Keywords

Introduction

Early Intervention (EI) for young children with disabilities such as autism spectrum disorder (ASD) is heavily influenced by ecological and family systems theories (Brofenbrenner, 1986; Bruder, 2000). At the crux of these theories are the empirically demonstrated bidirectional and transactional interactions within family units and their dynamic effects on children and their families (Sy, Gottfried, & Gottfried, 2013). Interventions addressing any part of the family unit (e.g. parent or child skill acquisition) may result in more positive child outcomes (Bailey, Raspa, & Fox, 2012; Guralnick, 2011) and/or improved parent and family outcomes (Dunst, Bruder, & Espe-Sherwindt, 2014; Espe-Sherwindt, 2008). Family-centered EI that includes parent education has been linked to improved child outcomes, more positive parent perceptions of child behavior, and greater perceptions of parental self-efficacy (Noyes-Grosser et al., 2014; Strauss et al., 2012). Moreover, federal legislation (i.e., PL 99-457; Individuals with Disabilities Education Act, 2004) supports family-centered practices in EI (e.g. active family participation in Individualized Family Service Plans (IFSPs ) ; Beckman & Bristol, 1991; Bruder, 2000).

Accordingly, EI for young children with or at risk for ASD includes family-centered capacity building and helpgiving practices in natural contexts such as family homes (Bailey et al., 2012; Friend, Summers, & Turnbull, 2009; Mahoney et al., 1999). Increasingly, research indicates that earlier, more intensive intervention for young children (infants and toddlers) with or at risk for ASD delivered by trained and supervised therapists improves outcomes (Dawson et al., 2012; Peters-Scheffer, Didden, Korzilius, & Sturmey, 2011; Wallace & Rogers, 2010). However, parents of children with ASD have a pivotal role in EI as care providers, interventionists, and early language and play partners (Kasari, Lawton, Shih et al., 2014). In keeping wit h other EI services, early intensive behavior intervention (EIBI) (McConachie & Diggle, 2006) and focused, targeted behavioral interventions (e.g. Nefdt, Koegel, Singer, & Gerber, 2010; Schertz, Odom, Baggett, & Sideris, 2013) for young children with ASD oftentimes involves parents as interventionists or parent-mediated EI.

However, the appropriateness of expecting parents to be their child’s teacher in EI has been questioned (Mahoney et al., 1999). Specific criticisms have included undue burden on parents (Rosenberg & Robinson, 1988) and tacit responsibility of the parent for their child’s current state of developmental delays (Turnbull & Turnbull, 1990). Additionally, the outcomes of parent-mediated intervention may suffer from a parent’s lack of time to implement and manage the intervention, barriers to accessing resources and technical knowledge, and difficulties adapting to the teacher role (Bagner & Graziano, 2012). Moreover, expecting parents to deliver large amounts of intervention could add significant stress to a population already at risk for stress and depression (Hodge & Runswick-Cole, 2008). While parenting any young child is both stressful and rewarding, parenting a young child with ASD has been shown to be potentially more stressful than a child who is typically developing, or even a child with another disability or developmental delay (Benson, 2006; Davis & Carter, 2008). High levels of parent stress can interfere with treatment adherence, reduce the likelihood the parent uses new skills, and decrease positive child outcomes (Osborne, McHugh, Saunders, & Reed, 2008). Despite these cautions, an extensive and growing body of literature suggests mostly positive effects from training and supporting parents to implement interventions to address the core symptoms of their child’s ASD (Oono, Honey, & McConachie, 2013; Strauss, Mancini, the SPC Group, & Fava, 2013).

Myriad studies indicate that EIBI can reduce core deficits in ASD such as social communication and language delay, rigid and repetitive behaviors and interests, and common comorbidities such as challenging behavior (Howlin, Magiati, & Charman, 2009; Makrygianni & Reed, 2010; Matson & Konst, 2013; McConachie & Diggle, 2006). Importantly, more positive child outcomes are seen with intensive (i.e. 20–40 h per week) services (Matson & Konst, 2013; Warren et al., 2011). Trained and supported parents and other caregivers can help to meet this high dosage (i.e. hours of direct intervention) of EIBI by delivering intervention during everyday family routines. Parent training for the implementation of EIBI is also cost effective, allows intervention to take place in the natural setting and increases opportunities for intervention and generalization of learned skills (Diggle, McConachie, & Randle, 2002).

Parents are uniquely able to intervene within common routines (e.g. bedtime, meals) and in an array of natural settings (e.g. home, playground, grocery store) and are often highly motivated to learn new strategies for supporting their child’s development as the gains directly impact them. Gains made with parent interventionists in the natural environment can allow for easier generalization than skills taught exclusively in a clinic or school setting (Makrygianni & Reed, 2010; McConachie & Diggle, 2006). Moreover, parent’s routine involvement in intervention planning and implementation can provide interventionists with important opportunities to individualize a child’s treatment plan, and can increase the acceptability and feasibility of interventions (Kaiser & Hancock, 2003; Mahoney et al., 1999; Woods, Kashinath, & Goldstein, 2004). Research on parent-mediated intervention in a variety of settings and intervention modes has shown that when trained with fidelity, parents can be effective interventionists (Kaminski, Valle, Filene, & Boyle, 2008). With support from professionals, parents can effectively assess, intervene, and monitor their child’s progress (Benzies, Magill-Evans, Hayden, & Ballantyne, 2013; Patterson, Smith, & Mirenda, 2012). The efficacy of parent-mediated intervention has been shown with a variety of skills, such as Discrete Trial Teaching (DTT; e.g. Lafasakis & Sturmey, 2007), Pivotal Response Training (PRT; e.g. Coolican, Smith, & Bryson, 2010) and packaged interventions (e.g. Oono et al., 2013).

A number of recent reviews have summarized the procedures and outcomes of parent-mediated early intervention with young children with ASD (e.g. Oono et al., 2013; Singer, Ethridge, & Aldana, 2007) and there are numerous topical reviews discussing the results of research addressing the core symptoms of ASD which include parents among other adult change agents as interventionists (Fettig & Barton, 2014; Meadan, Ostrosky, Zaghlawan, & Yu, 2009; Patterson et al., 2012; Roberts & Kaiser, 2011; Strauss et al., 2013; White et al., 2011). For instance, Lang, Machalicek, Rispoli, and Regester (2009) examined the available literature on training parents to implement communication interventions. Results indicated a range of research on parent-mediated communication intervention with a variety of strategies including PRT, Enhanced Milieu Training (EMT) and Early Start Denver Model (ESDM). Barton and Fettig (2013) conducted a review on attempts to incorporate parents into function-based interventions on challenging behavior, and showed several successful coaching strategies for the training of parents to implement interventions with fidelity. The literature on parent implemented EIBI for children with autism has also been reviewed more broadly, showing positive results for a range of formats and specific targets (Oono et al., 2013) However, the literature is vast, scattered across multiple disciplines and peer-reviewed journals, and varies in quality.

The purpose of the current chapter is to selectively summarize research related to parent-mediated EI for young children, ages 12–60 months, with or at risk for ASD, and to offer suggestions for practice and future research. The remainder of this chapter is organized into the seven sections of (a) overview of parent involvement in early intervention; (b) targeted parent skills and desired outcomes; (c) parent education and training methods; (d) training parents to address core symptoms of ASD; (e) summary and suggestions for future research; (f) implications for practice; and (g) conclusion.

