to be included in research published from 1998 to 2005 when compared to research from 1992 to 1998. Furthermore, parental gender was more likely to be analyzed separately when predominantly Caucasian samples were included as compared to when predominantly African American samples were studied. Despite some optimistic trends represented by these findings, overall inclusion rates for fathers continued to be very low across all demographic groups, ages, and publication years. Overall, it is clear that fathers are underrepresented within the broad field of child psychopathology. Research findings conducted within specific disorders suggests that a lack of empirical data on fathers also exists within research focused on Attention Deficit Hyperactivity Disorder (ADHD) (Fabiano, 2007) and anxiety disorders (Bo¨gels & Phares, 2008). For example, Fabiano (2007) analyzed research studies on behavioral parent training for children with ADHD and revealed that 87% of the reviewed studies did not include information on father-related outcomes. This lack of empirical data on fathers is

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particularly concerning in populations where parental involvement is highly and positively correlated with successful treatment outcomes. There is some evidence suggesting a similar trend for paternal inclusion in research of children with ASDs. Lamb (2010) summarized research published from 2000 to 2009 on fathers of children with developmental disabilities and reported that there is a need for research that explicitly focuses on fathers of children with developmental disabilities. Meadan, Ostrosky, and Zaghlawan (2009) reviewed studies published from 1997 to 2007 on parent-implemented interventions for children with autism and noted that there is a need for more studies in which fathers are the primary participants. Likewise, a recent review concluded that fathers were largely underrepresented in research on stressors and support for parents of children with ASDs (Meadan, Halle, & Ebata, 2010). Finally, Flippin and Crais (2011) conducted a systematic review of the literature to determine the amount of father involvement in programs specific to parents of young children with ASDs between the ages of 2–5 years old. Among the 25 reviewed studies, 14 of the studies included mothers only and 8 studies failed to report if fathers were involved. Of the 3 studies that included fathers, the aggregate ratio of fathers to mothers across studies was approximately 3:1. Taken together, findings suggest that fathers are very likely underrepresented within the research on parents of children with ASDs. To date, a systematic review of studies that examine parents of children with ASD has not been conducted. The goal of the current study was to address this gap in the literature and investigate trends in parental inclusion in empirical investigations of parents of children with ASDs published in high impact journals between 2001 and 2010. Based on results of prior literature reviews and recent studies examining parents of children with ASD (Cassano et al., 2006; Phares et al., 2005), four hypotheses were investigated. First, it was predicted that fathers of children with ASD would be underrepresented in research, consistent with trends observed in recent reviews of child clinical and development psychology journals. Second, it was hypothesized that high inclusion rates for fathers would be observed in investigations of older compared to younger children with ASD, consistent with results from recent reviews. Third, it was expected that father inclusion rates would be higher in studies published in more recent studies (2006–2010) compared to older studies (2001– 2005) given similar trends observed in a more broad analyses (e.g., Phares et al., 2005). Finally, rates of paternal inclusion as a function of journal type (psychiatry, clinical psychology, autism/developmental disabilities) were examined as an exploratory hypothesis. Included studies were only related to children with ASDs and did not examine sibling adjustment in a family raising a child with ASDs. 2. Method 2.1. Journal selection The goal of the present review was to examine trends in the most influential journals publishing contemporary research in areas of ASDs. Journals that published original empirical investigations of parents of children with ASD in the last decade (2001–2010) were selected based on a combination of content and the Journal Citation Reports Social Science Edition Impact Factor listings. Impact factor is calculated by counting the number of times a journal was cited within the past five years divided by the number of articles the journal published within that time span. The three journals with the highest impact factors were reviewed within areas of psychiatry, clinical psychology, developmental psychopathology, educational psychology and family functioning (Table 1). Additional journals were selected for review due to their impact factor and specific focus on autism or developmental disabilities. Additional journals were selected based on impact factor and their specific focus on children and families. Bulletins, monographs, and annual reviews were not included because the focus of the current study was the examination of original empirical studies rather than compilations of a series of studies. 2.2. Article selection and coding Once journals were identified, individual articles were selected using library databases Psych Info and Education Resources Information Center (ERIC). Subject and title key words included ‘‘autism,’’ ‘‘asperger,’’ ‘‘ASD,’’ and ‘‘developmental disabilities’’ in combination with ‘‘parents,’’ ‘‘caregivers,’’ ‘‘mothers,’’ and ‘‘fathers.’’ Search results were reviewed for articles that met inclusionary criteria: (1) An original empirical investigation that included a child participant (ages 0–18 years) diagnosed with ASD; (2) Inclusion of a parent variable as an independent variable or predictor variable. Examples of parent variables include parental outcome or functioning, level of participation in treatment, or parent gender as a moderator. Inclusion criteria required a parent variable beyond parent perception of a child’s behavioral adjustment (e.g., studies in which parent only completed a behavioral rating form about the child were excluded) were not included unless the purpose of the study was to specifically examine differential parental perceptions of behavior as a function of parent gender. To establish interrater reliability of the guidelines for inclusion, 25% of the articles from ten journals were randomly selected and coded by the fourth author. First-order agreement between two raters was estimated using Cohen’s Kappa, with a coefficient of 0.80–1.00 representing very good agreement (Altman, 1991). In this study, Kappas exceeded 0.93 for each rater (range of 0.93–1.00). After establishing reliability, subsequent article selection was conducted by the first, second, and third authors. A total of 404 met inclusionary criteria for the study.

