Review: Which components of behavioral parent and teacher training work for children with ADHD? – a metaregression analysis on child behavioral outcomes

Background

This metaregression analysis examined which behavioral techniques that are commonly used in behavioral parent and teacher training programs for children with attention-deficit/hyperactivity disorder (ADHD) were related to program effectiveness on children's behavioral outcomes.

Methods

We included 32 randomized controlled trials (N = 2594 children) investigating behavioral parent training, teacher training, or a combination, in children with ADHD under 18 years. Outcomes were symptom counts of total ADHD, inattention, and hyperactivity-impulsivity and behavioral problems. The dosage of techniques was extracted from the intervention manuals. Metaregression was used to assess which techniques and intervention characteristics (setting, delivery method, duration, and home-school collaboration) were associated with intervention effectiveness.

Results

Higher dosage of psycho-education for parents was associated with smaller effects on behavioral problems and, only in case of parent training, also with smaller effects on ADHD symptoms. Higher dosage of teaching parents/teachers to use negative consequences was associated with larger effects on behavioral problems. Individual training compared with group training was associated with larger effects on ADHD and hyperactivity-impulsivity symptoms.

Conclusions

This study provides first insights into the specific techniques that are essential in behavioral parent and teacher training programs for children with ADHD. This knowledge can eventually be used to improve and tailor interventions.     

家长培训对注意缺陷多动障碍儿童的干预

目的探讨家长培训对注意缺陷多动障碍(ADHD)儿童的干预效果。方法将30例符合DSM-Ⅳ诊断标准的ADHD患儿作为干预组,进行为期8周的家长培训;30例符合DSM-Ⅳ诊断标准的ADHD患儿作为对照组,不给予任何干预措施。干预前评诂Connem父母症状问卷(PSQ),干预8周后再次评诂Conners父母症状问卷、临床疗效总评和培训满意度调查问卷。结果干预组的PSQ各项因子分干预后比干预前均有下降,品行问题、学习问题、多动指数因子分改变有统计学显著性差异。主观评价家长认为培训方式容易接受、培训内容有帮助。结论家长培训对ADHD儿童干预效果较好,药物治疗结合家长培训可以增加干预效果,家长培训方式容易接受,方法值得推广。     

The Kazdin Method for Developing and Changing Behavior of Children and Adolescents

The Kazdin Method™ is a version of parent management training in which parents are trained to alter the behaviors of their children. The method draws on the principles and techniques of applied behavior analysis. The techniques focus on antecedents (what comes before the behavior), behavior (crafting the precise behaviors one wishes to develop), and consequences (usually praise to increase the likelihood that the desired behaviors will be performed again). The key focus is repeated practice in changing parent and child behaviors. The article traces the evolution of my use of parent training to treat severe aggressive and antisocial behavior among clinically referred samples and also to help parents with the routine challenges of child rearing. Research findings supporting the effectiveness of the techniques are highlighted. In addition, the article discusses issues and myths that may be of concern with the approach such as the exclusive focus on behavior, the extent to which the effects endure, and the use of consequences to change behavior. Resources are provide for parents and professionals for implementing the techniques and as well as for addressing topics of interest to parents in child and adolescent development.     

Effectiveness of alternative parent training formats

Alternative formats were compared for training parents of retarded children to teach self-help skills and manage problem behaviors. Sixty-six families with moderately to severely retarded children ages 3-13 were assigned for 3 months to group parent training (n = 37), individual parent training (n = 16), or delayed training control (n = 13). Measures administered before and after training evaluated: (1) parent knowledge of behavior modification, (2) a behavior sample of parent teaching, and (3) child self-help skills and behavior problems. Trained families gained significantly more than control families on parent measures but not on the child self-help skill measure. Group and individually trained families demonstrated almost identical gains. At a 6-month follow-up, group and individually trained families continued to show equal performance. Group training requires about half the professional time per family as individual training, and therefore seems a more cost-effective approach.     