Overview of Parent Involvement in Early Intervention

Parent involvement is EI and EIBI for young children with ASD is commonplace and well supported by the inclusion of family-centered practices in federally funded EI services (Bailey et al., 2012; Beckman & Bristol, 1991; Bruder, 2000; IDEA, 1990, 1997; IDEIA, 2004) and the provision of private insurance funding for medically necessary applied behavior analysis (Autism Speaks, 2015). Additionally, recent reviews of interventions involving parents of children with developmental disabilities including ASD validates the ubiquitous involvement of parents in EI (Brookman-Frazee, Stahmer, Baker-Ericzèn, & Tsai, 2006; Diggle et al., 2002; Hastings, Robertson, & Yasamy, 2012; Lang et al., 2009; McConachie & Diggle, 2006; Oono et al., 2013; Patterson et al., 2012; Roberts & Kaiser, 2011; Strauss et al., 2013). Parents have been involved in EI and EIBI by: (a) implementing intervention, (b) providing input about intervention procedures, (c) collaborating on the development of a behavior intervention plan, (d) informing a functional behavior assessment (FBA) or participating in an experimental functional analysis to determine the consequences maintaining challenging behavior, (e) taking data, (f) answering questions about the feasibility and acceptability of the goals, procedures, and outcomes of the intervention, and (g) teaching others intervention strategies (Machalicek et al., 2014).

Despite parents’ documented participation in EI and in research efforts in this area, we know relatively little about how well currently utilized interventions work to reduce the symptoms of ASD for diverse participants. In the literature, there is a worrisome absence of participant demographic information such as ethnicity/race, socio economic status, and severity of ASD diagnosis and adaptive behavior profiles. Additionally, intervention setting and the format (e.g. group based, one to one, online) of parent training are inconsistently reported. These gaps in the literature make it difficult to determine for whom parent training strategies and parent implemented interventions are most effective, Nevertheless, we can state some general known facts about the children and parents who have participated in parent-implemented early intervention research over the last 18 years (Machalicek et al., 2014). Although exceptions exist (Elder, Valcante, Won, & Zylis, 2003), mothers are more commonly interventionists in parent-implemented intervention for children with intellectual and developmental disabilities such as ASD (Flippin & Crais, 2011). This finding is not restricted to ASD and occurs across disability category (Fabiano, 2007; Tiano & McNeil, 2005). When reported, the ethnicity/race of participating parents is more often White or Hispanic/Latino than another ethnicity/race (Machalicek et al., 2014). This finding is not restricted to parent implemented intervention and likely reflects a larger problem of lack of diverse participant recruitment in special education research (Artiles, Trent, & Kuan, 1997; Vasquez III et al., 2011).

Parents of children with ASD have been effectively taught to implement a variety of focused interventions to increase their child’s social communication skills (e.g. Roberts & Kaiser, 2011) and to decrease challenging behavior (e.g. Brookman-Frazee et al., 2006; Fettig & Barton, 2014). Parents have also been taught to implement one or more components of early intensive applied behavior analysis focused on all educational and behavioral needs related to ASD (EIBA; e.g. Strauss et al., 2012). The focus of parent education programs on improving child social communication and on decreasing challenging behavior is well-aligned with the core diagnostic criteria of ASD. However, outside of EIBA programs, few parent-implemented interventions exist in the areas of functional life or self-help skills (e.g. dressing, bathing), feeding (see Najdowski et al., 2010), toileting (see Kroeger & Sorensen, 2010; Rinald & Mirenda, 2012) and sleep interventions (see Malow et al., 2014).

Group-based parent education is more commonly used than one-to-one parent training and the use of online technology (e.g. online learning modules, use of telecommunication technology such as laptop computers with wireless headset and videoconferencing software) to facilitate the delivery of parent education is rapidly growing, but until relatively recently, has been absent in the literature. A number of parent education interventions have been delivered via online technology (e.g. Machalicek et al., in press; McDuffie et al., 2013; McDuffie, Bullard, Nelson, Machalicek, & Abbeduto, in press).

Targeted Parent Skills and Desired Outcomes

Parent involvement in EI is typically focused on capacity-building interventions that support the parent to implement interventions addressing the core characteristics of ASD. However, EI also involves helpgiving interventions such as respite care, case management, and helping the parent to access existing s ocial supports and community resources (Dunst, Trivette, & Hamby, 2006, 2007, 2008; Dunst, Trivette, Humphries, Raab, & Roper, 2001). This chapter focuses on the role of parents as interven tionists rather than recipients of helpgiving interventions, but we also acknowledge the oftentimes necessity of using a team-based approach to moderate the impact of parent mental health symptoms. Although it is well-understood that both family-centered capacity-building and helpgiving practices positively influence child and family outcomes, most behavioral interventions for children with ASD focus exclusively on child outcomes, with an emphasis on managing the child’s behavior (Blackledge & Hayes, 2006). Considering that parents of children with ASD experience greater levels of parental stress and depression than parents of either typically developing children or children with other developmental disabilities (Falk, Norris, & Quinn, 2014), which may in turn influence less positive intervention outcomes, it is critical to target parental mental health outcomes in behavioral interventions for children with ASD. Therefore, in this section, we discuss both interventions aimed at teaching parents new skills (i.e. parent skill acquisition) to use with their children and interventions aimed at decreasing stress and depression of parents.

Parent Education and Training Delivery Methods to Increase Parent Skills

As previously discussed, parents of young children with ASD have successfully implemented both individualized and packaged interventions to improve their child’s social communication (Mahoney & Perales, 2005; Vismara & Rogers, 2008) and to decrease challenging behavior (Moes & Frea, 2002). Parents have also effectively implemented interventions to teach their child other adaptive behavior skills including school-readiness skills (Lafasakis & Sturmey, 2007), and age appropriate functional life skills such as making a simple snack (Shipley-Benamou, Lutzker, & Taubman, 2002). Consequently, much research is concentrated on increasing parent skill acquisition. This body of parent skill acquisition research can be categorized into three main categories based on the format and delivery modality of parent education: (a) Group-based parent education and training, (b) Individualized parent education and coaching, and (c) Internet-based parent training.

Parent training components across these three categories of parent education and training provide information through (a) didactic or written means (i.e. handouts, manual); (b) in-vivo modeling or video modeling the procedures; (c) involving the parents in role plays; and (d) providing corrective feedback while the parent practices targeted intervention strategies with their child. Past research suggests that performance feedback is the essential component in behavioral parent training that improves adult use of evidence-based strategies (Alvero, Bucklin, & Austin, 2001; Barton & Fettig, 2013; Hattie & Timperley, 2007; Sprick, Knight, Reinke, Skyles, & Barnes, 2010). Common elements in performance feedback protocols include: (a) positive feedback for strategies implemented correctly, (b) corrective feedback for strategies not implemented correctly, and (c) ensuring understanding of corrective feedback by asking questions or asking the individual to repeat corrective feedback (O’Reilly et al., 1992; Parsons & Reid, 1995). The reader can refer to Table 8.1 for a concise, defined list of common evidence-based components of parent education and training programs.

Table 8.1 Glossary of parent education, training, and coaching terms
Full size table

Group-Based Parent Education and Training

Group-based behavioral parent education programs deliver manualized material based on social learning principals to small groups of parents (i.e. 8–12 participants) over weekly sessions. They typically use randomized control group trials with wait-list control groups to evaluate outcomes. Group-based programs take a public health perspective to family intervention. They explicitly recognize the role of the broader ecological context for human development by changing the community context of parenting (Biglan, 1995; National Institute of Mental Health, 1998; Sanders, 1999). The larger system of intervention aims to change this broader ecological context of parenting by normalizing parenting experiences (particularly the process of participating in parent education), breaking down parents’ sense of social isolation, increasing social and emotional support from others in the community, and to validate and acknowledge publicly the importance and difficulties of parenting (Sanders, 1999). This method of parent education has its advantages. Group-based programs may require more resources to implement, but they are still more cost efficient than individually delivered interventions (McIntyre & Phaneuf, 2007). Not only is there a low individual training cost when used in groups, but also the possibility of mass dissemination (Webster-Stratton, 2001). Another advantage is the support and kinship available from other participants, which could lead to increased parental engagement with the intervention and the children’s early education programs (McIntyre & Phaneuf, 2007).

The majority of group-based parent education programs for parents of children with autism have been adapted from research-based programs for parents of children with behavioral difficulties or other developmental disabilities. They have focused on teaching parents to acquire behavior management skills.

