The same group [ 40 ] also found that children participating in the Pivotal Response Treatment programme showed a significantly greater overall improvement between baseline and at week 24 in total number of utterances compared with children in the control group at all time periods. When all three sites were taken together, there was a significant change in favour of ESDM but when sites were analysed separately in sites 1 and 2 there was a significantly better effect of treatment on the trajectory of language development in the ESDM group compared with the control community group.
However, in site 3, the intergroup difference was not significant. They found that after an average of Parents of 12 children in each group were randomised to receive either a week DIR or parent education.
At the end of this period, children in both groups showed improvement in communication. Children in the intervention group showed a significantly greater improvement in functional emotional capacities than those in the control group.
Also, the caregivers in the intervention group showed a significantly greater improvement in parenting skills than those in the control group. Bearss and colleagues [ 35 ] evaluated specifically the efficacy of parent training for children with ASD who displayed disruptive behaviour. In the parent training sessions, behaviour strategies were taught to parents which did not happen in the parent education group.
The parent training group score improved by Parent education and behaviour management resulted in significant improvement in adaptive behaviour and autism symptoms at 6 months follow-up for children with greater delays in adaptive behaviour. Malow and colleagues [ 24 ] investigated whether sleep education was best provided to parents in an individual or group format to improve sleep and aspects of daytime behaviour and family functioning.
Sleep related problems are common in children with ASD. Assessments included actigraphy a non-invasive means of monitoring human rest and activity cycles and parent questionnaires which were collected at baseline and 1 month after treatment. They found that mode of education, i. Sofronoff and Farbotko [ 38 ] aimed to help parents of children who were recently diagnosed with high functioning autism.
The intervention was compared across two formats, a one-day workshop and six individual sessions, and also with a non-intervention control group. The intervention included psychoeducation combined with the use of comic strip conversations [ 48 ] and social stories [ 49 ], management of behaviour problems, rigid behaviours, routines and special interests and anxiety. There was no significant difference in outcome between the workshop format and the individual sessions.
Jocelyn and colleagues [ 29 ] compared in an RCT the effect of psychoeducation for the parents of 16 children with autism with a control group of parents of 19 children who attended day care alone. Keen and colleagues [ 28 ] compared 17 parents of ASD children who had attended a workshop and then received home visits with 22 who had all the information on DVD and found that fathers experienced higher levels of child-related stress than mothers, but the professionally supported intervention reduced child-related stress relative to the self-directed intervention for both mothers and fathers.
Parents low in self-efficacy at baseline demonstrated a relatively higher level of self-efficacy if they received the professionally supported intervention than if they received the self-directed intervention. As per our search criteria, all 15 included studies are RCTs. Tonge and colleagues [ 26 ] describe their study as randomized group comparison-the children in the active intervention arms were allocated randomly while selected metropolitan and rural control regions provided 35 families as the control group.
Sofronoff and Farbotko [ 38 ] used parents of children in the waiting list and Keen and colleagues [ 28 ] parents who used self-directed help as the control group respectively. There was a heterogeneity of control groups; parents received psychoeducation in three studies [ 31 , 35 , 39 ]. Two studies [ 40 , 42 ] had wait list and delayed treatment group as the control group. Table 2 sets out the interventions and controls in all the studies. Two studies [ 24 , 42 ] did not provide any follow up data.
The parent training manual contained verbatim scripts and instructions for therapists. Each site had weekly supervision for therapists and every month, there were teleconferences across the sites to ensure integrity of study interventions. To ensure that the sleep curriculum was being followed across all the sites, the training sessions were video recorded.
The fidelity criteria used to score the sessions were a session integrity, b adherence to the manual, c characteristics of the educator and d educator interaction with parents. These were achieved in all the sessions. The Early Start Denver Model ESDM sessions were conducted in the three university clinics by highly experienced and credentialed therapists trained to fidelity by the authors Rogers and colleagues [ 22 ] who monitored it quarterly throughout the study. Therapist fidelity average score in coaching interactions with the parent was a mean of 3.
Apart from the studies mentioned in this section, no other study provided treatment fidelity data. Pooling data was limited due to use of different outcome measures across the studies. Although there were three studies that used pivotal response treatment, as one study [ 39 ] used psychoeducation as the control intervention, this study was excluded from meta-analysis to avoid any potential contamination of data. Using a random effects model all meta-analysis showed significantly better outcomes in the intervention compared with the control group; a DIR, effect size: 0.
Blinding of participants and those providing the interventions did not happen in any of the studies see Fig. This is inherent in interventions of this kind. In addition, in all the studies, it was unclear whether allocation was concealed. This systematic review included 17 papers from 15 RCTs. Two studies [ 24 , 28 ] also compared outcome of delivering same intervention through two different methods. Sixteen of the 17 papers favour interventions, although not all with a statistically significant result.
However, it is well known that studies with a positive finding tend to find their way to publications more easily than the ones with a negative finding thus causing a publication bias. Although most studies have shown a positive effect of intervention on the outcomes, it is difficult to draw any definitive conclusion from this as the studies are small, and both interventions, control groups and outcomes measures are varied.
This also makes it difficult to pool data for meta-analysis. Although meta-analyses showed positive treatment effects, it was only possible to pool data from two studies respectively for each of the three different specific interventions. Also, pooled data included different outcome measures. None of these are ideal for a meta-analysis and will raise question about their validity.
Each group had created its own intervention which was not used by any other group for independent validation thus limiting generalisability apart from DIR, pivotal response treatment, and parent focus training each of which was used by two groups respectively. Another problem is that psychoeducation in the form of providing information through self-directed learning as opposed to a face to face training by a trainer has been used in the control arm in three studies and in the intervention arm in two studies.