Effects on parental mental health of an education and skills training program for parents of young children with autism: a randomized controlled trial

OBJECTIVE: To determine the impact of a parent education and behavior management intervention (PEBM) on the mental health and adjustment of parents with preschool children with autism. METHOD: A randomized, group-comparison design involving a parent education and counseling intervention to control for nonspecific therapist effects and a control sample was used. Two metropolitan and two rural regions were randomly allocated to intervention groups (n = 70) or control (n = 35). The parents of consecutive children with autism (2(1/2)-5 years old) from the autism assessment services for the intervention regions were then randomly allocated to either a 20-week manual-based parent education and behavior management intervention (n = 35) or a manual-based parent education and counseling intervention (n = 35). The main outcome measure of parental mental health was the General Health Questionnaire used pre- and postintervention and at 6-month follow-up. RESULTS: Both treatments resulted in significant and progressive improvement in overall mental health at follow-up (F = 2, 97, p =.007) and mental health significantly improved over time in the 54% of principal caregivers who had the highest levels of mental health problems. The parent education and behavior management intervention was effective in alleviating a greater percentage of anxiety, insomnia, and somatic symptoms and family dysfunction than parent education and counseling at 6-month follow-up. CONCLUSIONS: A 20-week parent education and skills training program for parents of young children newly diagnosed with autism provides significant improvements in parental mental health and adjustment, justifying its addition to early intervention programs at least for parents with mental health problems.     

Instructing individuals to deliver discrete-trials teaching to children with autism spectrum disorders: A review

Early intensive behavioral intervention (EIBI) has been identified as the treatment of choice for children with autism spectrum disorders. A common strategy for conducting EIBI is discrete-trials teaching (DTT). There is a demand for research-based, economical, rapid training techniques to teach tutors and parents of children with autism to conduct DTT. This paper provides a review of research that has focused on teaching individuals how to conduct DTT. Considering the high demand for personnel trained in delivering DTT to children with autism, research in this field is highly warranted.     

Parent training: acquisition and generalization of discrete trials teaching skills with parents of children with autism

This study examined the effects of an intensive parent training program on the acquisition and generalization of discrete trial teaching (DTT) procedures with two parents of children with autism. Over the course of the program, parents applied the DTT procedures to teach four different functional skills to their children, which allowed for an assessment of "free" and programmed generalization across stimulus exemplars. Parent training was conducted by the first author utilizing instructions, demonstrations, role-play, and practice with feedback. Parents' use of DTT skills and children's correct and incorrect responding were measured. A within-subject multiple-baseline across stimulus exemplars (functional skills taught) design was employed both to demonstrate control of the training program over parents' correct use of DTT, and to allow a preliminary investigation of the generalized effects of training to multiple stimulus exemplars. Results demonstrate initial control of the training program over parent responding, and the extent to which each parent extended her use of DTT procedures across untrained and topographically different child skills. The potential for designing more generalizable and thus more cost-effective parent training programs is discussed.     

A video parent-training program for families of children with autism spectrum disorder in Albania

BackgroundBehavioral intervention with parent participation is effective in reducing symptoms of Autism Spectrum Disorder (ASD), but access to intervention is limited. The current study explored whether a video-enriched parent-training program would (a) be comprehensible and acceptable to parents in the Republic of Albania, (b) increase parental knowledge of behavioral strategies, and (c) increase parental self-efficacy.MethodsTwenty-nine parents of children with ASD aged 18–70 months completed the Early Intervention Parenting Self-Efficacy Scale (EIPSES, Guimond et al., 2008) and a quiz to assess their knowledge of behavioral strategies. Parents in the Treatment Group then received access to a parent-training (PT) program on evidence-based teaching and behavior management techniques. The program was based on empirical research, but considered Albanian cultural norms and included topics Albanian parents requested. Parents in the Treatment Group rated the program using the Treatment Evaluation Inventory Short Form (TEI-SF; Kelley et al., 1989). Change in parents’ quiz scores and EIPSES ratings from baseline to post-treatment were compared by group.ResultsParents rated this video training program as comprehensible and valuable. The program modestly increased aspects of self-efficacy as well as parents’ knowledge of effective teaching strategies.ConclusionRemote PT may be useful in low-resource settings to help parents develop techniques for teaching skills and forestalling problem behavior in children with ASD. Additional research, with a larger sample size, that observes the effect of the program on child behavior is warranted.     