For example, Webster-Stratton’s Incredible Years (Webster-Stratton, 2001) is a video-based parent intervention for parents of children ages 0–13 years. They offer four separate age range programs that includes age-appropriate video examples (i.e. infant (0–1 years), toddler (1–3 years), preschool (3–6 years), and school age (6–13 years)). The program procedures consist of a lead therapist showing video vignettes of modeled parenting skills to groups of 8–12 parents. The videos demonstrate social learning and child development principles and serve as the stimulus for focused discussions, problem solving, and collaborative learning. Depending on child age, 8–20 weekly sessions of 2-h in length are held. The efficacy has been demonstrated in numerous published randomized control group trials (RCT) by the program developer et al. (Reid, Webster-Stratton, & Hammond, 2007; Webster-Stratton, 1984; Webster-Stratton & Hammond, 1997; Webster-Stratton, Hollinsworth, & Kolpacoff, 1989; Webster-Stratton, Kolpacoff, & Hollinsworth, 1988; Webster-Stratton, Reid, & Hammond, 2004). In all of these studies, the program has been shown to improve parental attitudes and parent-child interactions. It also reduces harsh discipline and child conduct problems compared with both wait-list control groups. A treatment component analysis indicated that the combination of group discussion, trained therapist, and video modeling produced the most lasting results compared with treatment that involved only one training component (Webster-Stratton et al., 1988, 1989).

Sanders’s Triple P-Positive Parenting Program (Sanders, 1999) is a multilevel, preventively oriented parenting and family support strategy that aims to prevent severe behavioral, emotional, and developmental problems in children by enhancing the knowledge, skills, and confidence of parents. There are five levels of intervention on a tiered continuum of increasing strength for parents of children from birth to age 16 (Sanders, Cann, & Markie-Dadds, 2003). Level 1 provides universal parent information about parenting through print and electronic media, as well as user friendly parenting tip sheets and videotapes which demonstrate specific parenting strategies. Level 2 is one- to two-sessions and provides early anticipatory developmental guidance to parents of children with mild behavior difficulties. Level 3 is four-sessions and includes active skills training for parents with children who have mild to moderate behavior difficulties. Level 4 is up to 12, 1-h intensive sessions that are delivered individually or in a group-based parent training format for children with more severe behavioral difficulties. Level 5 is up to 11, 60–90 min sessions for enhanced behavioral family intervention program for families where parenting difficulties are complicated by other sources of family distress (e.g. marital conflict, parental depression, or high levels of stress). The multilevel strategy was designed to maximize efficiency, contain costs, avoid waste and over-servicing, and to ensure the program has wide reach in the community (Sanders, 1999). In a meta-analysis and review of articles (Thomas & Zimmer-Gembeck, 2007), it was found that participation in Triple-P improved parenting (i.e. improving parental warmth, decreasing parental hostility, increasing parental self-efficacy, and reducing parental stress) and reduce negative child behaviors (i.e. aggression and extreme tantrums and opposition) .

Individualized Parent Education and Coaching

The most common package used to train parents in a one to one fashion is behavioral parent training (BPT ; Serketich & Dumas, 1996; Van Camp et al., 2008). BPT is based on the empirical and applied concepts of behavior modification and the principles of social learning theory (Maughan, Christiansen, Jenson, Olympia, & Clark, 2005). BPT is one of the most successful and well-researched approaches used in the treatment and prevention of child problem behavior with a large body of empirical support for its clinical utility (see Shaffer, Kotchick, Dorsey, & Forehand, 2004). BPT is often designed and implemented by someone considered an expert in parent training in a clinic or home setting. The education is focused on training the parents how to define behavior problems accurately, implement assessment measures that further define the problem and its intensity, and teach parents in the treatment plan that would be appropriate for the problems within their individual context (Briesmeister & Schaefer, 1998). BPT typically involves describing behavioral procedures, modeling of the procedures, including parents in role plays, and providing corrective feedback while the parent practices targeted intervention strategies with their child. One advantage of BPT is training parents who have more frequent influence on the child in their natural environment to manage the challenging behaviors will increase the likelihood that behavior change will occur, generalize, and maintain treatment gains (Maughan et al., 2005). Another advantage is addressing the parent’s ability to deal with the challenging behaviors displayed by a child will decrease parental stress and increase parental confidence in the ability to manage the child (Baker-Ericzèn, Brookman-Frazee, & Stahmer, 2005). Due to the shortage of mental health professionals, there may not be enough qualified therapists to treat all children individually; therefore, training parents also provides greater economy and cost-effectiveness (Maughan et al., 2005).

There is a vast and growing literature related to behavioral parent training for parents of children with ASD (Brookman-Frazee et al., 2006; Kaminski et al., 2008; Matson, Mahan, & LoVullo, 2009; Matson, Mahan, & Matson, 2009). The majority of studies have focused on (a) challenging behavior, (b) social communication (i.e. picture exchange communication system (PECS) , (c) pivotal response training (PRT), (d) functional assessment, and (e) early intervention (i.e. Early Intensive Behavioral Intervention (EIBI); Early Start Denver Model (ESDM) ).

For example, Butter (2007) used a manualized parent training program to reduce noncompliant behavior and enhance adaptive behavior in children with ASD. During the 24-week study, parents were seen weekly for 75–90-min training visits until week 14 and then for a home visit (week 17) and booster sessions (weeks 18, 20, and 22). An initial home visit was also conducted between week 2 and 3’s session. The program targeted irritability, tantrums, aggression and self-injury. The package included 11 required sessions covering topics such as prevention strategies, schedules, reinforcement, planned ignoring, compliance training, functional communication training, teaching techniques (task analysis, chaining, and prompting), and generalization. Additionally, there were up to four optional sessions including time-out, contingency contracting, imitation training, and crisis management that could be implemented at the clinician’s discretion. Parent training sessions included a structured curriculum and clinician script, video vignettes depicting various skills to be taught to the parents, worksheets, and parent handouts. Children were required to participate in portions of up to eight sessions, which allowed for direct observation of parent-child interactions demonstrating the interventions introduced in sessions. Parents had high attendance to sessions, satisfaction with the program, and adherence to assignments. The program was implemented with high treatment integrity. Parent-reported rates of noncompliance were reduced by 39 %, irritability was reduced by 34 %, and daily living skills were enhanced by 19 %.

In a study about training parents to increase communication, Park, Alber-Morgan, and Cannella-Malone (2011) trained mothers to teach their child with ASD independent communication with PECS. A formal preference assessment was conducted at the beginning of this study to identify potential reinforcers for each child. A training session was implemented with each parent at their home without the child prior to baseline and each phase of PECS training. Each session lasted for 40–60 min. For Phases 1 and 2, the mother was trained to serve as the communication partner and was trained to initiate each trial by presenting preferred items and pictures, provide the appropriate consequence (e.g. allowing access to the item, naming the item, praising, conducting error correction procedures), and then ending the trial. The first experimenter provided the mother with written guidelines for each phase, explained the details of how to conduct each step in each phase, modeled the procedures, and showed a video clip in which adult models conducted the procedures. The mother was asked to practice the procedures until she reached at least 90 % accuracy across three consecutive trials. During the practice sessions, the experimenter took the child’s role, observed the mother, and provided feedback when necessary. During PECS training, the mother taught her child Phases 1 through 3B as described in the PECS manual (Frost & Bondy, 2002). Specifically, the child was taught how to exchange a picture (Phase 1), spontaneously exchange a picture for requesting despite the increased distance from both the communication partner and the book (Phase 2), and discriminate a correct picture and exchange it when a preferred and a nonpreferred item or activity were presented (Phase 3A) and when two preferred items or activities were presented (Phase 3B). During sessions where the mother was training her child, the experimenter provided a prompt or feedback on the mother’s implementation of the training procedures. The parents implemented the procedures with high fidelity and all three children successfully acquired independent picture exchanges that were generalized to a different communication partner and maintained for at least 1 month. Vocalizations across participants showed limited or no improvement.

