A Pilot Study of Parent Training in Young Children with Autism Spectrum Disorders and Disruptive Behavior

Effects of Parent-Implemented Interventions on Outcomes of Children with Autism: A Meta-Analysis

Children with autism spectrum disorder (ASD) have been shown to benefit from parent-implemented interventions (PIIs). This meta-analysis improved on prior reviews of PIIs by evaluating RCTs and multiple potential moderators, including indicators of research quality. Fifty-one effect sizes averaged moderately strong overall benefits of PIIs (g = 0.553), with studies having lower risk of research bias yielding lower estimates (g = 0.47). Parent and observer ratings yielded similar averaged estimates for positive behavior/social skills (g = 0.603), language/communication (g = 0.545), maladaptive behavior (g = 0.519), and to a lesser extent, adaptive behavior/life skills (g = 0.239). No other study, intervention, or participant characteristic moderated outcomes. PIIs with children with ASD tend to be effective across a variety of circumstances.

Systematic Review and Meta-analysis: Pharmacological and Nonpharmacological Interventions for Persistent Nonepisodic Irritability

OBJECTIVE

This meta-analysis examined the efficacy of available pharmacological and nonpharmacological interventions for irritability among youth with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorders (DBD), disruptive mood dysregulation disorder (DMDD), and/or severe mood dysregulation (SMD).

METHOD

Literature searches were conducted in October 2020, resulting in 564 abstracts being reviewed to identify relevant papers, with 387 articles being reviewed in full. A random effects model was used for the meta-analysis, with subgroup meta-regressions run to assess effects of study design, intervention type, medication class, and clinical population.

RESULTS

A total of 101 studies were included (80 pharmacological, 13 nonpharmacological, 8 combined). Despite high heterogeneity in effects (I2 = 94.3%), pooled posttreatment effect size for decreasing irritability was large (Hedges' g = 1.62). Large effects were found for pharmacological (g = 1.85) and nonpharmacological (g = 1.11) interventions; moderate effects were found for combined interventions relative to monotherapy interventions (g = 0.69). Antipsychotic medications provided the largest effect for reducing irritability relative to all other medication classes and nonpharmacological interventions. A large effect was found for youth with ASD (g = 1.89), whereas a medium effect was found for youth with ADHD/DMDD/DBD/SMD (g = 0.64).

CONCLUSION

This meta-analysis provides a comprehensive review of interventions targeting persistent nonepisodic irritability among youth with various psychiatric disorders. Strong evidence was found for medium-to-large effects across study design, intervention type, and clinical populations, with the largest effects for pharmacological interventions, particularly antipsychotic medications and combined pharmacological interventions, and interventions for youth with ASD.

Adjunctive Parental Support Within Manualized Parent Training for Children with Autism Spectrum Disorder

Parent training is a central focus of behavioral intervention, with emphasis on teaching parents to become change agents for their children by using behavioral management skills. However, its effectiveness is limited by a parent's ability to engage in the learning process. Parents managing external stressors, psychopathology, or poverty often do not gain the skills and thus, the treatment may minimally impacts parent and child behavior. In order to increase a parent's ability to acquire and implement new skills accurately, referred to as parent treatment integrity, the current study added a parent-support component to the RUBI Autism Network's Parent Training for Disruptive Behaviors protocol. The parent-support component was intended to remove barriers to skill acquisition during the parent training session by alleviating some of the interfering parental stress. In an alternating treatments design, a community-based sample of five parent-child dyads (average age of child = 32 months) participated in the parent-training protocol; half of the intervention sessions included a 15-min parent-support component. The addition of the parent-support component increased parent engagement, treatment integrity, and learned parenting skills, like parent praise. Results support a model of change for parenting behavior. Inclusion of a parent-support component is supported as an effective practice for parent training.

Advances in Supporting Parents in Interventions for Autism Spectrum Disorder

The rising prevalence of autism spectrum disorder (ASD) calls for clear referral and treatment guidelines for children with ASD and their caregivers. Caregiver involvement in intervention is a standard practice of care and research suggests that teaching intervention strategies to caregivers can improve child outcomes and increase caregiver efficacy. Caregiver-mediated interventions that are naturalistic, developmental, and behavioral are effective in improving social and communication skills for children with ASD. Caregiver training models that use behavioral strategies are effective in reducing challenging behaviors. Finally, reducing caregiver barriers to treatment implementation, including stress and strain, are becoming critical components for improving the well-being and care of children with ASD and their families.

