Parent Training Interventions To Reduce Challengin

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Parent Training Interventions to Reduce Challenging Behavior in Children with

Intellectual and Developmental Disabilities
Article · December 2013

DOI: 10.1016/B978-0-12-401662-0.00008-7
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CHAPTER EIGHT
Parent Training Interventions to

Reduce Challenging Behavior in
Children with Intellectual and
Developmental Disabilities
Laura Lee McIntyre
Department of Special Education and Clinical Sciences, University of Oregon, Eugene, OR, USA
E-mail: llmcinty@uoregon.edu
Contents
1. Introduction 246
2. Review of Parent Training Interventions for Children with IDD 248
2.1. Participants 258
2.2. Dependent Measures 259
2.3. Study Design 259
2.3.1. Generalization, Maintenance, Consumer Satisfaction, and Treatment Integrity 260
2.4. Parent Training Interventions 260
2.4.1. Incredible Years 261
2.4.2. Stepping Stones Triple P 262
2.4.3. Signposts for Building Better Behavior 262
2.4.4. RUPP Parent Training 263
2.4.5. Sing & Grow Music Therapy 263
2.4.6. Mindfulness Training 264
2.4.7. Parent–Child Interaction Therapy 264
2.4.8. Autism Spectrum Conditions—Enhancing Nurture and Development 265
2.4.9. Parent Training with Smaller Groups and Shorter Schedules 265
2.4.10. Video Modeling Parent Training 265
2.4.11. Parent Management Training for Asperger Syndrome 266
2.5. Treatment Outcomes 266
2.5.1. Challenging Behavior 266
2.5.2. Parenting Behavior 267
2.5.3. Parental Competence, Self-Efficacy, and Confidence 267
2.5.4. Parenting Stress and Depression 268
2.6. Strengths of Extant Literature 268
2.6.1. International Literature Base 268
2.6.2. Tailoring Interventions for ASD 269
2.6.3. Evidence-Based Behavior Management Strategies 269
2.6.4. Multimethod Assessment 270
International Review of Research in Developmental Disabilities, Volume 44 © 2013 Elsevier Inc.

ISSN 2211-6095, http://dx.doi.org/10.1016/B978-0-12-401662-0.00008-7 All rights reserved. 245
246 Laura Lee McIntyre
2.7. Limitations and Future Directions 270

2.7.1. Study Design 270
2.7.2. Attrition 271
2.7.3. Sample Size 271
2.7.4. Power, Moderators and Mediators 272
2.7.5. Generalization and Maintenance 273
2.7.6. Treatment Integrity 273
3. Conclusions 274
References 274
Abstract
It is well established that parents and other caregivers play an important role in
shaping child development. Given the important link between parenting and child
adjustment, a variety of parent management training interventions have been
adopted from the disruptive behavior disorder treatment literature and applied
to the prevention and treatment of challenging behavior in children with intel-
lectual and developmental disabilities (IDD). This chapter reviews empirical studies
published from 2003 to 2012 that examine the effects of parent training interven-
tions on challenging behavior of children with IDD. Nineteen studies representing
11 parent training programs are reviewed. Parent training interventions include the
Incredible Years, Stepping Stones Triple P, Signposts for Building Better Behavior,
Research Units in Pediatric Psychopharmacology Parent Training, Sing and Grow Music
Therapy, Mindfulness Training, Parent–Child Interaction Therapy, the Autism Spectrum
Conditions—Enhancing Nurture and Development program, Parent Training for
Smaller Groups and Shorter Schedules, video modeling and feedback parent training,
and parent management training. Taken together, results from these studies suggest a
growing evidence base for the use of parent training interventions for reducing chal-
lenging behavior in children with IDD. Results suggest a smaller body of evidence for
effects of parent training interventions on altering parenting behavior and enhancing
parent mental health. Questions remain about the durability and generalization of find-
ings, moderators and mediators of change, and strategies for enhancing therapeutic
alliance and engagement with an aim to reduce attrition.
1. INTRODUCTION
It is estimated that 3% of the population has an intellectual or devel-
opmental disability (IDD; Batshaw, Shapiro, & Farber, 2007). Children with
IDD, including autism spectrum disorders (ASDs), have cognitive, social,
and language deficits which place them at particular risk for challenging
behavior in early childhood and throughout development (Emerson, 2003).
Research suggests that nonclinical samples of children with IDD as young
as 3-years-old already exhibit increased behavior problems that negatively
Parent Training Interventions to Reduce Challenging Behavior in Children 247
affect their families (Baker, Blacher, Crnic, & Edelbrock, 2002; Baker et al.,
2003). In the absence of targeted interventions, these behavior problems
appear to persist over the preschool period and into childhood and adoles-
cence (Baker et al., 2003; Einfeld et al., 2006; Eisenhower, Baker, & Blacher,
2007; McIntyre, Blacher, & Baker, 2006). Early intervention and treatment
are clearly needed to reduce challenging behavior in children with IDD.
At a very early age, families are children’s main socializing agents and
they can influence children’s behavior through their actions, attitudes, and
behavior (Patterson, 1982). Although care must be taken not to blame
families for child problems, positive parenting practices may promote
child adjustment while negative or coercive practices may be associated
with child problem behavior (Dishion & Stormshak, 2007). Indeed, family
processes influence the emergence of behavior disorders in young chil-
dren with and without disabilities (Baumrind, 1989; Bronson, 2000; Floyd,
Harter, Costigan, & MacLean, 2004; Kumpfer & Alvarado, 2003; Martin,
1981; Russell & Russell, 1996). In parsing family risk factors, Patterson
et al. (Patterson, 1982; Patterson, DeBaryshe, & Ramsey, 1989) suggest that
negative, coercive parenting practices place children at risk for behavior
problems. Existing behavior problems may be exacerbated by parental stress
over time (e.g. Baker et al., 2003). Furthermore, some evidence suggests that
the presence of parental stress influences the emergence and persistence of
behavior problems in school-age children with disabilities (Hastings, Daley,
Burns, & Beck, 2006). Thus, interventions that address child behavior and
parenting stress may be especially important.
Central to the emergence of early-childhood behavior problems are weak
or disorganized family management practices, which can result in coercive
parent–child interactions. As such, the child’s aversive behaviors increase in
intensity and frequency and the parent acquiesces, unwittingly reinforc-
ing problem behaviors (Gardner, 1989; Patterson, 1982; Patterson, Reid, &
Dishion, 1992; Shaw & Bell, 1993) and dedicating less time and engage-
ment to socialization processes. As the child’s behavior becomes increasingly
problematic, the parent may further escalate power assertion techniques,
or alternately, begin avoiding conflict with an increasingly coercive young
child. It is clear that coercive and rejecting parent–child relationships mea-
sured at age 2 are associated with child conflict with peers and teachers
at age 6 (Ingoldsby, Shaw, & Garcia, 2001), trajectories of persistent con-
duct problems from ages 2 to 10 (Shaw, Gilliom, Ingoldsby, & Nagin, 2003;
Shaw, Lacourse, & Nagin, 2005; Stormshak, Bierman, McMahon, Lengua, &
Conduct Problems Prevention Research Group, 2000), and serious problem
behavior between ages 11 and 15. Children with IDD and their families
may be particularly at risk for these outcomes because of higher levels of
parenting stress, parental depression, and contextual risks associated with
developmental disabilities (DD) (Baker et al., 2002; Emerson et al., 2010).
A recent study has shown that relative to a comparison group of parents of
typically developing preschool-age children, parents of children with IDD
were more detached, more negative, and less positive (Crnic, Pedersen y
Arbona, Baker, & Blacher, 2009). Clearly, supporting parenting skills can
reduce the risk of later problem behavior for children with IDD and may
support family well-being and parent mental health (Baker, Fenning, Crnic,
Baker, & Blacher, 2007; Floyd et al., 2004; McIntyre, 2008a,b).
Given the role that parents play in shaping children’s development, a
variety of parent management training procedures have been adopted from
the disruptive behavior disorder treatment literature and applied to the
prevention and treatment of challenging behavior in children with IDD
(Brookman-Frazee, Stahmer, Baker-Ericzen, & Tsai, 2006). The rest of this
chapter will review the empirical evidence for parent training approaches
with families with children with IDD and discuss limitations of these find-
ings. I will conclude with outlining future directions.
2. REVIEW OF PARENT TRAINING INTERVENTIONS