Parent training in PRT has also shown to enhance the communication skills of children with autism. For example, Coolican et al. (2010) evaluated the effects of a brief parent training in PRT for parents of preschool children with ASD. Parents received three separate 2-h training sessions over 2 consecutive weeks. Prior to the first session, parents were provided with ‘How to teach pivotal behaviors to children with autism: A training manual’ (Koegel et al., 1989). The first two parent training sessions were conducted in a clinical lab setting and the third session was conducted in the family home. Parents were introduced to basic PRT principles, and the trainer modeled the techniques with the child during the initial session. The second and third sessions consisted mainly of in-vivo feedback for the parents while implementing the PRT techniques with their child, as well as problem solving issues that arise since the previous session. PRT was taught in the context of play with the child. Overall, children’s communication skill s, namely functional utterances, increased following training. Parents’ fidelity in implementing PRT techniques also improved after training, and generally these changes were maintained at follow-up.

Stokes and Luiselli (2008) examined the effects of a consultant teaching two sets of parents to conduct a functional analysis (FA) under simulated condition with a graduate student in their homes using verbal, written, and video performance feedback. Each simulated session lasted 5 min and consisted of the social disapproval, demand, or play condition. During sessions, one parent from each family interacted with the student. There were three sessions per day (17 total sessions), implemented in random order, and scheduled over a 1-week period. The participants first received verbal and written feedback for each step in the form of praise or correction immediately following each FA session. The trainer met with each participant for 3–5 min. The trainer used a flow chart to discuss each step comprising the FA condition that had been implemented. Video feedback was added next. The participants viewed a videotape that had been made of them conducting each of the three FA conditions. The trainer watched the videotape with each participant, using verbal feedback (praise and correction) as each step of the FA condition was reviewed. The parents FA skills improved when family members received verbal and written feedback, and their performance was enhanced further after observing themselves on videotape. The parents were able to learn quickly how to implement a functional analysis and generalize implementation with their child in the home environment.

In another study, Rogers et al. (2012) examined the efficacy of a 12-week, low intensity, parent-delivered intervention for toddlers at risk for ASD. Parent-delivered Early Start Denver Model (P-ESDM ) consists of 12 consecutive sessions that each last 1-h in length. The intervention sessions were conducted in a clinic setting. In session one, the children’s learning objectives were developed. Session 2–10 parents were introduced the new topic each week through verbal description and written materials from the manual and briefly modeled the interaction skill with the child in play. Parents were coached in each of ten intervention techniques: increasing child’s attention and motivation; using sensory social routines; promoting dyadic engagement and joint activity routines; enhancing nonverbal communication; building imitation skills; facilitating joint attention; promoting speech development; using antecedent–behavior–consequence relationships (“ABCs of learning”); using prompting, shaping, and fading techniques; and conducting functional assessment of behavior to develop new interventions. Sessions 11 and 12 focused on mainten ance after treatment and review of progress. Both groups of parents improved interaction skills, and both groups of children demonstrated progress.

Joint attention is another area of focus for children with ASD. Kasari, Gulsrud, Paparella, Hellemann, and Berry (2015) compared the effects of two parent-mediated interventions on joint attention. Parent-child dyads received 10 weeks of hands-on parent training in a naturalistic, developmental behavioral intervention (joint attention, symbolic play, engagement and regulation (JASPER)) or a parent-only psychoeducational intervention (PEI) . PEI provided one-on-one interventionist meetings with the parents in informational sessions of 1-h per week for 10 weeks. Sessions covered content of the manualized intervention which included information on autism, details of specific behavioral impairments, principles of managing behavior, strategies for teaching new skills, improving social interaction and communication, service availability, managing parental stress, and sibling, family, and community responses to autism. JASPER is a manualized treatment for toddlers and preschoolers with a primary focus on sustaining periods of joint engagement and increasing joint attention gestures and play skills. Intervention sessions were based on developmental and behavioral principles consistent with JASPER. Parents were first taught to recognize the child’s current developmental level of play and use of social-communication gestures. Parents provided opportunities for the child to initiate interest in a toy/activity and to establish jointly engaged play routines. Parents used a number of strategies to keep children engaged while also improving their frequency of social communication gestures, spoken words, and play acts. PEI intervention was effective in reducing parenting stress associated with child characteristics. All secondary effects were generally small to moderate. JASPER intervention had significant effects on the primary outcome of joint engagement. The treatment effect was large and maintained over the 6-month follow-up. JASPER also had significant effects on the secondary outcom es of play diversity, highest play level achieved, and generalization to the child’s classroom for child-initiated joint engagement.

Internet-Based Parent Training

There is a reported shortage of healthcare, educational, and medical services for children diagnosed with an ASD and their families (World Health Organization [WHO], 2007). This is especially true for families who live in rural areas due to a lack of specialized training and professionals, the distance to and transportation of services, and the increased expense of providing services (Graeff-Martins et al., 2008). This situation has created a significant gap between the intensive service requirements for children with a disability and s ervice providers’ availability (Baharav & Reiser, 2010). Telepractice (also called ‘telehealth’ and ‘telemedicine’)—“the application of telecommunications technology to deliver professional services at a distance by linking clinician to client, or clinician to clinician for assessment, intervention, and/or consultation” (American Speech-Language Hearing Association [ASHA], 2005) has shown to be a cost-effective service-delivery model in bridging this gap in service delivery (e.g. Barretto, Wacker, Harding, Lee, & Berg, 2006; Machalicek et al., 2010; Vismara, Young, Stahmer, Griffith, & Rogers, 2009).

For example, Vismara, Young, and Rogers (2012) piloted a 12, 1-h per week parent intervention program using telehealth delivery with nine families with ASD. The parents became skilled at using teachable moments to promote children’s spontaneous language and imitation skills. They were pleased with the support and ease of telehealth learning, so the pilot was followed-up with a randomized control trial contrasting the telehealth intervention to an online control group. The study reported on the first eight families who used a telehealth program consisting of two-way, live video conferencing and a self-guided website to conduct the 12-week parent training in the homes of families of young children with ASD. Parents’ intervention skills and engagement with the website, as well as children’s verbal language and joint attention skills were assessed and the preliminary results suggests that parents were able to implement the intervention strategies with fidelity and alter their engagement styles to be more attentive and responsive to their children after the hybrid telehealth programs. Furthermore, children in both studies demonstrated gains in important social communicative behaviors (e.g. language, imitative behaviors) as their parents participated in the telehealth programs.

In another study, Wacker et al. (2013a) examined behavior consultants’ use of telehealth consultation to coach parents to conduct functional analyses (FA) with 20 young children with ASD between the ages of 29 and 80 months who displayed problem behavior and lived an average of 222 miles from the tertiary hospital that housed the behavior consultants. The children’s parents conducted all procedures during weekly telehealth consultations in regional clinics located an average of 15 miles from the participants’ homes. Parent assistants were briefly trained by the behavior consultants and were on-site to provide support for families during consultations. The FA identified environmental variables that maintained problem behavior for 18 of the 20 cases, as a result, this suggest that behavior analysts can conduct FA effectively and efficiently via telehealth. Wacker et al. (2013b) followed-up with a study investigating behavior consultants’ coaching parents of 17 young children with ASD who displayed problem behavior via telehealth to conduct FAs with telehealth consultation and then conducted functional communication training (FCT) that was matched to the identified function of problem behavior. All procedures were conducted at regional clinics located an average of 15 miles from the families’ homes and the behavior consultants were located an average of 222 miles from the regional clinics. Parent assistants located at the regional clinics supported the families during the clinic visits. The FCT conducted by the parents reduced problem behavior by an average of 93.5 %. These results suggest that when experienced applied behavior analysts provide consultation, FCT can be conducted by parents via telehealth.

