Extended Abstract
Introduction
Although parents have a strong motivation to keep and promote their child’s health, they cannot act effectively due to lack of knowledge and or an organized pattern in this area. The importance of parental involvement in children’s medical interventions is a well-known issue for therapists, and common methods in children’s health care are mostly family-centered [1, 2]. The integration of therapeutic interventions in the context of daily living activities can improve a child’s performance and increase parent-child interactions [3]. Findings from previous studies on family-centered interventions have suggested that learning skills, empowering parents, and learning ways to cope with the problems of children are essential parental expectations [4-6].
Children with Autism Spectrum Disorder (ASD) often show more or less responsiveness to sensory stimuli or unusual interests in sensory aspects of the environment [7]. Using sensory inputs and adapting the home and school environment, occupational therapists adjust the child’s arousal level and develop the child’s participation [13]. To play their special duty, occupational therapists should be completely aware of the person-environment-occupation model [14].
Occupational Performance Coaching (OPC) is a special intervention in the family-centered approach that has recently received a lot of attention in the context of early interventions. It develops parent-oriented goals and their solutions and enhances the capacity of parents to implement therapeutic interventions during daily life routines [18, 19]. In this approach, therapists do not tell parents what to do but coach them to find appropriate solutions and assessing the needs of the child and family [20, 21]. Contextual interventions using OPC are evidence-based interventions that develop adults’ learning and have emerged in recent years as a way to increase problem-solving ability and helped parents achieve functional goals [10].
In this study, it is assumed that the implementation of contextual intervention adapted for ASD (CI-ASD) in family activities and daily life routines can increase children’s occupational performance and promote parents’ self-efficacy. For this purpose, we used Dunn’s model of sensory processing in a contextual intervention. This study aimed to investigate the feasibility of CI-ASD implementation and its effectiveness in the occupational performance of ASD children and their mother’s self-efficacy. The research questions were as follows:
Does CI-ASD intervention lead to an increase in children’s performance of daily activities?
Does CI-ASD intervention lead to the development of maternal self-efficacy?
How are the levels of satisfaction, adherence, and participation of mothers in CI-ASD intervention?
Materials and Methods
This is a single-subject quasi-experimental study with ABA design. Participants included three mothers with children suffering from ASD referred to Navid-e-asr Rehabilitation Center. Their children had at least one abnormal sensory processing pattern and aged 3-10 years. The level of education of mothers was high school diploma or higher, and all three parents had sufficient proficiency in understanding and speaking the Persian language. 
The first child was a 5-year-old boy adopted at the age of 6 months. The parental self-efficacy measurement (PSEM) score of his mother at baseline was more than 53 (high level). Based on the Short Sensory Profile (SSP) score, he had three abnormal sensory patterns and earned a Gilliam Autism Rating Scale (GARS) score of 85, indicating a moderate level.
The second child was a 7-year-old boy living with his parents and older sister. The PSEM score of his mother at baseline was 43 (moderate level). Based on the SSP score, he had six abnormal sensory patterns and earned a GARS score of 108 indicating a poor level.
The third child was a 4-year-old boy living with his parents and older sister. His mother did not seem to know the family-centered approach and did not present the necessary cooperation in coaching sessions. Her PSEM score at baseline was 34 (moderate level). Based on the SSP score, he had three abnormal sensory patterns and earned a GARS score of 77, indicating a moderate level.
The study was performed at three stages: first, 4 weeks of Treatment As Usual (TAU), then 10 weeks of CI-ASD intervention (2 group training sessions for one week and 9 individual coaching sessions for 9 weeks) plus TAU, and finally 4 weeks of TAU again. Coaching sessions focused on occupational goals and family priorities. These goals were determined by Canadian Occupational Performance Measurement (COPM) and GAS questionnaires. The occupational goals should be clear, measurable, and achievable to the most in 10 weeks. 
By examining the child’s sensory processing patterns and related goals, the therapist used reflective questions and phrases and encouraged mothers to discuss possible ways to achieve occupational goals. Measurements of dependent variables (children’s occupational performance, satisfaction with children’s occupational performance, and parents’ self-efficacy) were performed in four time periods: before the first stage, after the first stage, after the second stage, and follow-up (after the third stage). A semi-structured interview was conducted to examine the mothers’ satisfaction with CI-ASD after the end of the intervention (the second stage).