FOR CHILDREN WITH IDD
A comprehensive literature search was conducted using PsycINFO
to identify empirical studies published between 2003 and 2012 investigat-
ing the effects of parent training interventions on challenging behavior in
children or adults with IDD. The following inclusionary criteria were used
to identify articles for this review: (1) peer-reviewed journal article, (2)
published in English between 2003 and 2012, (3) quantitative study with
methods and results related to parent training, (4) focus on children or adults
with IDD or at risk for IDD, and (5) inclusion of child/adult challenging
behavior as a dependent variable. Articles that included parent training as a
component of a multifaceted treatment were excluded if the effects of par-
ent training could not be isolated. IDD was inclusive of children diagnosed
with an ASD. The initial search yielded 160 studies that were reviewed in
depth to determine eligibility for this review.
Nineteen studies representing 11 different parent training interventions
met the above criteria (Table 8.1). Although it is beyond the scope of this
chapter to include standardized estimates of treatment effects, study features
Table 8.1 Parent training intervention studies for child challenging behavior in children with IDD published between 2003 and 2012 (n = 19)
Study Target group Sample size Intervention Design/Approach Dependent variables Key outcomes
Aman et al. Caregivers and their N = 124 RUPP Parent Training - Randomized control - Parent-reported child Relative to MED group,
(2009) 4–13-year-old n = 75 COMB - Combined treatment trial compliance (HSG) COMB group had:
children with n = 49 MED (COMB) of indi- - ITT analysis - Observed - More parent-reported
PDD and elevated Attrition 24% vidual parent training - Blinded evaluation improvement on the child compliance
behavior problems plus risperidone - Treatment integrity CGI scale - Less parent-reported
- Medication alone reported - Parent-reported maladaptive behavior
(MED) maladaptive behavior - No difference on clinical
(ABC) impressions of symptoms
Bagner et al. Caregivers and their N = 28 Parent–Child Interaction - Randomized wait-list - Parent-reported Relative to WL group, the
(2010) 18–60-month-old n = 14 immedi- Therapy (PCIT) control trial behavior problems IT had:
children born ate treatment - Immediate treatment - ITT analysis (CBCL & ECBI) - Less reported problem
premature n = 14 wait-list (IT) - RCI analysis - Observed parent behavior
(<37 weeks Attrition 21% - Wait-list control (WL) - Treatment integrity and child behavior - More observed child
gestation) with reported (DPICS) compliance
elevated behavior - 4-Month follow-up - Parent-reported - Less reported parenting
problems parenting styles (PS) stress
- Parent-reported - Less reported laxness,
parenting stress overreactivity, and
(PSI-SF) verbosity in parenting
styles
Continued
Table 8.1 Parent training intervention studies for child challenging behavior in children with IDD published between 2003 and 2012 (n = 19)—cont’d
Hames and Parents of 3–11- N = 39 - Video modeling - Group design Evaluation questionnaire Posttreatment parents
Rollings year-old children Attrition 46.3% parent training - No control group designed to collect reported:
(2009) with severe ID incorporating video - Retrospective self- consumer satisfaction - Gains in children’s
and challenging modeling and reports surveying and parent reports of behavioral functioning
behavior feedback parent participants child behavior, parent - Increase in positive
- Group-based spanning 8 years behavior, and parent attitudes and positive
intervention - No treatment attitudes parenting
integrity reported
- No published
outcome measure
Hudson et al. Mothers and their N = 115 Signposts for Building - Group design - Parent-reported Posttreatment parents
(2003) 4–19-year-old n = 29 Better Behavior - Wait-list control behavior problems reported:
children with ID self-directed program group (DBC) - Less child problem
and ASD n = 13 telephone 4 Levels: - Semi-randomized - Parent-reported behavior
n = 46 group - Self-directed assignment competence (PSOC) - Less stress
n = 27 wait-list - Telephone - 4–6 month follow-up - Parent-reported - More competence in
Attrition: - Group (no follow-up data for mental health (DASS) parenting
43% prepost - Wait-list control wait-list controls) - Parent-reported - Fewer parent needs
72% pre-follow- - No treatment parenting hassles reported in parenting
up integrity reported (PHS) hassles
- Consumer satisfaction
Hudson et al. Parents of 2–18- N = 2119 Signposts for Build- - Group design - Parent-reported Posttreatment parents
(2008) year-old children n = 22 self- ing Better Behavior - No control group behavior problems reported:
with ID and directed program - Wide-scale imple- (DBC & DBAF) - Less child problem
challenging n = 119 tele- 4 Levels: mentation trial - Parent-reported behavior
behavior phone - Self-directed - 3-month follow-up competence (PSOC) - Less stress, depression, and
n = 1675 group - Telephone - No treatment integ- - Parent-reported anxiety
n = 303 indi- - Group rity reported mental health (DASS) - More competence and
vidual - Individual - Parent-reported satisfaction in parenting
Attrition: parenting hassles - Less parenting hassle
58% pre-post (PHS)
87% pre-follow- - Consumer satisfaction
up
Kleve et al. Parents of 2–11- N = 128 Incredible Years Parent - Group design - Parent-reported Postintervention, parents
(2010) year-old children Attrition 31% Training - No control group behavior problems reported:
with a range of - Group-based inter- - No treatment (ECBI) - Decreased problem
neurodevelop- vention integrity reported - Visual analog scales behavior
mental disorders
and challenging
behavior involved
in social services
Continued
McIntyre Parents of N = 25 Incredible Years Parent - Group design - Parent-reported Postintervention:
(2008a) 2–5-year-old chil- Attrition 11% Training—DD - No control group behavior problems - Decreases in observed
dren with IDD, Modifications - Parent–child (CBCL) child problem behavior
including ASD - Group-based interaction - Observed parent- and negative parenting
intervention observations scored child interactions - Increase in
by coders naïve to - Parent-reported parent-reported positive
study goals impact of the child impact of the child
- Treatment integrity on family (FIQ) - No significant changes in
reported - Parent-reported parent-reported behavior
- RCI analysis depression (CES-D) problems, child nega-
- Analysis of correlates - Consumer satisfaction tive impact, or maternal
of change depression
McIntyre Parents of N = 49 Incredible Years Parent - Randomized control - Parent-reported Postintervention, children in
(2008b) 2–5-year-old chil- n = 24 IYPT- Training—DD trial behavior problems IYPT-DD group showed
dren with IDD, DD modifications - Blinded evaluation (CBCL) - Reductions in observed