Suess et al. (2014) examined a retrospective, descriptive evaluation of the fidelity with which parents of three children with ASD conducted FCT in their homes. All training was provided to the parents via t elehealth by a behavior consultant. FCT trials coached by the behavior consultant were conducted during weekly 1-h visits. Parents made video recordings of treatment trials in which they conducted the procedures independent of coaching. Levels of fidelity were evaluated during both coached and independent trials and the results showed no consistent differentiation between the coached and the independent trials. All children showed substantial reductions in problem behavior during the final treatment trials and especially during the coached trials. These results suggest that behavior analysts can use telehealth to train parents to implement FCT with acceptable fidelity and achieve substantial reductions in children’s problem behavior .

Psychosocial Interventions to Decrease Parent Mental Health Symptoms

Parent training can potentially result in improved parental mental health outcomes through support and advice, but most programs are not designed to support parental mental health . There is some evidence to suggest that psychological interventions can remediate parental stress in parents of children with ASD (Hastings & Beck, 2004). Cognitive Behavioral Therapy (CBT) is one type of psychological intervention to decrease parent stress. CBT teaches parents coping skills and muscle relaxation techniques to handle stressful situations and cognitive strategies to modify dysfunctional thoughts. For example, Tonge et al. (2006) used a group-comparison design to examine the effectiveness of (a) a behavioral management intervention using early intervention and CBT for parents compared to (b) a parent education program on improving parental mental health. They found that both treatments contributed to improved mental health outcomes at follow-up, but the behavior management intervention (early intervention and CBT) was more effective in alleviating anxiety, insomnia, somatic symptoms and family dysfunction. A meta-analysis examining the effects of parenting and stress management interventions for parents of children with developmental disabilities in six studies (Singer, 2006), suggests that CBT has small, but consistent positive outcomes on parental stress.

Acceptance and Commitment Therapy (ACT ) is another type of psychological intervention that has been used with parents of children with ASD that appears particularly applicable to the experiences of this population, in which the challenges faced by raising a child with ASD are unlikely to change (Blackledge & Hayes, 2006). ACT is an alternative approach to traditional cognitive and emotional change strategies that focuses on challenging the content of difficult and invalidating thoughts and feelings (Blackledge & Hayes, 2006). ACT emphasizes acceptance of unpleasant moments, diffusion from difficult thoughts, clarification of the parent’s personally held values and corresponding goals, and enhancement of the parent’s effectiveness in moving toward those goals and values (Blackledge & Hayes, 2006). Blackledge and Hayes (2006) conducted a within-subject, repeated measures design to examine the effects of a 2-day (14 h) group ACT workshop for parents and guardians of children with ASD. Findings suggested that participation in the ACT workshop lead to improved parental mental health outcomes, including positive outcomes on Beck Depression Inventory-II (BDI-II) and the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI). Most of the gains achieved were retained at 3-month follow-up. It should be noted that this study had several limitations, including a small sample size and no comparison group. Although these findings are promising, more research is needed to evaluate the effectiveness of ACT on parent mental health outcomes.

Mindfulness-based interventions have also been used with parents of children with ASD. Mindful parenting involves applying the practices of paying attention in an intentional and non-judgmental way to the child (Kabat-Zinn & Kabat-Zinn, 1997). Mindfulness training teaches parents to modify maladaptive cognitive schemata, habits, and reinforcement patterns, while using a gentle, compassionate, and self-reflective parenting approach (Cachia, Anderson, & Moore, 2015). For example, Neece (2014) examined the effectiveness of a group-based Mindfulness-Based Stress Reduction Program on depressive symptoms and stress in parents of children with autism, using a randomized group design. Parents in the intervention group experienced a significant decrease in stress and a significant decrease in depressive symptoms. Cachia et al. (2015) systematic literature review on the efficacy of mindfulness-based interventions in reducing stress and increasing psychological well-being in children with ASD found that mindfulness-based interventions may have long-term positive effects on parental mental health outcomes, with positive effects maintaining or even increasing up to 3 months post-training. These findings corroborate previous evidence from the literature that mindfulness training reduces stress in parents of children with a range of disabilities (Cachia et al., 2015; Dabrowski & Pisula, 2010). In addition, mindful parenting also impacts child behavior, including decreased aggressive and maladaptive behavior and increased social behavior (Singh et al., 2007).

Training Parents Acros Autism Symptomology

Children with ASD present with delayed social communication skills and rigid and repetitive behaviors and interests (RRBIs) (American Psychiatric Association, 2013). Children also often present with comorbid diagnosis of ADHD, ODD, anxiety and mood disorders, as well as challenging behaviors such as aggression and self-injury, sleep disorders and feeding issues (Babbit et al., 1994; Machalicek et al., 2016; Richdale, 1999). This section will present research evaluating parent-implemented interventions to address social communication deficits, RRBIs, challenging behavior, pre-academic skills, and functional life skills. Parent involvement in intervention research addressing sleep disorders, feeding issues and comorbid mental health diagnoses is not covered in this chapter (interested readers see Binnendyk & Lucyshyn, 2009; Malow et al., 2014; Machalicek et al., in press; Weiskop, Richdale, & Matthews, 2005). Comprehensive EIBI models of EI (Leaf, Taubman, McEachin, Leaf, & Tsuji, 2011), such as the UCLA Young Autism Project (Lovaas et al., 1981), address multiple symptoms of ASD at once, but utilize focused, individualized interventions to address specific areas of need. Learning sessions are provided in a one-to-one discrete trial (DTT) format , focusing on the systematic teaching of measurable behavioral units, repetitive practice, and structured presentation of tasks from the simplest to the more complex. Table 8.2 cross references a select number of studies evaluating parent implemented focused intervention for young children with ASD against the categories of EIBI, Social communication, restricted and repetitive patterns of behaviors and interests (RRBIs), challenging behavior, functional life, and pre-academic skills. Within this section, we summarize the goals, procedures, and outcomes of two illustrative single-case research studies evaluating the effects of parent-implemented intervention on social communication, RRBIs, challenging behavior, functional life skills, and pre-academic skills.

Table 8.2 Targeted child outcomes in parent implemented early intervention for young children with autism spectrum disorder
Full size table

Social Communication

Social communication is a core deficit in ASD (Williams White, Koenig, & Scahill, 2007). Examples of important social communication skills targeted in EI for children with ASD include joint attention, functional communication including mands (requests) and tacts (labeling), and social pragmatic skills like entering and sustaining play (Williams White et al., 2007). Parents are often a child’s earliest communication partners; for that reason, parent-mediated interventions on pivotal social skills, language, and early play skills for children with ASD is a rich area of research.

Social communication skills are of particular importance to parents because of their role in facilitating every day routines, as well as in allowing for sharing positive experiences with their child. Early social skills, such as joint attention, may be pivotal to later successful social communication. Parent-mediated interventions on social communication have covered a range of skills and include parent training on the use of teaching strategies such as DTT and visual supports (Crockett et al., 2007). In one such study, Rocha et al. (2007), taught parents to intervene on joint attention skills in a single-case concurrent multiple baseline design across participants. Joint attention is a dynamic shift in attention between someone who points out an object or event and the object. In this study, parents used strategies including DTT and elements of PRT to teach three preschool age children to respond to parent joint attention bids. Parents were taught to train children to respond to increasing levels of difficulty of joint attention bid using most to least prompting. For example, parents began by putting their hand on the object, and faded prompts until the child could respond to a gaze shift from parent towards an object. Data indicated parents were able to learn to teach these joint attention skills with fidelity across participants. Additionally, child data indicated that responses to parent bids for joint attention increased for all three children as a result of participation in this intervention.

Kaiser and Roberts (2013) investigated the benefits of adding parent training to interventionist-led Enhanced Milieu Training (EMT) to increase child language use and functional play skills in a randomized control trial. 77 participants were randomly selected to either the EMT condition or the EMT plus parent training condition. Children in the EMT condition received interventionist led EMT and children in the EMT plus parent training condition received the same amount of EMT delivered by a therapist as well as simultaneous EMT delivery by a parent. Results indicated while both groups showed improvement in targeted language, there was significantly greater improvement in those children whose parents were also trained to implement the strategies.