Results
In this section, we present the study results for the mothers of the first two children at four measurement phases. The third mother discontinued participation after two group training sessions and three coaching sessions and did not complete the intervention period. Table 1 presents the occupational goals set by the children and the results of mothers’ evaluations by using the COPM questionnaire. The results showed that the children’s occupational performance improved after the intervention compared with other measurement phases, and this improvement continued in the follow-up phase. Table 2 presents the results of four evaluation phases by using the GAS and PSEM questionnaires. As can be seen, there is an increase in scores after the intervention and follow-up phase compared with the scores before the intervention. 
Table 3 shows the mothers’ participation in the intervention sessions, satisfaction with the intervention, and adherence to the intervention. As can be seen, they had a high level of participation, satisfaction, and adherence. These results confirm the improvement in dependent variables (children’s occupational performance, the satisfaction of children’s occupational performance, and parents’ self-efficacy). Figures 1 and 2 illustrate the results of the evaluation for the two participants.
Discussion
The present study aimed to evaluate the feasibility of implementing CI-ASD intervention and its possible effectiveness in developing the occupational performance of ASD children and their mothers’ self-efficacy. Comparing data before and after the intervention showed a significant improvement in children’s occupational performance. This increase continued during the follow-up phase, which indicates that their mothers may have used the learned strategies after the end of the intervention period. Moreover, there was a significant improvement in the mothers’ self-efficacy after the intervention (assessed by the PSEM questionnaire). The improvement lasted for up to 4 weeks after the intervention and remained constant. It can be said that CI-ASD may be an effective treatment program for children with sensory problems and reducing worries in families with ASD children.
The results of this study are consistent with the results of other studies that examined the effect of parental empowerment [37, 38]. Previous studies have confirmed that parental training on sensory strategies enables the child to engage in daily living activities and develops a parent-child interaction [20, 39, 40]. The development of ASD children’s performance and parental self-efficacy after OPC has also been reported in previous studies [41, 42]. 
In the present study, the OPC was integrated with the sensory processing model, and a new program called CI-ASD was developed. Kessler et al. (2017) used the OPC approach for the elderly with stroke and reported its moderate effect on occupational performance. In the field of occupational performance enhancement, the findings of all studies are consistent and confirm the effectiveness of the intervention [10, 22, 42, 43]. 
The results of previous research are in line with the findings of the present study and regarding the high participation rate of parents in family-centered interventions [41] and therapists can properly use the existing capacity in families in treatment programs. Overall, all variables in this study had significant improvement after the intervention. These changes remained stable for up to 4 weeks after the intervention. 
In the present study, the number of participants was low for conducting a pilot study. It is necessary to increase the number of participants in future studies to determine the effectiveness of the CI-ASD intervention. On the other hand, the duration of the follow-up was short due to administrative constraints. In future research, it is necessary to determine clear parameters for the correct implementation of the CI-ASD intervention so that the intervention can be performed by other therapists and achieve the desired results.
Conclusion
The CI-ASD intervention program has the feasibility to be implemented and can increase the occupational performance of children with ASD and improves their mothers’ self-efficacy. In the present study, it is possible to teach the CI-ASD method to the experienced occupational therapists and transfer evidence for its practical implementation. Although satisfactory results were obtained in the present study with two participants, stronger evidence is needed for evaluating the effectiveness and implementation of the CI-ASD intervention. Families are strong resources for managing and improving their lives. Parents have enough motivation to participate and collaborate to achieve their self-determination goals. 
Parental participation in group training sessions and finding people with similar problems help them share their experiences and benefit from other perspectives and experiences. By teaching sensory processing patterns and their linking to daily life and different situations, parents are provided a way of recognizing a child’s sensory problems and the ways to solve them. The ability to solve problems creates more motivation in ASD children for learning. This process can help the child, and as a result, parents feel more qualified and competent in their role.
Ethical Considerations
Compliance with ethical guidelines
Ethical clearance was obtained by the ethics committee at the University of Social Welfare and Rehabilitation Sciences (IR.USWR.REC.1395.189)
Funding
The present paper was extracted from the PhD thesis of the first author, Department of Occupational Therapy, School of Rehabilitation, Shahid Beheshti University of Medical Sciences. 
Authors' contributions
Investigation, data collection, preparing the manuscript: Zahra Pashazadeh Azari; designe, supervision: Seyed Ali Hosseini, Mehdi Rassafiani; Preparing the intervention protocol, revision: Seyed Ali Samadi, Winnie Dunn.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
The authors would like to appreciate Bemanali Mardani and Mohsen Alishiri for administrative supports, and Soraya Gharebaghi for insightful guidance on the completion of the goal attainment scale.