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Table 1 Journals by content area. Content area

Journal

Psychiatry

American Journal of Psychiatry Schizophrenia Bulletin Journal of Child Psychology and Psychiatry

Clinical Psychology

Consultation and Clinical Psychology Journal of Abnormal Psychology Journal of Clinical Child and Adolescent Psychology

Developmental Psychology

Developmental Psychopathology Journal of Child Psychology and Psychiatry Journal of the American Academy of Child & Adolescent Psychiatry

Educational Psychology

Child Development Educational Psychologist Journal of Learning Sciences

Autism Spectrum Disorders

Journal of Autism and Developmental Disorders Autism Research in Autism Spectrum Disorders Autism Research Focus on Autism and Other Developmental Disabilities

Developmental Disability

Research in Developmental Disabilities Journal of Applied Research in Intellectual Disabilities Journal of Intellectual and Developmental Disability The American Journal on Mental Retardation American Journal of Intellectual and Developmental Disabilities

Children and Families

Journal of Child and Family Studies Journal of Abnormal Child Psychology Developmental psychology

After articles were selected for inclusion, each article was coded to capture trends in recent research regarding the inclusion of fathers in research on ASD. Specific variables included: (1) Number, age range, mean age, and gender of child participants; (2) Number of parents and nature of relationship to child; (3) Statistical approach used to analyze parent data (i.e., mother data only, father data only, mothers’ and fathers’ combined as ‘‘parents’’, mothers’ and fathers’ data analyzed separately); (4) type of journal (e.g., clinical psychology, psychiatry, autism specific); (5) year of publication. To establish interrater reliability of the article codes, 10% of the articles from ten journals were randomly selected and coded by the fourth author and compared to codes from the first, second, and third authors. Cohen’s Kappas were computed for each categorical variable. All raters exceeded a kappa of 0.89 for all variables (range of 0.89–0.99). 3. Results Across 404 articles, a total of 47,076 mothers and 8714 fathers participated in empirical investigations of families with a child with ASD published from 2001 to 2010. In addition, studies included 26,063 parents whose gender was not identified in the description of the method or results. Regarding the primary hypothesis, it was predicted that fathers would be underrepresented in research on parents of children with ASD. This hypothesis was clearly supported by the results. Specifically, only 13.6% of reviewed studies explicitly included fathers; 12.1% of studies included both mothers and fathers and conducted analyses separately by gender and 1.5% were investigations of fathers only. In contrast, 21.3% of reviewed studies examined only mothers and 65.1% reported to be studying ‘‘parents’’ but did not specify or analyze separately by gender. This distribution differed significantly from chance, x2(3, 404) = 378.20, p < .001. In general, these results are consistent with prior reviews of general developmental and child clinical literatures that identified a broad-based underrepresentation of fathers in empirical studies (Cassano et al., 2006; Phares et al., 2005). In fact, the rates of father inclusion in studies of parents of children with ASDs appear to be even lower than those found in other recent reviews (Table 2). It was also hypothesized that investigations including older children with ASD would have higher inclusion rates for fathers. In this review, 10 (2.5%) studies used samples of infants and toddlers (birth to 2 years), 120 (29.7%) included preschool-age children (3–5 years), 231 (57.2%) used elementary school age children (6–12 years), and 43 (10.6%) studied adolescents (13–18 years; see Table 3). Two-tailed Fisher’s exact probability test for independent samples (p < .05) was used to compare proportions of parental composition between adjacent age groups (e.g., comparing inclusion of fathers for elementary school age versus adolescent periods; comparing inclusion of mothers for birth to age two versus preschool-age children). Contrary to expectations and results from previous reviews of developmental and child clinical literatures, results revealed that paternal inclusion remained stable and low over the lifespan of the child, as low as 0% from birth to age two and