including ASD n = 25 usual care (IYPT-DD) - Treatment integrity - Observed parent– problem behavior and
control - Group-based reported child interactions parent-reported problem
Attrition 10% intervention - Parent-reported behavior
impact of the child - Reductions in observed
on family (FIQ) negative parenting
- No treatment effect on
parent-reported impact of
the child on family
Nicholson Caregivers and their N = 358 Sing & Grow music - Group design - Parent-reported - No effects on child prob-
et al. (2008) 0–5-year-old Attrition 41% therapy program - No control group behavior problems lem behavior
children from - Group-based - No treatment (NEILS Scales) - Improvements in parent-
disadvantaged intervention integrity data - Parent-reported reported irritable parenting,
backgrounds or responsiveness (CRQ) educational activities in the
with IDD and irritable parenting home, parent mental health
(PPBS) - No effects on parenting
- Parenting self-efficacy self-efficacy
- Parent-reported - Improvements in parent-
mental health (Kessler reported child communi-
K6) cation and play skills
- Observed quality of - Improvements in therapist
parental behavior and observed child responsive-
child responsiveness ness, interest, and social
and engagement participation
- Improvements in
observed parent sensitivity,
engagement, and accep-
tance
Okuno et al. Mothers and their N = 14 Parent Training with - Group design - Parent-reported child - Decrease in parent-
(2011) 4–9-year-old Attrition 0% Smaller Groups and - No control group problem behavior reported behavior
children with Shorter Schedules - Treatment integrity (CBCL) - Increase in parent confi-
ASD and (PTSS) monitored but no - Parental confidence dence for handling child’s
challenging - Group-based data reported (CDQ) challenging behavior
behavior intervention
Continued
Phaneuf and Parents of N=8 Three-tier model of -Single-case design -Parent-reported child -Decreased parent-reported
McIntyre 2–4-year-old chil- Attrition 25% interventions based - Used parents’ response behavior problems child problem behavior
(2011) dren with IDD, pre-follow-up on the Incredible to intervention to (CBCL) - Decreased observed child
including ASD Years inform treatment - Observed child problem behavior
- Self-administered - 3 months follow-up problem behavior - Decreased observed
- Group-based program - Treatment integrity - Observed parenting negative parenting
(IYPT-DD) reported behavior behavior
- Individual sessions - Consumer satisfaction
with video feedback
and modeling
Pillay et al. Parents and their N = 58 parents ASCEND intervention - Group design - Parent-reported child - Reduction of parent-
(2011) 5–15-year-old N = 44 children - Group-based - No control group behavior (DBC) reported problem
children with Attrition 24% intervention - No treatment integ- - Parental learning behavior
ASD rity data - Consumer satisfaction - Increase in parental
knowledge and skills
Plant and Parents and their N = 74 Stepping Stones Triple - Randomized control - Parent-reported child Both SSTP-S and SSTP-E
Sanders preschool- n = 24 SSTP-E P Standard version trial behavior (ECBI, DBC) interventions were associ-
(2007) aged children n = 26 SSTP-S (SSTP-S) &SSTP - Coders blind to - Parent–child ated with:
(<6 years) with n = 24 wait-list Enhanced (SSTP-E) intervention interactions - Reduced levels of
IDD, including Attrition 10% - Individualized sessions condition (FOS-RIII) observed negative child
ASD, and chal- RCI analysis - Care-giving problems behavior
lenging behavior - Treatment integrity (CPC) - Reductions in the number
data reported - Parenting skills and of care-giving settings
- 1 year follow-up ability (PS) with child problem
- Parenting competence behavior
(PSOC) - Improvements in parental
- Parental depression competence
and anxiety (DASS) - Improvements in
- Marital quality (ADAS) satisfaction parenting role.
- Consumer satisfaction
(CSQ)
Research Parents and children N = 17 RUPP Parent Training - Group design - Parent-reported child Postintervention there were:
Units on aged 14–13 years Attrition 17.6% All children were - No control group noncompliance (HSG) - Reductions in
Pediatric with PDD and receiving medication - Treatment integrity - Parent-reported mal- parent-reported rates of
Psycho- challenging for irritability, reported adaptive behavior (ABC) noncompliance
pharma- behavior tantrums, aggression, - Observed improvement - Reductions in parent-
cology and self-injury. on the CGI scale reported rates of
[RUPP] - Adaptive behavior irritability
Autism (Vineland) - Increases in daily living
Network, - Basic language and skills
2007 learning (ABLLS) - Reeducations in parenting
- Parenting stress (PSI-SF) stress.
- Parent satisfaction
questionnaire
Sofronoff et al. Parents of children N = 51 Parent management - Group design - Parent-reported child - Postintervention, there
(2004) aged 6–12 years n = 18 individual training for Asperger - No random assign- behavior problems was a significant reduc-
with Asperger sessions syndrome ment (ECBI) tion in the number of
syndrome n = 18 workshop - Individual sessions - Treatment integrity - Parent-reported social parent-reported problem
n = 15 wait-list - 1 day workshop not reported skills (SSQ) behavior for children in
Attrition not - Wait-list control - 3 month follow-up - Usefulness and accept- both treatment groups
reported group ability questionnaire (workshop and individual
sessions) compared to the
wait-list control group
- Relative to the workshop
group and the wait-list
control group, parents in
the individual sessions
group reported lower
intensity of problem
behavior
- Relative to the control
group, both intervention
groups demonstrated
an increase in parent-
reported child social skills
Continued
Singh et al. Mothers and their N = 3 mother– Mindfulness training - Single-subject - Parent-observed - Reduction in par-
(2006) 4–6-year-old chil- child dyads Individual sessions experimental design aggression, noncom- ent-observed child
dren with autism - Multiple baseline pliance, and self-injury noncompliance, aggression,
and challenging across mother–child - Subjective Units of and self-injury
behavior dyads Parenting Satisfaction - Increase in parenting
− 12 month follow-up (SUPS) satisfaction
- No treatment integrity - Subjective Units of - Increase in interaction
data Use of Mindfulness satisfaction
(SUUM)
Singh et al. Mothers and their N = 4 mother– Mindfulness training - Single subject - Parent-observed - Reduction in parent-
(2007) 4–6-year-old chil- child dyads Individual sessions experimental design aggression observed child aggression
dren with IDD - Multiple baseline - Parent-observed child - Increase in parent-observed
and challenging across mother–child social interactions child social interactions
behavior dyads with siblings with siblings
- 12 month follow-up - Subjective Units of - Increase in parenting
- No treatment integrity Parenting Satisfaction satisfaction
data (SUPS) - Increase in interaction