Restricted and Repetitive Behaviors and Interests (RRBIs)

In addition to social communication deficits, children with ASD experience behavioral excesses, which include the presence of restricted and repetitive patterns of behavior and interests (RRBI ) (American Psychiatric Association, 2013). RRBIs are a core feature of ASD and encompass a variety of behaviors such as repetitive motor movements, speech, or use of objects (e.g. motor stereotypies, lining up objects, echolalia, idiosyncratic speech), often referred to as stereotypy . RRBIs also include a need for insistence on sameness, fixed adherence to routines, or ritualized patterns of verbal or nonverbal behavior, which often entail significant distress during minor activity changes or transitions. RRBIs also involve highly restricted, fixated interests of abnormal focus or intensity such as preoccupation with peculiar objects or remarkably circumscribed or perseverative interests. Finally, hyper- or hypo-sensory related reactions or unusual interactions to sensory aspects of the environment (e.g. indifference to pain, extreme responses to particular sounds, textures, or smells, visual attraction to lights or movement) are also observed in children with ASD (American Psychiatric Association, 2013, Machalicek et al., in press). RRBIs are often divided into two categories: (a) lower order , which consist of stereotypies including repetitive motor movement, object manipulation, and repetitive self-injurious behavior; and (b) higher order , which include insistence on sameness, repetitive language, perseverative interests, and rigidity (Boyd, McDonough, & Bodfish, 2012; Machalicek et al., in press, Patterson, Smith, & Jelen, 2010).

RRBIs can be observed in young children with ASD (Kim & Lord, 2010); however, there remains a lack of consensus in the literature regarding the use of RRBIs during the diagnostic process for an ASD (Stronach & Weatherby, 2014). One of the reasons for this could be that typically developing young children engage in repetitive behaviors especially between the ages of 2 and 4 years old (Evans et al., 1997; Richler, Biship, Kleinke, & Lord, 2007). For example, it is common for an infant to bang toys and objects repetitively or body rock (Arnott et al., 2010) and for a toddler to request the same book be read over and over again, insist on a familiar bedtime routine or certain clothing, or carry around a special object of high interest. These aforementioned examples are a part of normal infant and toddler development, which may be a reason RRBIs have received less attention in the literature (Arnott et al., 2010). However, research has shown that repetitive patterns of behavior are highly elevated in children who later go on to receive ASD diagnoses (Wolff et al., 2014). Repetitive behaviors have been shown to be strongly correlated with comorbid conditions such as mood and behavior problems in children with ASD and are also associated with increased parent stress levels (Boyd, McDonough, & Bodfish, 2011). Thus, there is a need to train parents to address this core symptom of ASD.

When compared to the abundant collection of available focused and comprehensive interventions to address social communication skills (e.g. joint attention, language), evidence-based practices aimed at RRBIs currently represent a scant piece of literature (Boyd et al., 2011). An even smaller part of that is devoted to parent-implemented interventions. Boyd et al. (2011) trained parents of five preschool aged children with ASD to implement the Family Implemented Treatment for Behavioral Inflexibility (FITBI). The FITBI involved training parents to implement response interruption and redirection (RIRD; Martinez & Betz, 2013) for lower order repetitive behavior (e.g. spinning objects, lining up objects) and/or differential reinforcement of variability (DRV) for higher order RRBIs (e.g. repeatedly watching the same movie, perseveration with cars). Parents were trained to address two RRBIs with their child. RIRD is a common intervention used with individuals with developmental disabilities to decrease stereotypy and other challenging behavior (Boyd et al., 2011) that entails physically or verbally blocking or interrupting a targeted inappropriate behavior and redirecting (sometimes with prompts) the child to engage in a different, or alternative, behavior. Boyd et al. (2011) taught a parent to use RIRD to decrease a child’s “object attachment” with sticks by redirecting the child to hold other objects in his hand. DRV is a strategy that is primarily used with higher order RRBIs that are non-functional (e.g. perseveration with certain toys), and it involves using behavioral shaping to gradually increase the variety of a child’s behavior by using reinforcement (Boyd et al., 2011). In this study, Boyd et al. (2011) trained a parent to decrease a child’s perseveration with cars by teaching the child new play routines with the car, therefore, increasing the child’s varied behavior while engaged with the toy cars. The method of training the parents involved 12 weekly clinic-based sessions (60–120 min) with parent education and training, which included teaching trials wherein the triggering stimuli (i.e. item that evoked the RRBI) was present in the clinic room and the child was prompted to refrain from engaging in the RRBI with RIRD or to appropriately engage with the item using DRV . The FITBI initially used repeated practice in discrete trial training format and then transitioned to embedded trials into play-based activities. Supplemental individualized behavior management plans were developed if needed. A single-case concurrent multiple baseline across behaviors (two for each child) design was employed to evaluate the effects of FITBI, and the authors reported substantial reductions in RRBIs for all five participants (Boyd et al., 2011).

Perhaps much of the literature surrounding RRBIs is covered within challenging behavior and self-injury studies, specifically behavior maintained by non-social consequences , as RRBIs are often hypothesized to be self-stimulatory, or that the reinforcement for the behavior is not mediated by another person. Many procedures have been shown to be effective in reducing such behaviors such as differential reinforcement (e.g. Azrin, Besalel, Jammer, & Caputa, 1988), environmental enrichment strategies (e.g. Piazza, Adelinis, Hanley, Goh, & Delai, 2000), visual and verbal cues (e.g. Horner, Carr, Strain, Todd, & Reed, 2002). What seems to be missing from the current literature is the inclusion of these procedures within comprehensive treatment models for young children with ASD [e.g. Early Intensive Behavioral Intervention (EIBI), Early Start Denver Model (ESDM)]. A randomized control trial of 48 infants (Dawson et al., 2010) found significant improvements in adaptive behavior and IQ for the ESDM group; however, this intervention did not yield specific change in RRBIs as measured by the Repetitive Behavior Scale (Bodfish, Symons, Parker, & Lewis, 1999) (Leekam, Prior, & Uljarevic, 2011). Sallows and Graupner (2005) compared two applied behavior analysis (ABA ) programs , one was clinic-based EIBI, and the other group was parent-implemented ABA. The parent-implemented ABA group performed as well as the clinic-based group including significant improvements on RRBIs as measured by the Autism Diagnostic Inventory—Revised (ADI-R; Lord, Rutter, & Le Couteur, 1994) for children described as “rapid learners” (Leekam et al., 2011). More research is needed investigating educating and coaching parents to address RRBIs in young children with or at risk for ASD using focused interventions and embedding them into existing, effective comprehensive treatment models.

Challenging Behaviors

Challenging behaviors such as tantrums, self-injury, and aggression are common among children with ASD (Durand, Hieneman, Clarke, Wang, & Rinaldi, 2013; Einfeld & Tonge, 1996; Emerson et al., 2001; Hemmeter, Ostrosky, & Fox, 2006) and often develop as a result of environmental issues, lack of reinforcement for desirable behaviors, and communication impairment for both the child and parent (Harrower, Fox, Dunlap, & Kincaid, 2000). Such challenging behaviors can cause direct harm to themselves or other people, and interfere with efforts to help these individuals live more independently by disrupting educational and vocational efforts as well as home life (Emerson, 1995; Fox, Vaughn, Wyatte, & Dunlap, 2002).