Marital Satisfaction and Perceived Family Support in Families of Children with Autistic Spectrum Disorder: Dyadic Analysis

Background: Raising children with autism spectrum disorder (ASD) causes tremendous stress for parents that may lead to marital conflict and relationship dissatisfaction. Many factors are associated with parent relationships including severity of autistic behaviors and social support. This study aimed to investigate whether severity of autistic behaviors, perceived family support, and complementarity of interpersonal styles between husbands and wives predicted couple satisfaction among the parents of children with ASD. Method: Seven hundred ninety-seven parent dyads of children aged 7–14 years old with ASD participated in the study. Measurements used included couple satisfaction index, perceived family support using the Multidimensional Scale of Perceived Social Support, inter-personal style using the inventory of interpersonal problems, the ABC autism checklists as well as sociodemographic and related factors. The Actor Partner Interdependence Model estimated by multilevel modeling was used for analysis. Results: Perceived family support was relevant in married couples regarding their marital relationship, but the effects on husbands and wives differed. Husbands’ relationship satisfaction was predicted by how they perceived being supported by family. The severity of autistic behaviors predicted relationship satisfaction but only actor effect. Negative prediction of interpersonal complementarity on couple satisfaction was observed. In addition, time spent on raising children had a negative impact on the quality of the relationship. Partner effect of time spent was observed among women. Conclusion: Dyadic analysis using an actor–partner independence model confirmed perception of family support predicts relationship satisfaction among parents of children with ASD in addition to the severity of autistic behaviors and time spent caring for children. Complementarity of individual interpersonal style had no effect on couple satisfaction. This research suggests implications for interventions regarding building skills that elicit support from family members.

From Clinic Room to Zoom: Delivery of an Evidence-Based, Parent-mediated Intervention in the Community Before and During the Pandemic

Disruptive behaviors (DBs) are common in children with autism, affecting child and family quality of life. Parent-mediated interventions (PMIs) are a cost-effective and accessible way to decrease DBs. COVID-19 increased need for telehealth interventions. This study explored a group delivery of an evidence-based PMI (RUBI), delivered face-to-face and virtually in Israel, before and during the pandemic. Fifty-five families of children with autism and DB participated, 24 receiving face-to-face intervention and 31 receiving virtual. Outcome measures included the Aberrant Behavior Checklist and Home Situations Questionnaires. Results indicate reduction of DBs across groups, with > 50% of treatment-responders showing reliable change. This study is the first to assess RUBI outside the US among a sociodemographically diverse population, in both in-person and virtual contexts.

Parent-Implemented Positive Behavior Support Strategies for Young Children on the Autism Spectrum: A Pilot Investigation

PURPOSE

Parents of children on the autism spectrum enrolled in early intervention often receive coaching to address both social communication and disruptive behavior, which are the two most frequently reported concerns by parents. Intervention techniques for both are often recommended to be implemented across daily routines and require the parents to learn new ways of interacting with their child. A sequential approach to instructing parents in these key intervention targets may reduce burden and increase adherence.

METHOD

This multiple-baseline design pilot study included three mother-child dyads who received instruction in a disruptive behavior intervention immediately following a social communication intervention. Maternal maintenance of social communication strategies and child disruptive behaviors were measured during probes throughout the study.

RESULTS

Results indicate that although mothers readily learned to implement the techniques, fidelity of implementing social communication strategies declined after introduction of the positive behavior support strategies.

CONCLUSIONS

A sequenced approach to parent-mediated intervention is feasible and acceptable. Clinical implications and future directions are discussed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19528978.

Iterative redesign of a caregiver-mediated intervention for use in educational settings

LAY ABSTRACT

Teachers often report concerns about behavior challenges in their students with autism spectrum disorder (ASD) in the school setting. Furthermore, teachers often report that they do not have adequate training in how to manage these challenging behaviors effectively. The RUBI program is an intervention initially developed for parents of children with ASD and co-occurring challenging behavior in clinic settings. The present project used school staff input to systematically redesign RUBI to be used with educators in schools. School staff gave input at multiple stages of development to ensure the adapted intervention was appropriate to use in a school setting. Responses were coded and analyzed to identify strengths and weaknesses of the RUBI manual in schools and adaptations were made accordingly. Scores of how appropriate, possible, likable, and usable RUBI would be in schools rose after the intervention was redesigned. The redesigned RUBIES manual may give school staff the tools they need to manage disruptive behaviors. In addition, collaborating with providers over multiple stages to redesign established interventions for new contexts may be a promising way to help bring research tools to practice in the future.

Examining Feasibility and Outcomes of the PEERS® for Preschoolers Program

Social impairments characteristic of autism spectrum disorder (ASD) are evident in early childhood and often worsen. There is a paucity of evidence-based interventions explicitly targeting social skill development for young children with ASD and few actively integrate caregivers. The PEERS® program, an evidence-based caregiver-assisted social skills program, was extended for young children with ASD (i.e., PEERS® for Preschoolers (P4P)). This pilot study expands upon initial results by examining the feasibility of a briefer intervention period and the effectiveness in improving child social skills among 15 children with ASD. Results suggest P4P recruitment, participant retention, and implementation are feasible across clinicians and sites. Further, P4P appears to improve social skills, maintained post-intervention. Future research might examine mechanisms that lead to results.

