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IntroductionAutism spectrum disorder (ASD) is a heterogeneous neurodevelopmental condition with impacts on behaviour, cognition, communication, social interaction and family mental health. This paper reports the protocol of a randomised controlled trial (RCT) of a very early intervention, ENACT (ENvironmental enrichment for infants; parenting with Acceptance and Commitment Therapy), for families of infants at risk of ASD.Methods and analysisWe aim to recruit 66 mothers of infants at risk of ASD (ie, infants with a sibling or parent diagnosed with ASD) to this RCT. Families will be randomly assigned to care-as-usual or ENACT. ENACT is a very early intervention, leveraging parent–child interactions to improve early social reciprocity, while supporting parental mental health and the parent–child relationship through Acceptance and Commitment Therapy. Intervention content is delivered online (approximately 8 hours) and supported by more than 7 consultations with a clinician. Parents will perform the social reciprocity intervention with their child (30 min per day). Assessments at four time points (baseline, 3 months, 6 months, and 12 months corrected age) will assess parent–infant interaction, parental mental health, infant development and early ASD markers. Analysis will be by intention to treat using general linear models for RCTs.Ethics and disseminationThis protocol has been approved by the Children’s Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/19/QCHQ/50131) and the University of Queensland Human Research Ethics Committee (2019000558). If efficacy is demonstrated, the intervention has the potential for wide and accessible dissemination.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12618002046280).

Mothers of children with autism spectrum disorder are more likely to have features of the broad autism phenotype and adverse mental health outcomes. The broad autism phenotype can contribute to poorer mental health; however, the mechanism behind this relationship remains uncertain. This study investigated both the predictors of mental health and the relationship between the broad autism phenotype and mental health symptoms in mothers of children with autism spectrum disorder. This cross-sectional survey recruited 232 Australian mothers (⩾18 years) of children with autism spectrum disorder (0–10 years) and assessed maternal broad autism phenotype, mental health, adult attachment style, degree of social support and parenting experience. Hierarchical multiple regressions, t-tests, correlations and mediation analyses were conducted. Psychological inflexibility was the greatest unique predictor of anxious, depressive and stress symptomatology. Challenging parenting experiences predicted depressive, anxious and stress symptomatology while the broad autism phenotype also uniquely predicted anxious symptoms. Both psychological inflexibility and challenging parenting experiences were significant mediators of the relationships between the broad autism phenotype and depressive symptoms and between the broad autism phenotype and anxiety. Psychological inflexibility alone mediated the relationship between the broad autism phenotype and stress. Targeting psychological inflexibility and supporting parenting are promising avenues for future interventions to support the mental health of mothers of young children with autism spectrum disorder. Lay abstract Mothers of children with autism tend to have poorer mental health outcomes compared to most mothers. Lack of social support, parenting challenges and relationship difficulties are more common for mothers of children with autism and can all affect maternal mental health. Mothers of children with autism are also more likely to have some autistic features, called the broad autism phenotype, that can contribute to poorer mental health; however, how these factors relate to one another are unclear. This study found that mothers who were less flexible in their thinking and behaviour and had more difficult parenting experiences tended to have poorer mental health. Mothers with more autistic features were less flexible in their thinking and behaviour, which, in turn, was linked to greater symptoms of depression, anxiety and stress. Mothers with greater autistic features also reported more difficult parenting experiences, which was in turn linked with greater symptoms of anxiety and depression. This study suggests that supporting mothers of young children with autism to manage parenting challenges and become more flexible with their thinking and behaviour could help to improve their mental health.

Aim: To investigate the efficacy of psychological interventions delivered to mothers of young children with autism spectrum disorder (ASD) in improving maternal mental health and the parent-child relationship.Method: Electronic databases were searched from inception to December 2021.Studies were included if they were randomized controlled trials (RCTs) of psychological interventions that targeted maternal mental health (primary outcome) and/ or the parent-child relationship (secondary outcome), delivered to mothers of children (mean age < 60 months) with ASD. Meta-analyses of three parent mental health outcomes (stress, depressive symptomatology, and general mental health) and seven parent-child relationship outcomes (parent responsiveness, affect, directiveness, non-directiveness, child initiation, infant positive affect, and infant attentiveness) were conducted using both mean and standardized mean differences.Results: Thirty-two RCTs met the inclusion criteria (2336 participants). Six RCTs showed improved maternal mental health (Cohen's d = 0.41-1.15), with moderate certainty of evidence for improvement in parental stress. There was low and high certainty of evidence of treatment effect on parental depressive symptoms and general mental health respectively, which did not show significant treatment effects post-intervention. Seventeen RCTs showed improved parent-child relationship (d = 0.33-2.28; low certainty of evidence).Interpretation: Results demonstrated that parenting interventions promoting responsiveness had the largest positive effect on the parent-child relationship and a moderate effect on overall parenting stress; however, the studies were heterogeneous, making it difficult to identify the intervention components that were responsible for the positive treatment effects. There was no significant treatment effect for studies targeting depression or general mental health, likely due to the lack of an interventional component directly targeting mental health.