Parent Training Proves Superior to Psychoeducation in Autism Spectrum Disorder Outcomes

Parent training (PT) is more effective than psychoeducation (PEP) in reducing disruptive behavior in children with autism spectrum disorder (ASD), and in decreasing parental stress and improving competence, according to recent research.

Cynthia Johnson, PhD, Director of Cleveland Clinic Children’s Center for Autism, was a member of the team of researchers from six institutions that conducted the study during her time at the University of Pittsburgh and University of Florida.

“We demonstrated that when parents learned additional behavioral parenting skills, their sense of competence improved and their stress related to caring for their child’s difficult behavior went down,” says Dr. Johnson. “For the first time, we also showed that a direct link exists between behaviorally- based PT and parent stress levels in ASD.”

The results suggest that PT is effective enough to be more broadly applied for young children with ASD and disruptive behavior.

Autism Speaks, a United States-based autism advocacy organization, named the study one of its top 10 autism studies for 2018.

Since joining Cleveland Clinic in 2018, Dr. Johnson has expanded the Center for Autism’s research program with two federally-funded studies focused on alleviating sleep problems and assessing the effects of intensive behavior therapies in young children with autism.

Assessing the effects of PT and PEP on parent outcomes

PT is a well-recognized intervention strategy for disruptive behavior in non-ASD children. Previous studies have shown PT is associated with decreases in disruptive behavior in children with ASD, but whether it affected parental outcomes had been unclear. The research by Dr. Johnson’s group was a multicenter trial to test the efficacy of PT program for disruptive behaviors in young children with ASD, focusing on reporting parent outcomes. It was the largest such randomized controlled trial to date.

One hundred and eighty children with ASD between the ages of 3 and 7 years participated in the 24-week study. One parent per child was assigned to either of the PT or PEP intervention groups and agreed to report all outcome measures. Child disruptive behavior was assessed according to the irritability subscale of the Aberrant Behavior Checklist.

PT consisted of 60- to 90-minute-long core sessions and included direct parental instruction, video vignettes, role playing, and practice examples. The participating parent was expected to practice the strategies learned during therapy sessions in weekly homework assignments. A total of 11 sessions were delivered over 16 weeks and included two home visits.

PEP consisted of 12 individually-delivered instructional sessions and one home visit. During PEP sessions, parents were educated about important topics/issues related to caring for young children with ASD.

“In the PT program we taught behavioral strategies,” Dr. Johnson explains. “In the scope of PEP, we provided very helpful information about the diagnosis, as well as how parents can advocate for their child, where they can get support and how they can choose treatment, but we did not teach the parents specific behavioral strategies.”

Multiple outcome measures were assessed in the study, including parental stress (Parenting Stress Index-Short Form), parental competence (PSOC—Parenting Sense of Competence) and parental strain (CGSQ—Caregiver Strain Questionnaire). The effects of PT and PEP on parent outcomes were assessed at weeks 12 and 24, after controlling for baseline scores.

Parent training results in benefits for children and parents

Participating parents were predominantly women in their mid-30s and participating children were mostly boys (79 percent) with a mean age of 4.2. years. Although both interventions resulted in improvements by the end of the study, PT was more effective than PEP in reducing disruptive child behavior and caregiver strain, and in increasing parental competence. Positive effects of PT on child behavior, global caregiver strain, and satisfaction with parental competence were observed during the first half of treatment and reported by parents at week 12. Positive changes in parental efficacy, overall parent competence and externalized caregiver strain were observed after the full 24 weeks of intervention.

“PT was superior in decreasing child disruptive behavior and decreasing parental stress, as well as increasing parental confidence over PEP,” says Dr. Johnson. “Furthermore, we have found that if we teach parents behavior management to address their child’s disruptive behavior, parents’ stress is likely to decrease as well, which turned out to be a positive side effect in our study.”

Study authors also were able to identify an association between the observed decrease in child disruptive behavior and improvement in parental competence and parental stress facilitated by PT.

Bringing PT to a wider community of families

Dr. Johnson emphasizes that the positive child and parent outcomes demonstrated in this study support the wider application of PT in managing young children with ASD and disruptive behavior.

“We have shown that PT is an important component of caring for children with ASD,” she says. “Our next goal is to reach more families that live far away from specialized autism clinics and disseminate this intervention to a wider audience by reaching communities that might not have access to PT.”

To bolster the wider dissemination of PT, Dr. Johnson and her collaborators are planning to apply for funding to test whether the PT program maintain its efficacy when administered by community providers.

Since PT and PEP each produced improved parental and child outcomes, a tiered or blended intervention employing both strategies might amplify the positive effects, Dr. Johnson and her colleagues note.