Telepractice parent-implemented training and coaching in a rural area in the UK: Impact on mothers and their children with autism

BackgroundParent-implemented interventions are reported to have positive outcomes for both children with autism and their parents. Online parent training and coaching have been increasingly used as an effective alternative or supplemental to traditional face-to-face services, especially after the start of the Covid-19 pandemic. The purpose of this study was to examine the extent to which parents of children with autism can implement a set of newly acquired strategies and the impact these had on their children’s communication skills.MethodFour mother–child dyads from a rural area in the UK participated in the study following a multiple-baseline design across strategies. Asynchronous training and synchronous coaching were provided, all online.ResultsThe present study extended the results of the original US based study it replicated (Meadan et al., 2016). Mothers learned to use the targeted naturalistic teaching strategies they were trained and coached in (i.e., i-PiCS- internet-based Parent-implemented Communication Strategies) and their children’s responsiveness and initiations of communication increased and were mostly maintained after the end of the study. Changes in the mothers’ use of strategies were observed in many cases even after training only, and the strategy of time delay was linked to increases in the children’s initiations of communication.ConclusionsThis replication study showed that i-PiCS is an appropriate intervention to use with mothers of children with autism in the UK and telepractice training and coaching can be a feasible and effective service delivery method.     

A pilot randomised control trial of a parent training intervention for pre-school children with autism. Preliminary findings and methodological challenges

Few attempts have been made to conduct randomised control trials (RCTs) of interventions for pre-school children with autism. We report findings of a pilot RCT for a parent training intervention with a focus on the development of joint attention skills and joint action routines. Twenty-four children meeting ICD-10 criteria for childhood autism (mean age = 23 months) were identified using the CHAT screen and randomised to the parent training group or to local services only. A follow-up was conducted 12 months later (mean age = 35 months). There was some evidence that the parent training group made more progress in language development than the local services group. However, the present pilot study was compromised by several factors: a reliance on parental report to measure language, non-matching of the groups on initial IQ, and a lack of systematic checking regarding the implementation of the parent training intervention. Furthermore, three parents in the local services group commenced intensive, home-based behavioural intervention during the course of the study. The difficulties encountered in the conduct of RCTs for pre-school children with autism are discussed. Methodological challenges and strategies for future well-designed RCTs for autism interventions are highlighted.     

Initial Efficacy of Project ImPACT: A Parent-Mediated Social Communication Intervention for Young Children with ASD

Project ImPACT is a parent-mediated social communication intervention for young children with ASD that was developed in community settings to encourage dissemination. A single-subject, multiple-baseline design was conducted across 8 preschoolers with ASD and their mothers to examine the efficacy of the model for improving parent intervention fidelity and child spontaneous language. Multilevel modeling was used to examine the relationship between parent fidelity and child language within session. All parents increased their use of the intervention techniques. Improvements in spontaneous use of language targets were observed for 6 of the 8 children. There was a significant association between parents’ use of the intervention strategies and their child’s spontaneous language use.     

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

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

     

Errorless compliance training: building a cooperative relationship between parents with brain injury and their oppositional children

Errorless compliance training, a noncoercive intervention for improving child compliance, was evaluated in a multiple baseline across-subjects design with 12 oppositional children (ages 2-7 years) and their brain-injured parents, who suffered from cognitive deficits, impulsivity, and/or emotional instability. Generalized and durable increases were observed in child compliance after treatment. Pre/post improvements were also noted on a measure of parent self-esteem. Errorless compliance training may be well suited to intervention with parents with cognitive and behavioral impairments that decrease their potential to benefit from traditional parenting approaches.     