Additionally, managing challenging behavior, the most commonly reported parenting difficulty (Bromley, Hare, Davison, & Emerson, 2004), is a significant source of parental stress and impacts the quality of life of children with ASD and their families. Whether identified and described as behavioral deficits (e.g. a lack of socially appropriate communication skills) or behavioral excesses (e.g. repetitive and disruptive behaviors), persistent behavioral challenges, presented by a child with developmental delays can negatively impact the family unit (Baker et al., 2003). It is important to equip parents with the necessary tools to create a desirable family environment (Meadan et al., 2009). For example, Dunlap et al. (2006) taught two mothers to use functional communication training (FCT) during home routines to address serious challenging behaviors of their toddlers. The study procedures included (a) selecting home routines deemed especially problematic by the children’s mothers, (b) conducting a functional behavior assessment, (c) training the mothers to use FCT, and (d) having the mothers implement the procedures in the home in accordance with a single-case concurrent multiple baseline across routines design. The FCT training was 1-h in length and conducted in the home. The individualized instruction consisted of (a) an explanation regarding the reasons for replacing the challenging behaviors with more appropriate replacement behaviors; (b) a review of the functional assessment information including the child’s target behaviors, replacement communication behaviors, and selected reinforcers; (c) modeling by the researchers on how to prompt the child to use the replacement behavior to prevent the challenging behavior from occurring; (d) reminders that developing replacement behaviors also involves withholding reinforcers for challenging behavior; and (e) an opportunity for the mothers to ask questions regarding implementation of the FCT procedures. The mothers were also given a written script specific to their child as a guide and reference for how to implement the specific FCT procedures, which could be used as a prompt and referred to before intervention sessions. The results showed that the mothers were able to use the procedures correctly and interventions produced reductions in the children’s challenging behaviors and increases in their use of communicative replacement skills.

In another example, Sears et al. (2013) examined the use of the family-centered prevent-teach-reinforce (PTR) model with families of children with ASD to decrease challenging behavior. The PTR model includes five steps aligned with the problem-solving process. It is a collaborative team driven process facilitated by a consultant who has expertise in behavioral principles and guides the team through five steps: Step 1: teaming (i.e. establishes membership and an agreement on how the team will function); Step 2: goal setting (i.e. focuses on identifying and defining the social, behavioral, and academic targets); Step 3: PTR assessment (i.e. functional assessment includes direct and indirect observations covering three categories relating to antecedent variables (Prevent), function and replacement variables (Teach), and consequence variables (Reinforce)); Step 4: intervention (i.e. team selects interventions and develops a plan for training and coaching adults to implement the strategies as intended); and Step 5: evaluation (i.e. uses targeted behavior change data to make decisions about the plan’s effectiveness and next steps) (see Dunlap et al., 2010 for the model’s manual). The initial team meeting was 2-h in length and covered Step 1 and 2. The second meeting was held after baseline to conduct the functional behavior assessment (Step 3) and develop the behavior intervention plan (Step 4) which was 3-h in leng th for each routine. The parents were then provided with a task analysis of each strategy and 30-min of training on the implementation steps using verbal and written instructions, modeling, rehearsal, and feedback. Results indicated that the parents were able to implement the behavior intervention plan with fidelity and successfully use the PTR process for a novel routine. The PTR intervention was associated with reduction in child challenging behavior and increases in alternative behavior in both target and non-target routines.

Pre-Academic Skills

Parents of children with ASD are increasingly encouraged to become active participants in their children’s early education by applying behavioral intervention at home, often using Discrete Trial Teaching (DTT) (Crockett et al., 2007; Eikeseth, 2011; Sturmey & Fitzer, 2007). For example, Lafasakis and Sturmey (2007) taught three parents using behavioral skills training to implement DTT with their children with developmental disabilities. Behavioral skills training included giving the parent a typed list of definitions of the ten components of DTT, modeling three DTT trials with the child, and then having the parent perform the same three DTT trails with their child. Immediate performance feedback (i.e. positive comments on components performed correctly and corrective feedback on components that needed practice) was provided by the coach to the parent following the performance. Three additional discrete trials were modeled by the coach that included the specific components that were previously implemented incorrectly. The rehearsal and modeling procedure was repeated until 10 min elapsed. All three parents learned to implement DTT, parents were observed to use DTT with novel programs and children’s correct responding increased.

In another study, Crockett et al. (2007) examined the effects of an intensive parent training program on the acquisition and generalization of DTT procedures with two parents of children with ASD. Each parent was individually trained and attended between 6 and 9, 2-h weekly training sessions. Parent training included a didactic lecture (i.e. definitions and examples of antecedents, consequences, intertrial intervals, and data collection), video demonstrations, role-play, and practice with feedback. Parents taught their children four different functional skills using DTT to assess generalization across stimulus exemplars. Both parents were able to acquire DTT for teaching their children with autism. Both parents improved their teaching across child skills before receiving training on all child skills, which supports generalization and the extent to which each parent extended their use of DTT procedures across untrained and topographically different child skills.

Functional Life Skills

Parents of children with ASD are often concerned about their ability to live safe, productive and independent lives (Shipley-Benamou et al., 2002), which makes teaching functional life skills an important target for intervention. The child’s ability to perform functional life skills without assistance eases the burden placed on the parents, due to the time and energy needed to perform these tasks (Batu, 2014; Shipley-Benamou et al., 2002). Functional life skills include behaviors that allow the child to live more independently, such as preparing simple meals, performing household chores, and getting dressed. Several teaching strategies have been used to teach functional life skills, including backward and forward chaining procedures (Cooper, Heron, & Heward, 2007), task analysis (Test, Spooner, Keul, & Grossi, 1990), simultaneous prompting (Fetko, Schuster, Harley, & Collins, 1999), least-to-most and most-to-least prompting (Taber, Alberto, Seltzer, & Hughes, 2003), and in-vivo and video modeling (Ayres, Maguire, & McClimon, 2009; Goodson, Sigafoos, O’Reilly, Cannella, & Lancioni, 2007; Shipley-Benamou et al., 2002). In one study, Shipley-Benamou et al. (2002) used instructional video modeling to teach functional life skills to three children with autism (ages 5–6 years). They used a single-case research multiple-probe design across five different tasks (i.e. making orange juice, preparing a letter to mail, putting a letter in the mailbox, feeding a pet, cleaning a fishbowl, and setting a table) to examine the efficacy of the video modeling strategies. Their findings suggest that video modeling was effective in promoting acquisition of functional life skills for all three participants. Results were maintained during a no-video phase and at 3-month follow-up.

In another study, Batu (2014) examined the effectiveness of teaching parents to use simultaneous prompting through visual supports to increase functional life skills (i.e. eating pudding and hand washing) in preschool-aged children with developmental delay. A single-case research multiple-probe design across three participants was used to determine the efficacy of the intervention. Results of the study suggest that mothers were able to learn the procedure and children were able to acquire skills, which maintained at 2-week follow-up and generalized to new skills. The authors suggest that both parent and child were able to generalize the acquired skills .

Discussion and Future Research

Parent training has emerged over the past 40 years as an important target for interventions regarding children with developmental disabilities (Kaminski et al., 2008; Maughan et al., 2005). Parents are recognized as the best intervention agents because of the amount of time they spend with their child as well as the variety of settings they have the chance to teach skills in (Sears, 2010). Research also indicates that parent training is time- and cost-effective and leads to better generalization and maintenance than therapist-implemented intervention models (Brookman-Frazee, Vismara, Drahota et al., 2009). BPT literature also suggests that parents typically find training acceptability, especially when compared to pharmacological intervention (e.g. Waschbusch, Cunningham, Pelham et al., 2011). However, there are several gaps in the literature that suggest several future research directions. Parent training in the ASD literature has not reached the level of treatment packages seen for typically developing children with compliance problems (Matson, Mahan & LoVullo, 2009; Matson, Mahan & Matson, 2009). Future research is needed to determine the best treatment package for ASD symptom severity, but also to identify essential intervention components, and to determine comparative effectiveness between intervention approaches. Parent education programs often use multiple intervention strategies (e.g. didactic instruction including lecture with video modeling and role play followed by practice with child with immediate performance feedback in natural setting) making difficult the extent to which we can identify the active ingredients of the intervention. Certainly the amount and type of parent education and coaching will vary across targeted skills and parent-child dyads, but the current literature base does not inform this type of clinical decision making. Identifying the essential components of a packaged parent education intervention given the target parent and child skills and parent-child demographic variables (e.g. age of child, severity of ASD symptoms, educational background of parent) could yield several benefits including decreasing response effort and time commitment for the parent and clinician, improving treatment fidelity and the amount of time it takes to reach a criterion level of performance supporting behavioral change, and maximizing clinical time so that more families can be served in a shorter amount of time or more intensive parent education and coaching can be delivered to those families whose situations warrant it. Research informing the individualization and intensity of parent education programs would also further theoretical models of tiered intervention for families (see Stepping Stones Triple P-Positive Parenting Program; Tellegen & Sanders, 2013; McIntyre & Phaneuf, 2007). Several research teams have suggested the need to conduct multi-component analysis of parent education interventions to determine which intervention components, training formats (group versus one to one), and dosage yield the most effect on parent and child outcomes (Lang et al., 2009; Patterson et al., 2012; Roberts & Kaiser, 2011; Strauss et al., 2013). Single-case research designs offer an efficient and flexible way to conduct multi-component analyses (Lerman, Swiezy, Perkins-Parks, & Roane, 2000; Moore & Fisher, 2007; Ward-Horner & Sturmey, 2010). Future research should conduct multi-component analyses of parent education programs with the goal of better understanding the active ingredients of parent education programs, dosage related issues, and how interventions are best adapted for individual parent-child dyads or populations.