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Table 2 Frequency of father inclusion by systematic review. Phares and Compas (1992)

Sample

Phares et al. (2005)

Cassano et al. (2006)

Current study

n

%

n

%

n

%

n

Mothers only Fathers only Mothers, fathers, or parents not analyzed separately Mothers, fathers, or parents analyzed separately

227 8 141 151

48 1.4 24.4 26.2

231 11 145 127

45 2.1 28.2 24.7

384 4 119 195

55 1.0 17 28

86 6 263 49

21.3 1.5 65.1 12.1

Total

577

404

100.00

514

702

%

Table 3 The inclusion of fathers in empirical investigations of children with autism spectrum disorders. Sample

Overall n

Birth-2 years %

n

%

Mothers only Fathers only Mothers, fathers, or parents not analyzed separately Mothers and fathers analyzed separately

86 6 263 49

21.3 1.5 65.1 12.1

3 0 7 0

Total

404

100.00

10

30 0 70 0

3–5 years

6–12 years

13–18 years

n

%

n

%

n

%

23.3 0.8 64.2 11.7

46 5 151 29

19.9 2.2 65.4 12.6

9 0 28 6

20.9 0 65.1 14.0

28 1 77 14 120

231

43

during adolescence and peaking at ages 6–12 at 2.2% for studies examining fathers only. Studies conducted with children ages 3–18 ranged from 11.7 to 14.0% in terms of proportion that included both mothers and fathers and analyzed separately by gender. Therefore, contrary to the initial hypothesis, this meta-analysis found that father inclusion did not increase with child age. It was expected that more recent publication dates would be more inclusive of fathers as compared to older studies. Contrary to the hypothesis, the studies published between 2001 and 2010 that were reviewed for this study showed very little change in paternal inclusion over time, with rates at an average of 0.9% from 2001 through 2005, to 1.7% from 2006 through 2010 for studies involving fathers only and 12.8% (2001–2005) vs. 11.9% (2006–2010) regarding studies including mothers and fathers and analyzing separately by gender (Table 4). Finally, an exploratory analysis was conducted to determine if paternal inclusion in empirical investigations differed as a function of type of journal (i.e., autism/developmental disabilities, clinical and family psychology (broad), psychiatry). Results indicated psychiatry journals were least likely to include fathers, with no studies examining fathers only and two (4.7%) studies including mothers and fathers analyzed separately by gender. Clinical psychology journals and journals with a specific focus on autism/developmental disabilities were comparable in rates of including mothers and fathers analyzed separately by gender: 12.6% for autism/developmental disabilities journals, 17.1% for clinical psychology journals (Table 5). 4. Discussion The current investigation evaluated the rate of inclusion of fathers within research specific to children with ASDs. Our purpose was to examine the recent rate of father inclusion in research with children with ASDs and the rate of father inclusion in research concerning abnormal development overall. Furthermore, we sought to identify trends in the rate of father inclusion as a function of child’s age, year of publication, and the type of journal that published the study. Results indicate that fathers are rarely included in empirical investigations of children with ASD regardless of child age, year of publication, or journal type. Rates for explicit paternal inclusion (studies with fathers only or studies including mothers and Table 4 Number of studies that included fathers by publication date. Research included

2001–2005

Mothers only Fathers only Mothers, fathers, or parents not analyzed separately Mothers and fathers analyzed separately Total

2006–2010 %

n

n

%

22 1 72 14

20.2 0.9 66.1 12.8

64 5 191 35

21.7 1.7 65.7 11.9

109

100.00

295

100.00

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Table 5 Frequency of father inclusion by journal type. Sample

Psychiatry %

n Mothers only Fathers only Mothers, fathers, or parents not analyzed separately Mothers and fathers analyzed separately