Repetitive Restricted Behaviors in Autism Spectrum Disorder: From Mechanism to Development of Therapeutics

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder characterized by deficits in social communication, social interaction, and repetitive restricted behaviors (RRBs). It is usually detected in early childhood. RRBs are behavioral patterns characterized by repetition, inflexibility, invariance, inappropriateness, and frequent lack of obvious function or specific purpose. To date, the classification of RRBs is contentious. Understanding the potential mechanisms of RRBs in children with ASD, such as neural connectivity disorders and abnormal immune functions, will contribute to finding new therapeutic targets. Although behavioral intervention remains the most effective and safe strategy for RRBs treatment, some promising drugs and new treatment options (e.g., supplementary and cell therapy) have shown positive effects on RRBs in recent studies. In this review, we summarize the latest advances of RRBs from mechanistic to therapeutic approaches and propose potential future directions in research on RRBs.

Remote PEERS® for preschoolers: A pilot parent-mediated social skills intervention for young children with social challenges over telehealth

INTRODUCTION

Social differences characteristic of autism spectrum disorder (ASD) and other developmental disabilities are evident in early childhood and are associated with later difficulties. Unfortunately, there is a paucity of evidence-based interventions explicitly targeting social skills development for young children, few actively integrate parents and caregivers, and even fewer have remote models. The importance of providing accessible, tailored services for families in the wake of the COVID-19 pandemic, prompted the creation of a parent-mediated telehealth version of Program for the Education and Enrichment of Relational Skills (PEERS^®) for Preschoolers (P4P), a pre-existing, evidence-based social skills intervention for children 4-6 years focused on making and keeping friends.

METHOD

This methodological paper documents the implementation, feasibility, and satisfaction of a novel telehealth group-based delivery of P4P.

RESULTS

Qualitative results indicate acceptable feasibility and satisfaction. Additionally, following completion there was an increase in parental confidence in social coaching and increased use of child social skills.

DISCUSSION

Future work will evaluate quantitative outcomes and comparisons between delivery methods (e.g., telehealth vs. in-person).

Effects of Acceptance and Commitment Training Plus Behavior Parent Training on Parental Implementation of Autism Treatment

The objective of this study was to examine the effects of acceptance and commitment training (ACT) plus behavior parent training (BPT), when delivered via telehealth, on parental implementation of behavioral strategies, experiential avoidance (EA), and stress. The study also examined the subsequent effects on the parents’ autistic children’s behaviors. A multiple baseline design was implemented across four parent-child dyads who participated in the online training. The findings showed that ACT+BPT resulted in parental implementation reaching and maintaining high levels. The training also decreased EA and stress in three parents. Moreover, the parents’ ratings of their children’s challenging behaviors decreased. However, such a trend was not as clearly depicted by direct measures of the children’s behaviors. A social validity interview revealed parents found ACT beneficial in assisting them to learn and use the BPT strategies. Implications and suggestions for future research are discussed.

Stress in Egyptian parents of children with developmental disabilities. The moderating effect of social support

BACKGROUND

Research shows that parents of children with developmental disabilities (DDs) are at increased risk for elevated stress. Child adaptive functioning as well as social supports are key factors influencing stress in parents. However, few studies have examined the interaction between these variables and their contribution to perceived stress especially in Egyptian parents.

AIMS

The present study investigated the relationship between parenting stress, child adaptive functioning, and social supports. It also examined the moderating role of social support in the relationship between child adaptive functioning and stress in Egyptian parents of children with DDs.

METHOD

Sixty-four Egyptian parents of children with DDs completed assessment measures of parenting stress, child adaptive functioning, and social supports.

RESULTS

Parenting stress was negatively associated with child adaptive functioning and informal social supports. However, there was no association between parenting stress and formal social supports. In addition, level of informal social support had a moderating effect on the relationship between child adaptive functioning and level of parenting stress.

CONCLUSIONS

The findings highlight the importance of interventions that reduce child-related stressors, particularly low adaptive functioning. Programs that address parenting stress and promote effective informal and formal social supports are crucial to help parents cope with stress.

A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes

Youth with autism spectrum disorder (ASD) have high rates of co-occurring mental health needs that necessitate mental health interventions. Given the unique clinical characteristics of youth with ASD, there have been significant efforts to adapt and test mental health interventions for this population. Yet, characterization of the nature and types of interventions adaptations is limited, especially across the wide range of interventions tested for youth with ASD with a focus on implementation factors. Additionally, understanding how these interventions may be implemented in community services is limited. The aims of this systematic review are to characterize the (1) types of interventions tested for co-occurring mental health conditions for youth with ASD; (2) adaptations to mental health interventions for use with youth with ASD; and (3) implementation strategies, outcomes, and determinants of mental health interventions to inform their translation to community service settings. Eighty-three articles testing interventions targeting mental health symptoms in youth with ASD that included implementation factors in analyses were reviewed. The Stirman et al. (2013; 2019) FRAME adaptation, Powell et al. (2012;2015) implementation strategies, and Proctor et al. (2011) implementation outcomes taxonomies were applied to characterize the nature and types of adaptations for use with youth with ASD and types of implementation strategies, outcomes, and determinants used, when available, respectively. Of the interventions examined, the majority (64.1%) were originally designed to target youth mental health concerns and were then adapted to be used with ASD. The most common adaptations included those to the intervention content, particularly adding elements with tailoring or refining aspects of the intervention while maintaining core functions. Half of the articles described at least one implementation strategy used during intervention testing. Fidelity and acceptability were the most frequently examined implementation outcomes, with some examination of appropriateness and feasibility. Nineteen percent of articles described implementation determinants (i.e. barriers/facilitators) of these implementation outcomes. The common adaptations for ASD provide direction for future intervention development and for training community therapists. Further examination, specification, and reporting of implementation strategies and outcomes within ongoing efforts to adapt and interventions to meet the co-occurring mental health needs of youth ASD are needed to facilitate their translation to community settings. Areas for future research as well as clinical implications are discussed.