- Subjective Units of satisfaction
Use of Mindfulness - Increase in use of
(SUUM) mindfulness
- Parent-reported par- - Decrease in parenting stress
enting stress (PSI)
Whittingham Parents of 2–9-year- N = 59 Stepping Stones Triple P - Randomized wait-list - Parent-reported child Relative to WL control
et al. (2009) old children n = 29 SSTP (SSTP) control trial behavior problems participants, children in
with ASD and n = 30 wait-list Partial-group format - RCI analysis (ECBI) SSTP group had
challenging Attrition 11% (group and individual - 6 month follow-up - Parent-reported par- - Decreased parent-reported
behavior sessions) - No treatment integrity enting styles (PS) behaviors
data - Parenting satisfaction - Decreased dysfunctional
and efficacy (PSOC) parenting
- increased parenting self-
efficacy at follow-up
Williams et al. Parents and their N = 201 Sing & Grow music - Group design - Parent-reported - No effects on child
(2012) 3–60-month-old Attrition not therapy program - No control group behavior problems problem behavior
children with reported - Group-based - Exploration of (NEILS Scales) - No effects on parent-
disabilities intervention predictors of - Parent-reported reported responsiveness
treatment responsiveness (CRQ) and irritable parenting
- No treatment and irritable parenting - No effects on parenting
integrity data (PPBS) self-efficacy
- Parenting self-efficacy - Improvements in parent
- Parent-reported mental health and child
mental health communication and play
(Kessler K6) skills
- Observed quality of - Improvements in
parental behavior and therapist observed child
child responsiveness responsiveness, interest,
and engagement and social engagement
- Improvements in
observed parent sensitivity,
engagement, and
acceptance
Note: ABC = Aberrant Behavior Checklist (Aman, Singh, Stewart, & Field, 1985); ABLLS = The Assessment of Basic Language and Learning Skills (Partington & Sundberg, 1998);
ADAS = Abbreviated Dyadic Adjustent Scale (Sharpley & Rogers, 1984); CBCL = Child Behavior Checklist (Achenbach & Rescorla, 2001); CDQ = Confidence Degree Question-
naire for Families (Iwasaka et al., 2002 as cited by Okuno et al., 2011); CES-D = Center for Epidemiology-Depression (Radloff, 1977); CGI = Clinical Global Impressions (Arnold
et al., 2000); CPC = Care-giving Problem Checklist (Plant & Sanders, 2007); CRQ = Child Rearing Questionnaire (Paterson & Sanson, 1999); CSQ = The Client Satisfaction
Questionnaire (Eyberg, 1993); DASS = The Depression Anxiety and Stress Scale (Lovibond & Lovibond, 1995); DBAF = The Difficult Behaviour Assessment Form (Hudson et al.,
2001); DBC = The Developmental Behaviour Checklist (Einfeld & Tonge, 2002); DPICS = Dyadic Parent–Child Interaction Coding System (Eyberg, Nelson, Duke, & Boggs, 2005);
ECBI = Eyberg Child Behavior Inventory (Eyberg & Pincus, 1999); FIQ = Family Impact Questionnaire (Donenberg & Baker, 1993); HSG = Home Situations Questionnaire
(Barkley, Edwards, & Robin, 1999); ITT = Intent-to-treat analysis; Kessler K6 = Kessler K6 screening scale (Furukawa, Kessler, Slade, & Andrews, 2003); NEILS Scales = The National
Early Intervention Longitudinal Study (SRI International, 2003); PHS = The Parenting Hassles Scale (Gavidia-Payne, Richdale, Francis, & Cotton, 1997); PPBS = Parental Percep-
tions and Behaviors Scale (Institut de la Statistique du Quebec, 2000); PS = The Parenting Scale (Arnold, O’Leary, Wolff, & Acker, 1993); PSI = Parenting Stress Index (Abidin, 1995);
PSI-SF = Parenting Stress Index-Short Form (Abidin, 1995); PSOC = Parenting Sense of Competence Scale (Johnston & Mash, 1989); RCI = Reliable Change Index (Jacobson
& Truax, 1991); ROS-RIII = Revised Family Observation Schedule (Sanders, Waugh, Tully, & Haynes, 1996); RUPP = Research Units on Pediatric Psychopharmacology Autism
Network; SSQ = Social Skills Questionnaire (Spence, 1995); SUIS = Subjective Units of Interaction Satisfaction (adapted from Stanley & Averill, 1998 as cited in Singh et al., 2006);
SUPS = Subjective Units of Parenting Satisfaction (adapted from Stanley & Averill, 1998 as cited in Singh et al., 2006); SUUM = Subjective Units of Use of Mindfulness (adapted
from Stanley & Averill, 1998 as cited in Singh et al., 2006);Vineland = Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984).
and main findings pertaining to child and parent outcomes are reviewed
below. In particular, the following study characteristics are described: (1)
participants; (2) dependent measures; (3) study design; (4) generalization,
maintenance, consumer satisfaction, and treatment integrity; (5) parent
training interventions; and (6) treatment outcomes.
2.1. Participants
Eighteen of the 19 studies reported the number of children participat-
ing in the study. The sample sizes ranged from 3 to 2119 children. The
median number of child participants was 51 (mean = 191). Fourteen stud-
ies provided a gender breakdown for child participants. Across all studies,
the majority of child participants were boys. More than a third of stud-
ies (n = 7) focused exclusively on early childhood, with target children
ranging from birth to 5 years (Bagner, Sheinkopf, Vohr, & Lester, 2010;
McIntyre, 2008a,b; Nicholson, Berthelsen, Abad, Williams, & Bradley,
2008; Phaneuf & McIntyre, 2011; Plant & Sanders, 2007; Williams,
Berthelsen, Nicholson, Walker, & Abad, 2012). The remainder of the stud-
ies included child participants up through age 18. Parent training studies
targeting adults with IDD were not identified. Children’s disability status
varied across the 19 studies; however, more than one-third (n = 7) focused
exclusively on children with ASD (Aman et al., 2009; Okuno et al., 2011;
Pillay, Alderson-Day, Wright, Williams, & Urwin, 2011; Research Units
on Pediatric Psychopharmacology [RUPP] Autism Network, 2007; Singh
et al., 2006; Sofronoff, Leslie, & Brown, 2004; Whittingham, Sofronoff,
Sheffield, & Sanders, 2009). Participants in the Hudson et al. (2003) and
Plant and Sanders (2007) studies included children with ASD and IDD
conditions. Participants in the Bagner et al. (2010) study were considered
at risk for developmental delays given their premature births (>37 weeks
gestation). Williams et al. (2012) did not specify the nature of the chil-
dren’s disabilities. The remaining eight studies included children with
multiple IDD conditions. The presence of child challenging behavior was
an inclusionary criteria in 58% (n = 11) of studies reviewed (Aman et al.,
2009; Bagner et al., 2010; Hames & Rollings, 2009; Hudson, Cameron,
& Matthews, 2008; Kleve, Crimlisk, Shoebridge, Greenwood, Baker, &
Mead, 2010; Okuno et al., 2011; Plant & Sanders, 2007; Research Units
et al., 2006, 2007; Whittingham et al., 2009). Twelve of the nineteen
studies reported the gender of caregivers, with all focusing primarily or
exclusively on mothers or other female caregivers. Eleven studies included
demographic information on caregivers (Hudson et al., 2003; McIntyre,