Relatedly, parent education and training studies are complicated in their “study within a study” design (Meadan et al., 2009). That is, the logic model of any parent-implemented intervention involves cascading logic where (a) a parent education program is implemented to effect change on parent behavior, and (b) the trained parent subsequently implements intervention with his/her child. However, the majority of parent-implemented intervention studies do not take baseline data on parent use of targeted strategies. Therefore, it is impossible to say a functional relation exists between the parent education training and change in parent behavior. We acknowledge two possible reasons for this oversight: (a) the worry that providing parents with any training prior to baseline will not constitute baseline performance, and (b) the difficult inherent in obtaining a baseline of parent behavior when the intervention is based on child assessment (e.g. parent implemented function based intervention for challenging behavior). In our own work, we have been successful in obtaining stable baseline data on parent performance by conducting assessment before the start of the study and providing parents with limited instruction (e.g. reading or lecture and task analysis of behavior intervention plan) prior to baseline. This also allows us to evaluate whether a functional relation exists between a single component of parent education and intervention (e.g. performance feedback) and change in parent behavior. Future research on parent-implemented interventions should include baseline measures of parent use of targeted strategies wherever possible.

In addition, although cultural and socioeconomic variables are widely acknowledged to be important when designing parent education programs (e.g. Mueller, Singer, & Grace, 2004), we currently lack sufficient evidence of effectiveness and social validity for use of parent education and training programs supporting parents’ implementation of EI for ASD for diverse populations (Lang et al., 2009; Magaña, Lopez, & Machalicek, in press; Patterson et al., 2012; Roberts & Kaiser, 2011; Strauss et al., 2013). Moreover, there is a current focus on the involvement of mothers and middle-class families (and parents who have agreed to participate in study) (Meadan et al., 2009). For those families facing the double disadvantage of a child with a developmental disability and stressful life situations (e.g. incarceration of family members, teen parents, parents with IDD, poverty), evidence-based parent education and training programs will likely require some degree of adaptation. Two obvious barriers to conducting research with diverse populations is recruiting and maintaining such families in research studies and the absence of available templates for culturally adapting EIBI and focused interventions. Researchers may find helpful literature in other fields on cultural adaptation of interventions (Davidson et al., 2013) and the recruitment and retention of diverse families (UyBico, Pavel, & Gross, 2007). Despite the barriers to conducting research with diverse populations, to assure the effectiveness and ecological validity of currently available parent education and training programs for all types of families, future research must be conducted with fathers and other family members from diverse cultural, linguistic, socio economic backgrounds.

Finally, there is a relative lack of research evaluating the bidirectional relationship between parent and child outcomes . Understandably, research on parent-implemented EI/EIBI is primarily concerned with measuring the impact of the intervention on child outcomes. However, parental well-being has been correlated with a range of child outcomes in cognitive, behavioral, and psychological development (Brand & Brennan, 2009). Parent and child variables may have a mutually escalating effect on each other (Baker et al., 2003; Neece, Green, & Baker, 2012). For example, high levels of child challenging behavior exacerbate parental stress over time, while high levels of parental stress can lead to increased child challenging behavior. In addition, parental mental health outcomes may contribute to less positive outcomes of behavioral interventions (Osborne et al., 2008), including failure to engage with services, less effective parenting, less developmental progress, and higher incidences of behavioral problems (Brinker, Seifer, & Sameroff, 1994). Due to the strong link between parental and child outcomes, it is important that future research both directly target and measure parental outcomes in behavioral interventions with children with ASD (for a review and proposed intervention model see Karst & Van Hecke, 2012).

Suggestions for Practice

Based on the extant literature and concerns discussed in this chapter, the following suggestions for practice in EI for ASD are made:

  1. 1.

    Pre-service and in-service training programs for EI professionals working with families of children with ASD must ensure coverage of applied behavior analysis principles and evidence-based assessment and intervention, but should also cover family-systems theory and best practices in working with families of young children including capacity-building interventions, helpgiving interventions and family and professional collaboration. The Council for Exceptional Children Division for Early Childhood (2014) offers a free download of DEC Recommended Prac tices in Early Intervention/Early Childhood Special Education that includes coverage of family-centered practices at (see www.dec-sped.org/recommendedpractices).

  2. 2.

    EI professionals should gain competency in using BPT with diverse parents and children through direct instruction and supervision by professionals competent in BPT with high needs populations.

  3. 3.

    EIBI and focused intervention programs for children with ASD should develop programs that include parent participation as an interventionist, but do not entirely rely on parent-implemented intervention. We know that EIBI program are more effective than less intensive EIBI (Reichow & Wolery, 2009) and less intensive EIBI is more effective than eclectic treatment (Strauss et al., 2013), but findings are mixed if parent implemented EIBI programs are as effective as center-directed programs with some research suggesting effects are equal (Sallows & Graupner, 2005) and other research suggesting clinical programs have superior outcomes on intelligence, visual-spatial skills, language and academics when compared to parent-implemented programs (Smith, Groen, & Wynn, 2000).

  4. 4.

    Intensive parent training yields better outcomes and there is some evidence that children may benefit more from parent implemented when they have basic skill prerequisites (Strauss et al., 2013).

  5. 5.

    EI programs should guarantee that parent education and training offerings prioritize the core symptoms of ASD and related comorbidities, but also deliver trainings on commonly experienced difficulties in early childhood such as feeding and sleep issues, and toilet training.

  6. 6.

    For maximal positive parent and child outcomes , parent education and training programs require ongoing measures of treatment fidelity or integrity (i.e. the degree to which an intervention is implemented as intended (usually an observer is present; Gresham, Gansle, & Noell, 1993)) of both the implementation of the education and training program and parent implementation of the intervention.

  7. 7.

    Professionals should program for and assess the maintenance of parent training effects (i.e. parent continues to implement intervention in the absence of clinician) to improve the longevity of treatment effects on child skills/behavior. A statewide survey of parents of children with autism suggests that adherence to prescribed behavioral and medical interventions to be very low (approximately 24 % and 16 %, respectively; Moore & Symons, 2009). Parent education programs and the interventions we ask parents to implement with their children should be routines-based so that they fit into the daily context of life and we should routinely assess the contextual fit of interventions for families by asking parents to rate the social validity of goals, procedures, and expected/obtained outcomes at beginning, middle, and end of intervention (Meadan et al., 2009).

  8. 8.

    Professionals using telecommunication technology to increase parent access to education and training programs should develop protocols to ensure confidentiality, parental choice of delivery options, and effective training (Lee et al., 2015).

Conclusion

Encouraging findings in the parent-implemented EI literature include a wide range of parent and child skills and behaviors targeted by interventions and the effectiveness of parent-implemented interventions to address the social communication delays and challenging behavior common to young children with ASD. As the literature base grows, professionals can look forward to gaining clarity on the comparative effectiveness of different approaches and dosages of parent education and training programs for children with differing ASD severity.