Correction to: A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes

Due to the errors occurred in the originally published version, this article is being reprinted in its entirety as Correction. All errors have been corrected. It is the correct version.

The Role of Family Accommodation of RRBs in Disruptive Behavior Among Children with Autism

Family accommodation refers to changes in families' behavior aimed at reducing children's psychopathology-related distress (Shimshoni et al. in Indian J ournal of Psychiatry 61(Suppl 1):S93-S103, 2019). Family accommodation of RRBs occurs frequently in families of children with autism, is linked to greater symptom severity (Feldman et al. in J Autism Dev Disord 49(9):3602-3610, 2019), and is unexplored in the context of disruptive behaviors. This study examined child and parent factors associated with disruptive behavior in children with autism. Parents (N = 90; age 2-9 years) reported on children's autism symptomatology, adaptive functioning, and disruptive behavior, alongside parenting stress and family accommodation of RRBs. Such accommodation contributed significantly to predicting disruptive behavior. These findings indicate that parent behavior is associated with the expression of disruptive behavior in this sample, highlighting potential intervention targets for children with autism.

Training Community Therapists to Deliver an Individualized Mental Health Intervention for Autism Spectrum Disorder: Changes in Caregiver Outcomes and Mediating Role on Child Outcomes

OBJECTIVE

This study examines the impact of training therapists to deliver "An Individualized Mental Health Intervention for Autism Spectrum Disorder (ASD)" (AIM HI) for children with autism spectrum disorder on caregiver outcomes and the mediating role of changes in caregiver outcomes on child outcomes.

METHOD

Data were drawn from a cluster randomized trial conducted in 29 publicly funded mental health programs randomized to receive AIM HI training or usual care. Therapists were recruited from enrolled programs and child/caregiver participants enrolled from therapists' caseloads. Participants included 202 caregivers of children 5 to 13 years of age with autism spectrum disorder. Caregiver strain and sense of competence were assessed at baseline and 6 month postbaseline. Child behaviors were assessed at baseline and 6, 12, and 18 months postbaseline. Therapist delivery of evidence-based intervention strategies were assessed between baseline and 6 months.

RESULTS

A significant training effect was observed for caregiver sense of competence, with AIM HI caregivers reporting significantly greater improvement relative to usual care. There was no significant training effect for caregiver strain. Observer-rated therapist delivery of evidence-based interventions strategies over 6 months mediated training effects for sense of competence at 6 months. Changes in sense of competence from baseline to 6 months was associated with reduced child challenging behaviors at 6 months and mediated child outcomes at 12 and 18 months.

CONCLUSION

Combined with research demonstrating effectiveness of therapist AIM HI training on child outcomes, this study provides further evidence of the positive impact of training community therapists in the AIM HI intervention.

CLINICAL TRIAL REGISTRATION INFORMATION

Effectiveness and Implementation of a Mental Health Intervention for ASD (AIM HI); https://clinicaltrials.gov/; NCT02416323.

Early Intervention with Parents of Children with Autism Spectrum Disorders: A Review of Programs

The aim of this article was to analyze the evidence regarding the effectiveness of intervention programs for children with autism based on the participation of their parents. To obtain the data, a systematic search was carried out in four databases (PsycARTICLES (ProQuest), ERIC (ProQuest), PubMed (ProQuest), and Scopus). The retrieved documents were refined under the inclusion/exclusion criteria, and a total of 51 empirical studies were selected. These studies were first classified according to the function of the intervention objective and, later, by the methodology applied (19 studies were based on comprehensive interventions, 11 focused on the nuclear symptoms of autism spectrum disorder (ASD), 12 focused on the promotion of positive parenting, and nine interactions focused on child play). Once all of the documents had been analyzed, the evidence indicated scientific efficacy in most studies, mainly in those based on child development and the application of behavioral analysis principles. Moreover, the positive influence of parent participation in such programs was demonstrated.