2008a,b; Nicholson et al., 2008; Okuno et al., 2011; Phaneuf & McIntyre,
2011; Plant & Sanders, 2007; Singh et al., 2006; Whittingham et al., 2009;
Williams et al., 2012).
2.2. Dependent Measures

All but two studies (Singh et al., 2006, 2007) included parent-reported
measures of children’s challenging behavior. Eight studies included direct
observations of child behavior, with five measuring challenging behavior
(Bagner et al., 2010; McIntyre, 2008a; Plant & Sanders, 2007; Singh et al.,
2006, 2007), two measuring children’s communication and social engage-
ment (Nicholson et al., 2008;Williams et al., 2012), and one using therapist’s
observations to form clinical impressions of behavioral stability (Research
Units on Pediatric Psychopharmacology [RUPP] Autism Network, 2007).
In addition to measuring child behavior, nearly half of the studies (n = 9)
assessed parenting behavior. Six studies assessed parenting behavior through
direct observations (Bagner et al., 2010; McIntyre, 2008a,b; Nicholson
et al., 2008; Phaneuf & McIntyre, 2011; Williams et al., 2012) and six stud-
ies measured parenting behavior through self-reports (Bagner et al., 2010;
Hames & Rollings, 2009; Nicholson et al., 2008; Plant & Sanders, 2007;
Whittingham et al., 2009; Williams et al., 2012). Seven studies assessed
parental competence, self-efficacy, or confidence in parenting (Hudson
et al., 2003, 2008; Nicholson et al., 2008; Okuno et al., 2011; Plant &
Sanders, 2007;Whittingham et al., 2009;Williams et al., 2012). Eight studies
measured parenting stress (Bagner et al., 2010; Hudson et al., 2003, 2008;
McIntyre, 2008a,b; Plant & Sanders, 2007; Research Units on Pediatric
Psychopharmacology [RUPP] Autism Network, 2007; Singh et al., 2007)
and six measured parental depression (Hudson et al., 2003, 2008; McIntyre,
2008a; Nicholson et al., 2008; Plant & Sanders, 2007; Williams et al., 2012).
2.3. Study Design