10 0 31

Total

43

2

23.3 0 72.1 4.7 100

Clinical psychology

Autism/developmental disabilities

n

n

%

6 0 23 6 35

17.1 0 65.7 17.1 100

%

70 6 209 41 326

21.5 1.8 64.1 12.6 100

fathers analyzed separately by gender) were relatively lower in the reviewed studies of children with ASD (13.6%) compared to averages of recent reviews examining broad trends in clinical and developmental literature bases (26.8–29.0%; Cassano et al., 2006; Phares et al., 2005). It is plausible that fathers represent a proportion of samples from the over 65% of studies that merely reported the participation of ‘‘parents,’’ but without additional information is it difficult to draw useful conclusions about this trend. In addition to revealing lower father inclusion rates in general, compared to investigations of families of children with ASD, results indicated differences from trends in the broad clinical and development literature. Specifically, in contrast to a trend of increased paternal inclusion in studies of older children (Cassano et al., 2006), results indicated that father inclusion does not increase with child age in investigations of ASD. One possible explanation for this unexpected result is that parents of children with ASDs have a higher divorce rate than other patient populations. It may be that fathers are less available when the child is older due to an increased rate of divorce among parents of adolescents and adults with ASD (Hartley et al., 2010). Increased rates of divorce may be associated with less coordination in care of the adolescent as well as less integration with the child’s mother regarding mental health treatment and, therefore, participation in research. A recent study, however, casts doubt on an increased divorce rate for parents of a child with ASD. In contrast to prior studies, Freedman, Kalb, Zablotsky, and Stuart (2011) found parents of children with ASD do not have higher divorce rates than parents of typically developing children (Freedman et al., 2011). Regardless, the underrepresentation of fathers in published studies throughout childhood and adolescence raises questions about the role of fathers, particularly in light of findings that mothers of adolescents with ASDs have increased levels of anger when compared to mothers of toddlers with ASDs (Smith, Greenberg, Seltzer, & Hong, 2008). Mothers of adolescents with ASD may be a particularly vulnerable population and may greatly benefit from the support of fathers’ involvement within interventions. It was also hypothesized that more fathers would be included in research published in more recent years (2006–2010 vs. 2001–2005). Results did not support this trend, in contrast to an increased paternal inclusion rate observed in recent reviews of clinical and development studies (Cassano et al., 2006). This finding is particularly surprising due to the government’s substantial efforts over the past decade to fund research focused on children with ASDs with the institution of The Combating Autism Act (2006). This act clearly states the importance of gaining input from family members of people with autism and developing programs that are able to demonstrate a family-centered approach. It appears that research on fathers of children with ASDs would help meet both of those proposed goals. Nonetheless, it is important to note that it is possible that research endeavors funded by this new initiative are still in progress and may produce more representative research over the next few years. 4.1. Reasons for the exclusion of fathers in research Researchers have suggested several possible causes for the underrepresentation of fathers in the research on children with psychopathology. In one of the first wide-scale reviews of father inclusion in research, Phares (1992) offered several possible explanations that still appear relevant, including an assumption that fathers are more difficult to assess, mothers are more available, and outdated gender-biased assumptions about social norms. More recently, Flippin and Crais (2011) stated that mothers of children with ADSs continue to be the primary participants in both early intervention services as well as autism research, despite increased co-parenting by fathers. In addition, the unique role of fathers and the study of father-child interaction is overlooked by professionals which results in interventions that are less effective for fathers. Lamb (2010) offers the possibility that the profession has historically ignored fathers and continues to do so out of habit rather than as a result of a measured decision making-process. Fabiano (2007) postulated that potential barriers to father involvement include a lack of research topics of interest to fathers, clinicians and researchers relying on maternal report, failing to ask for paternal involvement, lack of flexible scheduling for data collection, and less willingness among fathers to focus on skill deficits. 4.2. Impact of paternal exclusion The fact that fathers continue to be underrepresented in research is significantly problematic, especially regarding developmental outcomes for children with ASD, due to unique challenges faced by mothers and fathers. First, lack of