Reliability and Validity of the Simplified Chinese Version of the Aberrant Behavior Checklist in Chinese Autism Population

Background: The Aberrant Behavior Checklist (ABC) is a widely used scale in autism clinical intervention research for the assessment of core symptoms and comorbid emotional and behavioral problems among people with autism. The aim of this study was to examine the psychometric properties of the Simplified Chinese version of the Aberrant Behavior Checklist (SC-ABC) using a sample of people with autism in a Chinese population. Methods: In total, we enrolled 799 patients aged 1.5-33 years old. We collected data using the SC-ABC (n = 799), Autism Behavior Checklist (n = 743), Attention Deficit Hyperactivity Disorder Rating Scale-IV (ADHD-RS-IV) (n = 433) and Achenbach Child Behavior Checklist (CBCL) (n = 319). Eighty-four patients were separately assessed with the SC-ABC by two caregivers simultaneously. Forty-four patients were assessed with the SC-ABC again by same caregiver 2 weeks after the first assessment. SC-ABC data from the whole sample were used for confirmatory factor analysis. We evaluated criterion validity using Spearman's correlation coefficient between scores of the SC-ABC and scores of the Autism Behavior Checklist, ADHD-RS-IV and CBCL separately in the whole sample and different age groups. We calculated the intragroup correlation coefficients and Spearman's correlation coefficient for interrater reliability in 84 samples and test-retest reliability in 44 samples. We conducted Cronbach's α for internal consistency. Results: For the SC-ABC, the intragroup correlation coefficients of five subscales and the total score in interrater and test-retest reliability ranged from 0.87 to 0.92 and from 0.93 to 0.97 (all P < 0.01). The Spearman's correlation coefficient of five subscales and the total score in interrater and test-retest reliability ranged from 0.78 to 0.85 and 0.86 to 0.94, respectively (all P < 0.01). Cronbach's α of five subscales and the total score ranged from 0.75 to 0.96 (all P < 0.01). The Spearman's correlation coefficient for criterion validity for the whole sample and different age groups ranged from 0.39 to 0.76 (all P < 0.01). The model fit for the original five factor model was acceptable, with fit indices of SMR = 0.062 and RMSEA = 0.052. Conclusions: The SC-ABC has satisfactory psychometric properties and can be used in the assessment of core symptoms and comorbid emotional and behavioral problems in patients with autism.

Trauma and Autism Spectrum Disorder: Review, Proposed Treatment Adaptations and Future Directions

Empirical investigations of trauma and post-traumatic stress disorder (PTSD) in individuals with autism spectrum disorder (ASD) are lacking despite indications of increased risk for exposure to potentially traumatic events in this population. Research on the treatment of traumatic stress psychopathology in ASD is even more limited and suggests a critical need for guidance in the area of ASD-specific treatment adaptations. The current paper provides preliminary recommendations for adapting current evidenced-based, trauma-specific interventions, specifically trauma-focused cognitive behavioral therapy (TF-CBT), for individuals with ASD based on well-established and evidence-based practices for working with this population. These adaptations highlight the need to incorporate treatment goals related to ASD core symptoms and associated characteristics during treatment targeting traumatic stress symptoms. Future directions are discussed, including the development of instruments measuring trauma reactions in ASD, empirical investigations of modified trauma interventions for children with ASD to evaluate effectiveness, and collaboration between professionals specializing in ASD and trauma/PTSD to advance research and facilitate effective care for this community.

Self-directed or therapist-led parent training for children with attention deficit hyperactivity disorder? A randomized controlled non-inferiority pilot trial

BACKGROUND AND OBJECTIVES

Therapist-led behavioral parent training is a well-established treatment for behavior problems in children with attention-deficit/hyperactivity disorder (ADHD). However, parental attrition is high; self-directed forms of parent training may be a promising alternative. To date, no studies have compared these two forms of parent training in referred children with ADHD. The objectives of this pilot study were to examine the non-inferiority of a blended parent training (i.e. online program + supportive therapist contact) in comparison to its therapist-led equivalent (i.e. face-to-face parent training) regarding effects on behavioral problems, and to compare attrition rates, parental satisfaction, and therapist-time between both treatments.

METHODS

21 school-aged children with ADHD and behavioral problems, who had been referred to an outpatient mental health clinic, were randomized to blended (n = 11) or face-to-face (n = 10) parent training. Behavior problems were measured with the Child Behavior Checklist. Treatment completers and dropouts were included in the analyses.

RESULTS AND CONCLUSIONS

Blended parent training was not found to be non-inferior to face-to-face parent training in the reduction of behavior problems. Parents in the blended condition dropped out of treatment significantly earlier than parents in the face-to-face condition and were less satisfied. Therapists in the blended condition spent significantly less time on parent training than therapists in the face-to-face condition.

Parent-Mediated Interventions for Children With Autism Spectrum Disorder: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to evaluate the evidence for the effectiveness of parent-mediated interventions on occupational performance of children with autism spectrum disorder (ASD).

METHOD

We conducted a search of academic databases using terms such as autism spectrum disorder, parent, caregiver, and intervention. Five hundred eighty-two articles were reviewed, and 109 were selected for full-text review. The final analysis included 13 articles.

RESULTS

Strong evidence was found for the efficacy of parent-mediated intervention for increasing child joint attention. Moderate evidence was found for the improvement of language scores, expressive language, nonverbal communication, initiation and response to interaction, behavior, play, adaptive functioning, ASD symptoms, and social communication.

CONCLUSION

This systematic review suggests that parent-mediated interventions for children with ASD can improve various aspects of communication and ASD symptoms, with emerging support for occupational performance. Occupational therapy practitioners are well suited to facilitate these interventions to support families with children with autism.