Contextualized behavioral support in early intervention for children with autism and their families

Parent education programs have become an effective mode of treatment delivery for teaching families effective behavioral strategies to manage challenging behavior in young children with autism. Functional assessment and functional communication training (FCT) are empirically validated procedures that have recently been introduced into parent education programming to help resolve challenging behaviors. The success of these procedures, however, is contingent on family members' ability to integrate them into the specific contexts in which challenging behaviors occur. Consequently, the application of these procedures in home settings necessitates consideration of the family context in the assessment and treatment planning process. A study is presented that investigated the use of information on family context (i.e., caregiving demands, family support, patterns of social interaction) to direct the assessment and intervention planning process. More specifically, information on family context was used to individualize behavioral support plans designed to support family use of functional communication training within important family routines. Through parent-investigator collaboration we individualized the manner in which functional communication training procedures were taught and implemented so they were contextually relevant. Utilizing a multiple baseline design, the challenging behaviors and functional communication of three children with autism were monitored across baseline, intervention (i.e., FCT, and contextulized FCT), and follow-up phases. Multiple routines for each participant were selected and monitored across all phases to evaluate changes in the dependent measures within training and generalization routines. A self-report questionnaire was administered intermittently to parents to determine if consideration of family context improved the goodness of fit of the functional communication training treatment packages across FCT and contextualized FCT intervention phases. Results from the study indicate that consideration of family context in the assessment and intervention planning process does not jeopardize and may contribute to the stability and durability of reductions in challenging behavior achieved with functional assessment and functional communication training procedures.     

Enhancing the Application and Evaluation of a Discrete Trial Intervention Package for Eliciting First Words in Preverbal Preschoolers with ASD

This study evaluates the effectiveness of an intervention package including a discrete trial program (Rapid Motor Imitation Antecedent Training (Tsiouri and Greer, J Behav Educat 12:185-206, 2003) combined with parent education for eliciting first words in children with ASD who had little or no spoken language. Evaluation of the approach includes specific intervention targets and functional spoken language outcomes (Tager-Flusberg et al., J Speech Lang Hear Res 52:643-652, 2009). Results suggest that RMIA, with parent training, catalyzes development of verbal imitation and production for some children. Three of five participants acquired word production within the DTT framework and achieved milestones of early functional spoken language use (Tager-Flusberg et al., J Speech Lang Hear Res 52:643-652, 2009). The implications of these findings for understanding the role of discrete trial approaches to language intervention are discussed.     

Negative parenting behaviour as a mediator of the effects of telephone-assisted self-help for parents of pharmacologically treated children with attention-deficit/hyperactivity disorder

A previous randomised controlled trial demonstrated the effects of a telephone-assisted self-help (TASH) intervention for parents of pharmacologically treated children with attention-deficit/hyperactivity disorder (ADHD) on ADHD symptoms, oppositional symptoms, functional impairment, and negative parenting behaviour (per-protocol analyses). In the current study, we examined whether changes in positive and negative parenting behaviour mediated the effects on symptoms and impairment. Parents in an enhancement group (n = 51) participated in a 12-month TASH intervention (eight booklets plus up to 14 telephone consultations) as an adjunct to routine clinical care, whereas parents in a waitlist control group (n = 52) received routine clinical care only. Parents completed measures of child symptoms, child functional impairment, and parenting behaviour at baseline, at 6 months, and at 12 months. The mediating effects of parenting behaviour were examined using regression analyses. Per-protocol analyses (n = 74) revealed a significant indirect intervention effect on functional impairment through negative parenting behaviour at 6 months as well as indirect intervention effects on oppositional symptoms and functional impairment through negative parenting behaviour at 12 months. The indirect effect on ADHD symptoms through negative parenting behaviour at 12 months just failed to reach significance. The analyses yielded no indirect intervention effects through positive parenting behaviour. The study provides some, albeit limited, support for the importance of changes in negative parenting behaviour to achieve changes in symptoms and functional impairment during parent training. In consideration of the inconsistent results of previous studies concerning the mediating role of positive and negative parenting behaviour, further research is required to better understand the mechanisms of change during parent training, also including other possible mediators like parenting stress and parental self-efficacy.