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adequate father data leads to a perpetuation of outdated theory that ultimately drives future development and applied research efforts. Second, Papageorgiou and Kalyva (2010) found that fathers of children with ASDs have different needs regarding treatment and support compared to mothers of children with ASDs. Also specific to the population of parents of children with ASDs, gender differences were found among mothers and fathers regarding experiences such as the degree of motivation during interventions, acquired levels of self-efficacy (Grindle, Kovshoff, Hastings, and Remington, 2009) and sensitivity to children’s characteristics (Hartley, Barker, Seltzer, Greenberg, & Floyd, 2011). As a result, it is important to analyze parents separately by gender to measure and account for differences associated with the variable of parent gender. The underrepresentation of fathers in research also has significant implications for professionals working with families of children with ASD. For example, clinicians working with fathers are without guidance from empirical studies as to how to best involve and understand their experience and contribution. It is plausible that such clinicians might incorrectly generalize findings based on samples of mothers, thereby limiting the efficacy of family-based intervention approaches. This possibility is increased due to the vast number of studies purporting to study ‘‘parents’’ without clarifying the gender composition of the sample. Until the field adequately addresses these gaps, professionals working with fathers should be aware that clinical findings regarding parents may not generalize. 4.3. Recommendations Several recommendations to address concerns raised by these findings are indicated. First, investigators should clearly indicate the gender of participants in their studies and refrain from using the term ‘‘parents’’ when describing either a mother or a father whenever possible. Further, it is recommended that journals publishing research on parents of children with ASD encourage researchers to specify if the research participants include mothers, fathers, both or other caregivers. Researchers that omit the gender of the parent may unintentionally overlook a variable that impacts their results. Second, data on mothers and fathers should be analyzed separately to provide more information regarding the variable of gender. This information may then be used to inform interventions. This practice is essential due to findings that suggest fathers and mothers of children with ASD have different experiences and impact on development (Davis & Carter, 2008; Hartley et al., 2011; Hastings, 2003; Herring et al., 2006; Kayfitz et al., 2010; Epstein et al., 2008; Pisula & Kossakowska, 2010). Third, as there is a paucity of research on fathers in general, future studies that directly examine paternal experience, ideally in the context of the larger parenting context, are greatly needed. The trend observed in the ASD literature echoes Lamb’s assertion (2010) of a problematic gap in the research on fathers of adolescents and adults with developmental disabilities. For instance, due to the accumulation of studies on mothers only compared to fathers only, it would be advantageous for researchers to replicate studies conducted for only mothers with the population of fathers to determine similarities or differences related to the gender of the parent. Fourth, it is recommended that researchers clearly describe the recruitment process and indicate what strategies were used to include both mothers and fathers. Researchers should develop recruitment strategies that directly target fathers. A study focused on parents of children who receive early intervention services found that all family respondents to the survey were female (i.e., mothers, grandmothers, foster mothers; Crais, Roy, & Free, 2006). Upon inspection of the methods, the researchers provided only one survey per family to complete. Researchers should include separate forms, questionnaires or tasks that are to be completed by mothers and fathers separately. It is recommended that researchers explicitly encourage all caregivers (i.e., mothers, co-parents, fathers and stepfathers) to participate. Parents should be provided with information regarding the underrepresentation of fathers in research studies and the importance of father participation in research. Fabiano (2007) reported that merely encouraging father participation in treatment might not be sufficient and suggested adapting interventions to mirror the activities of common child-father interactions (e.g., sports activities). Fathers exhibit more variation in their play when compared to mothers and this is associated with increased cognitive stimulation and emotional support for infants (Roggman, Boyce, Cook, Christiansen, & Jones, 2004). This finding has unique implications within the population of children with ASDs. In particular, the floortime model of intervention for children with ASDs requires parental play to help children explore their environment through play. Flippin and Crais (2011) suggested incorporating the natural play style of fathers into interventions to make interventions more appealing to fathers of children with ASD. Due to findings that fathers are particularly adept at play activity and may even be preferred playmates with their children, compared to mothers, it may prove to be advantageous to have fathers engaged in this treatment method. 4.4. Limitations The results of this study should be interpreted after consideration of two primary limitations. First, the review did not include all articles on parents of children with ASDs published over the past decade. Therefore, these findings may not be generalizable to the complete literature base. Nonetheless, findings represent trends in articles found within journals with the highest impact factor that are therefore most likely to have a significant impact on the field. A second limitation is that firm conclusions about the nature of paternal inclusion cannot be drawn due to the overwhelming number of studies that did not indicate the gender of parent participants. The trend is certainly problematic, but it is possible that more fathers are better represented than it appears. Clearly future research can clarify the issues raised by the current review.

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