Teaching Parents Behavioral Strategies for Autism Spectrum Disorder (ASD): Effects on Stress, Strain, and Competence

We report on parent outcomes from a randomized clinical trial of parent training (PT) versus psychoeducation (PEP) in 180 children with autism spectrum disorder (ASD) and disruptive behavior. We compare the impact of PT and PEP on parent outcomes: Parenting Stress Index (PSI), Parent Sense of Competence (PSOC), and Caregiver Strain Questionnaire (CGSQ). Mixed-effects linear models evaluated differences at weeks 12 and 24, controlling for baseline scores. Parents in PT reported greater improvement than PEP on the PSOC (ES = 0.34), CGSQ (ES = 0.50), and difficult child subdomain of the PSI (ES = 0.44). This is the largest trial assessing PT in ASD on parent outcomes. PT reduces disruptive behavior in children, and improves parental competence while reducing parental stress and parental strain.

Stress and Parents of Children with Autism: A Review of Literature

The purpose of this review is twofold. The first is to synthesize factors that impact parents' experiences of caring for a child with autism spectrum disorder (ASD); the second is to identify factors that impact parental stress and parental decision-making to use autism services or not. Parents of children with ASD score higher on levels of stress than other groups of parents. The daily challenges of caring for the child are endless and effect all aspects of the child's care as well as the parent's mental health and ability to manage the needs of the child and family. Understanding more about the challenges parents face will provide direction for research, intervention development, and practice. Accordingly, a search was conducted using CINAHL and Medline. Inclusion criteria included articles available in full text, published in English, and focused on children with ASD distinct from other diagnoses, as well as parental experiences of caring for a child with ASD. Articles (N = 132) that met the inclusion criteria were summarized. Challenging aspects of the child's diagnosis and care are discussed, as well as the factors that impact parental stress and decision-making to use autism services. Recommendations for research and practice include interventional development related to early diagnosis, disparity, access to care, parental decision-making to use autism services, and parental stress management.

Systematic Review of the Measurement Properties of Tools Used to Measure Behaviour Problems in Young Children with Autism

Background

Behaviour problems are common in young children with autism spectrum disorder (ASD). There are many different tools used to measure behavior problems but little is known about their validity for the population.

Objectives

To evaluate the measurement properties of behaviour problems tools used in evaluation of intervention or observational research studies with children with ASD up to the age of six years.

Methods

Behaviour measurement tools were identified as part of a larger, two stage, systematic review. First, sixteen major electronic databases, as well as grey literature and research registers were searched, and tools used listed and categorized. Second, using methodological filters, we searched for articles examining the measurement properties of the tools in use with young children with ASD in ERIC, MEDLINE, EMBASE, CINAHL, and PsycINFO. The quality of these papers was then evaluated using the COSMIN checklist.

Results

We identified twelve tools which had been used to measure behaviour problems in young children with ASD, and fifteen studies which investigated the measurement properties of six of these tools. There was no evidence available for the remaining six tools. Two questionnaires were found to be the most robust in their measurement properties, the Child Behavior Checklist and the Home Situations Questionnaire—Pervasive Developmental Disorders version.

Conclusions

We found patchy evidence on reliability and validity, for only a few of the tools used to measure behaviour problems in young children with ASD. More systematic research is required on measurement properties of tools for use in this population, in particular to establish responsiveness to change which is essential in measurement of outcomes of intervention.

PROSPERO Registration Number

CRD42012002223

Parent Training in Autism Spectrum Disorder: What's in a Name?

Parent training (PT) is well understood as an evidence-based treatment for typically developing children with disruptive behavior. Within the field of autism spectrum disorder (ASD), the term parent training has been used to describe a wide range of interventions including care coordination, psychoeducation, treatments for language or social development, as well as programs designed to address maladaptive behaviors. As a result, the meaning of "parent training" in ASD is profoundly uncertain. This paper describes the need to delineate the variants of PT in ASD and offers a coherent taxonomy. Uniform characterization of PT programs can facilitate communication with families, professionals, administrators, and third-party payers. Moreover, it may also serve as a framework for comparing and contrasting PT programs. In support of the taxonomy, a purposive sampling of the literature is presented to illustrate the range of parent training interventions in ASD.

Systematic review of tools to measure outcomes for young children with autism spectrum disorder

BACKGROUND

The needs of children with autism spectrum disorder (ASD) are complex and this is reflected in the number and diversity of outcomes assessed and measurement tools used to collect evidence about children's progress. Relevant outcomes include improvement in core ASD impairments, such as communication, social awareness, sensory sensitivities and repetitiveness; skills such as social functioning and play; participation outcomes such as social inclusion; and parent and family impact.

OBJECTIVES

To examine the measurement properties of tools used to measure progress and outcomes in children with ASD up to the age of 6 years. To identify outcome areas regarded as important by people with ASD and parents.

METHODS

The MeASURe (Measurement in Autism Spectrum disorder Under Review) research collaboration included ASD experts and review methodologists. We undertook systematic review of tools used in ASD early intervention and observational studies from 1992 to 2013; systematic review, using the COSMIN checklist (Consensus-based Standards for the selection of health Measurement Instruments) of papers addressing the measurement properties of identified tools in children with ASD; and synthesis of evidence and gaps. The review design and process was informed throughout by consultation with stakeholders including parents, young people with ASD, clinicians and researchers.