However, psychoeducation is used as an intervention primarily in those studies which measured parent related outcomes such as parental stress and knowledge. Therefore, psychoeducation seems an appropriate intervention in those studies. However, it is worth remembering that psychoeducation may mean many things to many people. Another problem was that most interventions used in the included studies had multiple components.
In most cases the exact details of these components were not described apart from the mention of number of sessions and time taken to deliver the intervention. As a result, it became difficult to tease out the effect of individual components of each intervention.
The Risk of Bias assessment highlights the issues inherent to this kind of research; it is not possible to conceal interventions from those taking part or those delivering the assessment. Recruitment [ 55 ], as mentioned already, is another issue, so that it is difficult to mitigate against allocation bias and small sample size. Pooling data from Gengoux and colleagues [ 40 ] and Nefdt and colleagues [ 42 ] for Pivotal response training we obtained an effect size of 0.
However, the evidence in support of language interventions is small. Higher DQ or IQ may predict more language acquisition. Our findings were similar to other systematic reviews who also reported a large variety of interventions and heterogeneity in outcomes [ 6 , 9 , 10 , 11 , 12 , 13 , 14 ].
However, a high risk of bias affected most studies as the findings were limited by low quality studies, heterogeneity of content, outcomes and outcome measurement. For example, if the child is more likely to manifest repetitive behaviour than have difficulties in the area of social interactions, that is where the intervention needs to be focussed. Tonge and colleagues [ 26 ] found improvement in both the treatment and the control groups.
We were unable to pool data due to differences in research design used in these studies. These studies had overall shown improvement in these outcomes. However, as they were not blind, the placebo effect associated with parents getting attention from the intervention could not be ruled out. Often parents of children with ASD are under emotional stress [ 57 ], and the opportunity to discuss and receive information from a professional in itself is therapeutic for them [ 58 ].
It seems that the parents value support in the early days of diagnosis [ 59 ]. Reduction in parental stress, even in the control group is a product of parent education and training as observed in a number of studies [ 35 , 36 , 44 ]. We have used a broad criterion to capture a wide range of studies using standardised search engines and search terms. We have assessed quality of included studies using the validated Cochrane risk of bias template see Fig.
We have carried out a meta-analysis using the Cochrane guideline. Our findings are in line with those of other systematic reviews in this area. Our search criteria allowed for the inclusion of studies with heterogeneous methodologies and interventions, making comparison among studies and pooling of data difficult. This subsequently made it difficult to draw a definitive conclusion on the effectiveness of the interventions.
Heterogeneity of interventions has been observed in several systematic reviews in this area. However, due to the absence of clear definitions for parent training, our search criteria were necessarily broad to ensure studies were not arbitrarily excluded due to wording and not identified during the literature search. Also, we have excluded conference abstracts and grey literature as we thought it would be difficult to apply the eligibility criteria for screening and assess risk of bias based on the abstracts only.
We have excluded studies in which researchers provided interventions directly to children. Although this helped to avoid confounding but it also made it difficult to compare notes with previous systematic reviews. Exclusion of non-English publications may also have produced some bias. There were very little disagreements between the reviewers while screening abstracts, but the lack of interrater reliability data is a limitation.
Parental training for parents of children with ASD has the potential to vastly reduce use and reliance upon medication. In addition to this, parents of children with ASD are known to experience anxiety and disempowerment in relation to their children.
However, like previous systematic reviews we found a mild to moderate effect of different types of parental training on ASD symptoms of their children. Similar to other systematic reviews, we found it difficult to draw any definitive conclusion about the effectiveness and generalisability of any intervention because of the wide variation in the interventions, control groups and outcome measures used in the included studies.
For training to realise its potential to minimise medication use and empower parents, a future avenue for research must be an attempt to reach consensus on how to define parent training, clarifying essential and optional features. Such a checklist will enable future systematic reviews to assess interventions in the existing evidence base and enable the inclusion of comparable interventions without the risk of unintended exclusion, facilitating informative meta-analyses.
There is an urgent need for experts in various international centres to standardise a parent training intervention for children with ASD and carry out a large scale RCT to assess its clinical and economic effectiveness.
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Focus Autism Other Dev Disabil. Parent-mediated early intervention for young children with autism spectrum disorders ASD. Cochrane Database of SystematicReviews ; 4. Parent-mediated intervention training delivered remotely for children with autism spectrum disorder living outside of urban areas: systematic review. J Med Internet Res. Parent training programs for school-age children with autism: A systematic review. Remedial Special Edu. A systematic review and meta-analysis of parent training for disruptive behaviour in children with autism Spectrum disorder.
Clin Child Fam Psychol Rev. Functional communication training: A review and practical guide. Behav Anal Pract. National Autism Centre.
Findings and conclusions: national standards project, phase 2. Randolph: Author; Google Scholar. A systematic review of parent-implemented functional communication training for children with ASD. Behav Modif. Group-based parent training interventions for parents of children with autism Spectrum disorders: A literature review.
Parent education and training for autism spectrum disorders: scoping the evidence. PubMed Article Google Scholar. Training for parents of teens with ADHD teaches techniques that will work for older children. BPT for teens uses consequences like a loss of privileges or having teens do chores instead of time outs. Parents and their teenager meet with a mental health professional to come up with solutions for problem behavior.
They develop targets, such as better grades in school, so that the teen can be rewarded with things that they enjoy doing, such as being able to go out with friends. Using the skills learned in BPT takes a lot of hard work, but parents who use what they have learned regularly will see better behavior in their children.
They will also see improved relationship with parents and siblings. Parents are given homework assignments between sessions that focus on applying techniques to specific behaviors. Keywords: parent training , autism spectrum disorder , applied behavior analysis , behavior management , adaptive skills , disruptive behaviors.
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