All but three studies used a group design to evaluate the effects of parent
training interventions on child outcomes. Phaneuf and McIntyre (2011)
used a single case changing conditions design in eight mother–child dyads.
Singh et al. (2006, 2007) used multiple baseline designs across three or four
mother–child dyads. Of the 16 group design studies, nine (56%) did not
include a control or comparison group. All but one study (Sofronoff et al.,
2004) that included a control or comparison group used random assignment
to assign treatment condition. Aman et al. (2009) used a medication-only
comparison group and contrasted it with a combined parent training and

medication treatment group. Bagner et al. (2010) and Whittingham et al.
(2009) used wait-list control groups and McIntyre (2008b) used a usual
care control group. Plant and Sanders (2007) compared two experimental
groups (standard and enhanced versions of the Stepping Stones Triple P
(SSTP)) with a wait-list control group. Hudson et al. (2003) compared three
experimental groups (group support, telephone support, and self-directed
support) with a wait-list control group.
2.3.1. Generalization, Maintenance, Consumer Satisfaction, and

Treatment Integrity
Only Nicholson et al. (2008) assessed generalization of parent training
intervention effects, and this was done through parent reports of home
usage of intervention strategies. Nine studies (Bagner et al., 2010; Hudson
et al., 2003, 2008; Phaneuf & McIntyre, 2011; Plant & Sanders, 2007; Singh
et al., 2006, 2007; Sofronoff et al., 2004; Whittingham et al., 2009) included
follow-up data collection between 3 and 12 months posttreatment to assess
maintenance effects. Eleven studies reported on consumer satisfaction of
parent training intervention (Hames & Rollings, 2009; Hudson et al., 2003,
2008; McIntyre, 2008a,b; Nicholson et al., 2008; Pillay et al., 2011; Plant &
Sanders, 2007; Research Units on Pediatric Psychopharmacology [RUPP]
Autism Network, 2007; Sofronoff et al., 2004; Williams et al., 2012). The
majority of studies (n = 11) did not report on treatment integrity of par-
ent training interventions. Seven studies included data on treatment integ-
rity (Aman et al., 2009; Bagner et al., 2010; McIntyre, 2008a,b; Phaneuf
& McIntyre, 2011; Plant & Sanders, 2007; Research Units on Pediatric
Psychopharmacology [RUPP] Autism Network, 2007). Okuno et al. (2011)
did not provide treatment integrity data in the manuscript but specified that
the fidelity of treatment implementation was monitored and therapists were
supervised to ensure high fidelity of implementation.
2.4. Parent Training Interventions

As shown in Table 8.1, eight (42%) parent training studies used group for-
mats to deliver the intervention (Hames & Rollings, 2009; Kleve et al.,
2010; McIntyre, 2008a,b; Nicholson et al., 2008; Okuno et al., 2011;
Pillay et al., 2011; Williams et al., 2012). Six (32%) used individual one-
on-one sessions to deliver the intervention (Aman et al., 2009; Plant &
Sanders, 2007; Research Units on Pediatric Psychopharmacology [RUPP]
Autism Network, 2007; Singh et al., 2006, 2007). Although the individually
delivered parent training interventions used manualized procedures, there

was some flexibility built into the protocols to provide more support in
areas of greatest need. Five (26%) studies reported delivering parent train-
ing using multiple formats. Hudson et al. (2003) compared the use of three
delivery modes of the intervention, including a self-administered program,
telephone consultation, and group parent training program. Hudson et al.
(2008) added a fourth mode of delivery and compared the above three
modes of intervention delivery with an individually delivered interven-
tion. Phaneuf and McIntyre (2011) increased the intensity of parent train-
ing support depending on parents’ response to intervention. Parent training
interventions ranged from self-administered programs to therapist-delivered
programs that were either group-based or individually delivered. Sofronoff
et al. (2004) compared a 1 day workshop with six individually delivered
sessions of parent management training.Whittingham et al. (2009) provided
a partial-group format such that sessions were provided in group settings
with additional individually delivered sessions.
All studies reported using treatment manuals or protocols to guide
the parent training interventions. Below I summarize the parent training
approaches used in studies included in this chapter.
2.4.1. Incredible Years