RESULTS

The conceptual framework developed for the review was drawn from the International Classification of Functioning, Disability and Health, including the domains 'Impairments', 'Activity Level Indicators', 'Participation', and 'Family Measures'. In review 1, 10,154 papers were sifted - 3091 by full text - and data extracted from 184; in total, 131 tools were identified, excluding observational coding, study-specific measures and those not in English. In review 2, 2665 papers were sifted and data concerning measurement properties of 57 (43%) tools were extracted from 128 papers. Evidence for the measurement properties of the reviewed tools was combined with information about their accessibility and presentation. Twelve tools were identified as having the strongest supporting evidence, the majority measuring autism characteristics and problem behaviour. The patchy evidence and limited scope of outcomes measured mean these tools do not constitute a 'recommended battery' for use. In particular, there is little evidence that the identified tools would be good at detecting change in intervention studies. The obvious gaps in available outcome measurement include well-being and participation outcomes for children, and family quality-of-life outcomes, domains particularly valued by our informants (young people with ASD and parents).

CONCLUSIONS

This is the first systematic review of the quality and appropriateness of tools designed to monitor progress and outcomes of young children with ASD. Although it was not possible to recommend fully robust tools at this stage, the review consolidates what is known about the field and will act as a benchmark for future developments. With input from parents and other stakeholders, recommendations are made about priority targets for research.

FUTURE WORK

Priorities include development of a tool to measure child quality of life in ASD, and validation of a potential primary outcome tool for trials of early social communication intervention.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002223.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with intellectual disabilities

BACKGROUND

Outwardly-directed aggressive behaviour is a significant part of problem behaviours presented by people with intellectual disabilities. Prevalence rates of up to 50% have been reported in the literature, depending on the population sampled. Such behaviours often run a long-term course and are a major cause of social exclusion. This is an update of a previously published systematic review (see Hassiotis 2004; Hassiotis 2008).

OBJECTIVES

To evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly-directed aggressive behaviour in people with intellectual disabilities when compared to standard intervention or wait-list controls.

SEARCH METHODS

In April 2014 we searched CENTRAL, Ovid MEDLINE, Embase, and eight other databases. We also searched two trials registers, checked reference lists, and handsearched relevant journals to identify any additional trials.

SELECTION CRITERIA

We included studies if more than four participants (children or adults) were allocated by random or quasi-random methods to either intervention, standard treatment, or wait-list control groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies and extracted and assessed the quality of the data.

MAIN RESULTS

We deemed six studies (309 participants), based on adult populations with intellectual disabilities, suitable for inclusion in the current version of this review. These studies examined a range of cognitive-behavioural therapy (CBT) approaches: anger management (three studies (n = 235); one individual therapy and two group-based); relaxation (one study; n = 12), mindfulness based on meditation (one study; n = 34), problem solving and assertiveness training (one study; n = 28). We were unable to include any studies using behavioural interventions. There were no studies of children.Only one study reported moderate quality of evidence for outcomes of interest as assessed by the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We judged the evidence for the remaining studies to be of very low to low quality. Most studies were at risk of bias in two or more domains: one study did not randomly allocate participants and in two studies the process of randomisation was unclear; in one study there was no allocation concealment and in three studies this was unclear; blinding of assessors did not occur in three studies; incomplete outcome data were presented in one study and unclear in two studies; there was selective reporting in one study; and other biases were present in one study and unclear in four studies.Three of the six studies showed some benefit of the intervention on improving anger ratings. We did not conduct a meta-analysis, as we considered the studies too heterogeneous to combine (e.g. due to differences in the types of participants, sample size interventions, and outcome measures).Follow-up data for anger ratings for both the treatment and control groups were available for two studies. Only one of these studies (n = 161) had adequate long-term data (10 months), which found some benefit of treatment at follow-up (continued improvement in anger coping skills as rated by key workers; moderate-quality evidence).Two studies (n = 192) reported some evidence that the intervention reduces the number of incidents of aggression and one study (n = 28) reported evidence that the intervention improved mental health symptoms.One study investigated the effects of the intervention on quality of life and cost of health and social care utilisation. This study provided moderate-quality evidence, which suggests that compared to no treatment, behavioural or cognitive-behavioural interventions do not improve quality of life at 16 weeks (n = 129) or at 10 months follow-up (n = 140), or reduce the cost of health service utilisation (n = 133).Only one study (n = 28) assessed adaptive functioning. It reported evidence that assertiveness and problem-solving training improved adaptive behaviour.No studies reported data on adverse events.

AUTHORS' CONCLUSIONS

The existing evidence on the effectiveness of behavioural and cognitive-behavioural interventions on outwardly-directed aggression in children and adults with intellectual disabilities is limited. There is a paucity of methodologically sound clinical trials and a lack of long-term follow-up data. Given the impact of such behaviours on the individual and his or her support workers, effective interventions are essential. We recommend that randomised controlled trials of sufficient power are carried out using primary outcomes that include reduction in outward-directed aggressive behaviour, improvement in quality of life, and cost effectiveness.