     

Verbal communication outcomes in children with autism after in-home father training

Background This retrospective study examined the efficacy of in‐home father training on the communicative outcomes of children with autism. The in‐home training consisted of two components: (1) expectant waiting; and (2) imitation with animation. Methods Efficacy of parent training was examined by measuring the ratio of utterances produced by the parents to the utterances produced by the children and the number of verbal imitation by the parents. Outcomes of the children's verbal production were examined by measuring the number of (1) single word utterances; (2) different words produced; and (3) verbal response to questions. Results Following training there was a decrease in the ratio of parent to child utterances and an increase in (1) the use of imitation by the parents; and (2) the number of single words and different words produced by the children. Discussion Results of this study suggested that the parents had learned to wait for their children to communicate verbally during communicative interactions and to interact more efficiently with their children by using verbal imitation. Overall, the results of this study support the efficacy of parent training that focuses on promotion of social reciprocity, and have important implications for clinicians and future research.     

Teaching advance movement exploration skills in water to children with autism spectrum disorders

This study evaluated the effectiveness of the ‘most to least’ prompting (MLP) procedure on the teaching of advance movement exploration skills in water to children with autism spectrum disorders (ASD). Three 6-year old children with ASD, participated in the study and were taught 3 different aquatic skills, essential for movement exploration in water and swimming, in a one-to-one training format at three sessions per week. A multiple probe design across behaviors was used and was replicated across subjects to analyze the effects of MLP. The results of the study showed that MLP was effective in teaching advance movement exploration skills in water to children with ASD. Performing the exploration skills in water was continued after the training process during maintenance and generalization probe sessions. In addition, social validity results reflected that parents’ opinions were positive on the learning skills in terms of functionality, beginning swimming and participation in other aquatic settings for their children. The enjoyable intervention and appealing setting are recommended to increase the repertoire of leisure skills and level of physical activity for children with ASD.     

Home-based parent training for school-aged children with attention-deficit/hyperactivity disorder and behavior problems with remaining impairing disruptive behaviors after routine treatment: a randomized controlled trial

The objective is to investigate the effectiveness of home-based behavioral parent training for school-aged children with attention-deficit/hyperactivity disorder (ADHD) and behavior problems with remaining impairing disruptive behaviors after routinely offered treatments in clinical practice. In a randomized controlled study including 73 referred children with ADHD and impairing disruptive symptoms after routine clinical pharmacotherapy and/or clinic-based parent training had been tried or, at least, offered, home-based behavioral parent training (n?=?26) was compared to a waiting list (n?=?23) and a care-as-usual home-based treatment (n?=?24). It was unknown to families which of the home-based treatments that they received. Using mixed models for repeated measures, we examined the effectiveness on the primary outcome measure of children’s severity of disruptive behaviors and on a number of secondary outcome measures [the degree to which parents experienced the disruptive behaviors as troublesome, ADHD symptoms, oppositional-defiant disorder (ODD) symptoms, and internalizing problems]. Compared to the waiting list, children receiving home-based parent training improved significantly more regarding severity of disruptive behaviors (ES?=?0.75), ADHD symptoms (ES?=?0.89), ODD symptoms (ES?=?0.65), and internalizing problems (ES?=?0.60). Compared to care-as-usual, home-based parent training was more effective in reducing disruptive behaviors (ES?=?0.57), ADHD symptoms (ES?=?0.89), and ODD symptoms (ES?=?0.88). Significantly more reduction of children’s internalizing problems was not found. In conclusion, children with ADHD and residual behavioral problems after routine treatment may benefit from home-based behavioral parent training.