Four studies (Kleve et al., 2010; McIntyre, 2008a,b; Phaneuf & McIntyre,
2011) investigated the effects of Webster-Stratton’s Incredible Years Parent
Training program (IYPT; Webster-Stratton, 2001) on challenging behavior
in children with IDD. McIntyre (McIntyre, 2008a,b; Phaneuf & McIntyre,
2011) used an adapted version of the Incredible Years for use with parents
of children with DD (IYPT-DD; McIntyre, 2008a). IYPT is an evidence-
based parent training program based on principles of operant and social
learning theories (Webster-Stratton, 2000). IYPT is designed to be delivered
in approximately 12 weekly sessions. Group leaders use discussion, video
modeling, role-playing, and didactics to cover topics in five main areas: play,
praise, rewards, limit setting, and handling challenging behavior. Challeng-
ing behavior is reduced through altering negative and coercive parent–child
interactions (Webster-Stratton, 2001). DD modifications implemented
by McIntyre (IYPT-DD) included discussing the unique challenges and
blessings associated with raising a child with IDD, understanding children’s
developmental levels and support needs, conducting descriptive functional
behavioral assessments, and developing behavior support plans based on
the hypothesized function of the child’s challenging behavior (McIntyre,
2008a). Kleve et al. (2010) and McIntyre (2008a,b) used the Incredible Years
group program. Phaneuf and McIntyre (2011) incorporated a three-tiered
model of intervention that increased the intensity of support depending
on parents’ responsiveness to intervention. The three tiers of intervention
evaluated by Phaneuf and McIntyre included self-administered reading
materials (based on the Incredible Years: A Trouble-Shooting Guide for Parents
of Children Aged 2–8 Years; Webster-Stratton, 2005), group-based parenting
training based on the Incredible Years with DD modifications (IYPT-DD),
and individualized video feedback based on the behavioral skills training
literature (e.g. Himle, Miltenberger, Gatheridge, & Flessner, 2004) with
content covering the IYPT-DD (Phaneuf & McIntyre, 2007).
2.4.2. Stepping Stones Triple P

Two studies (Plant & Sanders, 2007; Whittingham et al., 2009) reported
on the effects of SSTP in families of children with IDD or ASD. Stepping
Stones is a variant of the evidence-based Triple P Positive Parenting Pro-
gram (Sanders, 1999) and was developed especially for use with caregivers of
children with disabilities. Triple P is grounded in operant and social learn-
ing theories and draws on principles guided by applied behavior analysis
and coercion theory in reducing child problem behavior through altering
parent–child interactions (Sanders, 1999). SSTP includes many components
of the original Triple P program (e.g. reinforcement-based approaches
for increasing positive behavior, differential reinforcement for decreasing
challenging behavior, and consideration of the function of the problem
behavior) and also teaching strategies from the special education literature
(e.g. skill acquisition and functional communication training). Plant and
Sanders compared SSTP with an enhanced version of SSTP. The enhanced
intervention consisted of SSTP with additional content focused on stress
and coping, strengthening social support, and partnering with profession-
als. In Whittingham et al. (2009) the SSTP focused on parents of children
with ASD and included generic SSTP plus strategies on using comic strip
conversations and social stories (Gray, 1998) developed to promote social
awareness, understanding, and problem solving.
2.4.3. Signposts for Building Better Behavior

Two studies reported on the effects of the Signposts for Building Better
Behavior program (Hudson et al., 2003, 2008). Signposts is a multilevel
program designed to be a preventive intervention of challenging behavior
in 3–16-year-old children with intellectual disability (Hudson et al., 2003).
Signposts is designed to teach parents strategies for reducing challenging

behavior before the behaviors escalate and warrant costly and time-
consuming specialized interventions. Signposts is based on operant and
social learning theories and uses behavioral parent training approaches
to reduce challenging behavior and promote positive child and family
adjustment (Hudson et al., 2003). In Hudson et al. (2003), three modes of
intervention delivery were evaluated, including self-directed intervention
using guidebooks and DVDs, telephone support, and group-delivery
intervention. Hudson et al. (2008) expanded on this initial efficacy trial and
reported on a wide-scale implementation trial of the Signposts program. In
this large implementation trial, a fourth level of intervention (i.e. individual
parent training sessions) was added and evaluated for effectiveness.
2.4.4. RUPP Parent Training

Two studies (Aman et al., 2009; Research Units on Pediatric Psychophar-
macology [RUPP] Autism Network, 2007) reported outcomes for the
Research Units in Pediatric Psychopharmacology (RUPP) Autism Network
medication trial which involved comparing the effects of psychotropic
medication to a combined treatment of medication and parent training in
children with pervasive developmental disorders (PDD). The RUPP Parent
Training (RUPP PT) program is a manualized, individually delivered treat-
ment based on principles of applied behavior analysis, operant theory, and
behavioral skill training ( Johnson et al., 2007). The goal of RUPP PT is to
increase compliance and decrease problem behavior in children with PDD.
RUPP PT consists of 11 core treatment sessions, three optional sessions, and
up to three booster sessions. Core sessions include topics on basic behav-
ioral techniques used to decrease problem behavior and increase adaptive
behavior, functional communication training, skill building, and promoting
generalization and maintenance ( Johnson et al., 2007). Up to 17 sessions
are individually delivered to parents over the course of a 24-week period
(Aman et al., 2009; Research Units on Pediatric Psychopharmacology
[RUPP] Autism Network, 2007).
2.4.5. Sing & Grow Music Therapy