Effects and Moderators of a Short Theory of Mind Intervention for Children with Autism Spectrum Disorder: A Randomized Controlled Trial

Limited perspective taking or "Theory of Mind" (ToM) abilities are a core deficit of autism, and many interventions are aimed to improve ToM abilities. In this study, we investigated the effectiveness of a ToM treatment for children with autism spectrum disorders (ASD) and, for the first time, the moderating roles of social interaction style (SIS) and disruptive behavior (DB), to determine which children are most likely to respond to this intervention. The trial protocol is registered at www.trialregister.nl, trial number 2327 and published before the data collection was finished (www.trialsjournal.com). Children with autism aged 7-12 years (n = 97) were randomized over a waitlist control or a treatment condition. Outcome measures included ToM and emotion understanding, parent and teacher questionnaires on children's social skills, ToM-related social behavior, and autistic traits. Six-month follow-up parent reported data were collected for the treatment group. The treatment had a positive effect on ToM understanding, parent-reported ToM behavior, and autistic traits, but not on parent or teacher-reported social behavior. Passive SIS was associated with diminished treatment effects on autistic traits, but DB was unrelated to outcomes. The ToM intervention improved conceptual social understanding and ToM-related behavior of children with ASD. However, broader application of learned skills to other domains of functioning was limited. Individual differences with regard to treatment response are discussed.

Peripartum depression and anxiety as an integrative cross domain target for psychiatric preventative measures

Exposure to high levels of early life stress has been identified as a potent risk factor for neurodevelopmental delays in infants, behavioral problems and autism in children, but also for several psychiatric illnesses in adulthood, such as depression, anxiety, autism, and posttraumatic stress disorder. Despite having robust adverse effects on both mother and infant, the pathophysiology of peripartum depression and anxiety are poorly understood. The objective of this review is to highlight the advantages of using an integrated approach addressing several behavioral domains in both animal and clinical studies of peripartum depression and anxiety. It is postulated that a greater focus on integrated cross domain studies will lead to advances in treatments and preventative measures for several disorders associated with peripartum depression and anxiety.

Behavioral parent training to address sleep disturbances in young children with autism spectrum disorder: a pilot trial

OBJECTIVES

A large percentage of children with autism spectrum disorders (ASD) have bedtime and sleep disturbances. However, the treatment of these disturbances has been understudied. The purpose of our study was to develop a manualized behavioral parent training (BPT) program for parents of young children with ASD and sleep disturbances and to test the feasibility, fidelity, and initial efficacy of the treatment in a small randomized controlled trial (RCT).

PARTICIPANTS AND METHODS

Parents of a sample of 40 young children diagnosed with ASD with an average age of 3.5years were enrolled in our study. Participants were randomized to either the BPT program group or a comparison group who were given nonsleep-related parent education. Each participant was individually administered a 5-session program delivered over the 8-week study. Outcome measures of feasibility, fidelity, and efficacy were collected at weeks 4 and 8 after the baseline time point. Children's sleep was assessed by parent report and objectively by actigraphy.

RESULTS

Of the 20 participants in each group, data were available for 15 participants randomized to BPT and 18 participants randomized to the comparison condition. Results supported the feasibility of the manualized parent training program and the comparison program. Treatment fidelity was high for both groups. The BPT program group significantly improved more than the comparison group based on the primary sleep outcome of parent report. There were no objective changes in sleep detected by actigraphy.

CONCLUSIONS

Our study is one of few RCTs of a BPT program to specifically target sleep disturbances in a well-characterized sample of young children with ASD and to demonstrate the feasibility of the approach. Initial efficacy favored the BPT program over the comparison group and suggested that this manualized parent training approach is worthy of further examination of the efficacy within a larger RCT.

Toward an exportable parent training program for disruptive behaviors in autism spectrum disorders

Autism spectrum disorders (ASD) are chronic conditions of early childhood onset characterized by profound deficits in social interaction, impaired communication, and repetitive behavior. The prevalence of ASD is now estimated to be 1 in 88 children. As the number of identified cases of ASD has grown, so have the challenges of serving these children and their families. Unfortunately, the empirical foundation for many interventions for this population is not firmly established. Thus, there is a pressing need to conduct trials that will expand the evidence base and guide clinical treatment. Investigators from the Research Units in Pediatric Psychopharmacology (RUPP; Indiana University, Ohio State University, University of Pittsburgh, Yale University) followed a treatment development model outlined by an NIMH ad hoc committee to develop and test a parent training (PT) treatment manual for children with ASD accompanied by disruptive behavior problems. This article describes the process of manual development and cross-site therapist training, establishment and maintenance of treatment integrity, assessment of treatment acceptance by families as well as primary outcomes of three trials. Results suggest the structured PT program can be delivered with a high degree of fidelity within and across therapists, is acceptable to parents and can produce significant reductions in disruptive behaviors in children with ASD.