Parent Training as an Evidence-Based Treatment for Children with Autism Spectrum Disorder

By Cynthia Johnson, PhD

Children with autism spectrum disorder often have co-occurring behavioral and emotional problems, such as tantrums, aggression, self-injury, hyperactivity, noncompliance, problematic feeding and sleep disturbances, which can add to parental stress and family burden. Recent studies test new applications and delivery methods, and reflect the feasibility and efficacy of parent training programs in changing specific problem behaviors.

Parents as behavioral change agents

Psychosocial interventions have been used in the treatment of autism spectrum disorder (ASD) for nearly two decades. Despite the development of several comprehensive programs, there was a dearth of randomized clinical trials (RCTs), with the first identified as recently as 2005. Subsequently, an NIH empanelled group identified the research needs in the field to include cost-effective, time limited, manualized treatments.1 Parent training is a fitting model of an intervention that that incorporates these parameters — and one that capitalizes on the central role parents play in the lives of young children. Parent training programs, which are frequently based on the principles of Applied Behavior Analysis, provides specific techniques for behavioral management in children with ASD.

Several parent training programs for co-occurring issues in ASD have since been developed and tested in RCTs. One study tested a behaviorally based parent training program specifically targeting the ubiquitous disruptive behaviors observed in 50%-60% of children with ASD as an adjunctive treatment to medication.2 Families receiving combined therapy (i.e., parent training plus risperidone for the child) saw greater decreases in challenging behaviors than those with children who received risperidone alone. A subsequent NIH-funded study evaluated this 11-session, individually delivered, structured program as a stand-alone intervention in a large, multi-site RCT. The parent training program was compared to a parent education program in which parents learned helpful information about ASD that did not include any behavioral strategies for disruptive behaviors. The parent training program was found to be superior to the parent education program in decreasing disruptive behaviors in 3- to 7-year-olds with ASD and improving self-help skills.3,4 At the time this study was completed in 2015, it was the largest psychosocial trial in ASD with a sample size of 180 participants. This intervention manual is now available and has been implemented in many clinical programs.5

Parent training program targets sleep disturbances

In another smaller, NIH-funded RCT, a parent training program specifically targeting sleep disturbances in young children with ASD was compared to a parent education program.6 The sleep parent training program consisted of five individual clinic sessions, which resulted in significantly reduced bedtime and sleep problems in contrast to children whose parents received parent education. Improvements in daytime behaviors were also observed. We are currently testing this parent training program for sleep in a larger RCT at Cleveland Clinic Children’s, delivered through Cleveland Clinic Express Care Online. The study, which is funded by the Department of Defense, plans to enroll 90 participants aged 2-7 over the next three years.

Parent training program for feeding issues

Given the success of these parent training programs, we developed a parent training program focusing only on mealtime and feeding problems. After conducting a small pilot, an initial multi-site RCT was conducted with funding from the NIH. This program involved 11 sessions delivered over 20 weeks. Participants who completed the parent training-feeding program reported significant reductions in mealtime and feeding problems compared to the wait-listed control group.7

Collectively, these training programs for parents of children with ASD demonstrate that parents can successfully learn and implement skills and strategies to mediate changes in their children’s behavior. Parent satisfaction ratings for all of these studies were high. Future studies will test additional parent training programs aimed at changing specific behaviors, as well as innovative ways of delivering the training sessions to reach a wider community of families.

References

1. Smith T, Scahill L, Dawson G, et al. Designing research studies on psychosocial interventions in autism. J Autism and Dev Disord. 2007;37(2):354-366.
2. Aman MG, McDougle CJ, Scahill L, et al. Medication and parent training in children with pervasive developmental disorders and serious behavior problems: results from a clinical trial. J Am Acad Child Adolesc Psychiatry. 2009;48(12):1143-54.
3. Bearss K, Johnson C, Smith T, et al. Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder. JAMA. 2015;313(15):1524-33.
4. Scahill L, Bearss K, Lecavalier L, et al. Effect of parent training on adaptive behavior in children with autism spectrum disorder and disruptive behavior: results of a randomized trial. J Am Acad Child Adolesc Psychiatry. 2016;55(7):602-609.e3.
5. Bearss K, Johnson CR, Handen BL, et al. Parent Training for Disruptive Behavior. New York, NY: Oxford University Press; 2018.
6. Johnson CR, Turner KS, Foldes E, Brooks MM, Kronk R, Wiggs L. Behavioral parent training to address sleep disturbances in young children with autism spectrum disorder: a pilot trial. Sleep Med. 2013;14(10): 995-1004.
7. Johnson CR, Brown K, Hyman SL, et al. Parent training for feeding problems in children with autism spectrum disorder: initial randomized trial. J Pediatr Psychol. 2019;44(2):164-175.

About the Author

Dr. Cynthia R. Johnson (autismresearch@ccf.org; 216-448-6440) is Director of Cleveland Clinic Children’s Center for Autism.