Two studies (Nicholson et al., 2008; Williams et al., 2012) reported on the
use of Sing & Grow, a 10-week group-based early childhood parenting
intervention that uses music-based play activities to enhance responsive par-
enting and promote child development (Abad, 2002). Sing & Grow is deliv-
ered by trained music therapists and is based on principles of attachment
theory, childhood development, and behavioral parent training interven-

tions, such as the Triple P Positive Parenting Program (Sanders, 1999). Sing &
Grow uses music to enhance parent–child relationships and foster intimacy,
trust, and bonding. Gains in child development are thought to be fostered
through the strengthening of the parent–child relationship (Abad, 2002).
Parent behaviors targeted in Sing & Grow include parental expression
of affection, physical touch, praise, appropriate instruction-giving, paren-
tal emotional responsiveness, and confidence-building of parenting skills
(Nicholson et al., 2008;Williams et al., 2012).Through their participation in
Sing & Grow, parents learn about the developmental needs of their children
and have more appropriate expectations for their children’s development
and management of challenging behavior.
2.4.6. Mindfulness Training

Two studies reported on the effects of mindfulness training to decrease chal-
lenging behavior in children with autism and developmental disabilities
(Singh et al., 2006, 2007). Mindfulness training in this context focused on
teaching parents to “have a clear, calm mind that is focused on the present
moment in a nonjudgmental way” (Singh et al., 2007, p. 752). Mindful-
ness training was individually provided to parents in 12 2 h sessions. The
book Everyday Blessings: The Inner Work of Mindful Parenting (Kabat-Zinn &
Kabat-Zinn, 1997) supplemented weekly topics covered in sessions. The 12
weekly topics included a general introduction to mindful parenting, know-
ing your mind, focused attention, focused attention on arousal states, being
present in the moment, beginner’s mind, being with your child, nonjudg-
mental acceptance, letting go, loving kindness, problem solving, and using
mindfulness in daily interactions (Singh et al., 2007).
2.4.7. Parent–Child Interaction Therapy

One study reported on the use of Parent–Child Interaction Therapy (PCIT)
for children born prematurely with externalizing behavior problems
(Bagner et al., 2010). PCIT is an evidence-based parent training interven-
tion grounded in attachment and social learning theories (Eyberg, Boggs, &
Algina, 1995) designed to reduce children’s disruptive behavior through
strengthening positive parent–child interactions. PCIT is an individually
delivered intervention that is paced according to the parent’s responsiveness
to intervention. There are two phases to treatment—a child-directed inter-
vention (CDI) phase and a parent-directed intervention (PDI) phase. The
parent must master aspects of CDI before moving on to the PDI portion of
treatment. CDI focuses on increasing positive interactions between the par-

ent and child through play and praise. PDI focuses on increasing the child’s
compliance and decreasing their aggression through limit setting and the
use of effective commands (Eyberg et al., 1995).
2.4.8. Autism Spectrum Conditions—Enhancing Nurture and

Development
Pillay et al. (2011) examined the use of Autism Spectrum Conditions—
Enhancing Nurture and Development (ASCEND) for parents of school-
aged children with ASD. This manualized program (Wright & Williams,
2007) focuses on providing parents with information about ASD, posi-
tive behavior intervention strategies, and behavior management strategies.
ASCEND also aims to empower parents to network with others to support
the needs of their child with ASD. Each session includes a review of the
previous session, introduction of a new topic, demonstrations and examples,
practice activities, group discussions, and overview of homework activi-
ties. Topics included in the 11 week program include social understanding
of children with ASD, language and communication, preoccupations and
repetitive behaviors, cognition and planning, behavior management, and
social communication strategies including Social Stories (Gray, 1998) and
Picture Exchange Communication System (Frost & Bondy, 2002).
2.4.9. Parent Training with Smaller Groups and Shorter Schedules

Okuno et al. (2011) examined the effects of Parent Training with Smaller
Groups and Shorter Schedules (PTSS) on mothers and their children with
ASD and challenging behavior. PTSS was developed in Japan and based on
evidence-based behavioral parent training approaches developed by Barkley
(1987) for use with parents of children with attention deficit/hyperactivity
disorder (ADHD). PTSS consists of six sessions that provide parents with
information about ASD, principles of positive reinforcement, environmental
modifications to prevent or reduce problem behavior, and management of
challenging behavior through the use of planned ignoring and nonphysical
discipline. Parent training groups were kept small (3–4 participants) with
90 min sessions scheduled every 1–2 weeks (Okuno et al., 2011).
2.4.10. Video Modeling Parent Training

Hames and Rollings (2009) developed a parent training program for use
in their school with parents of children with disabilities and challenging
behavior. Parent groups included an average of 6–8 parents and were led by
two facilitators. Hames and Rollings described that parent groups typically
ran for 6–8 weeks depending on the needs and interests of the participants.
As part of the parent groups, Hames and Rollings used videos of parents
interacting with their children carrying out a variety of tasks at home.Video
modeling and corrective feedback was used as a teaching strategy and a
mechanism to facilitate discussion.Videos of children interacting with their
teachers were also shown to demonstrate effective strategies used at school.
In addition to skill training using video modeling and feedback, the parent
group provided general social support and information to caregivers of chil-
dren with disabilities. Parents are invited to attend the parent group as fre-
quently as they wished to socialize and learn from other parents (Hames &
Rollings, 2009).
2.4.11. Parent Management Training for Asperger Syndrome

One study used a parent management training program designed for parents
of children with Asperger syndrome (Sofronoff et al., 2004) and compared
two formats of intervention delivery. Participants received intervention in
a 1 day workshop or in six weekly 1 h sessions. Components of the inter-
vention included psychoeducation surrounding Asperger syndrome, comic
strip conversations, social stories, management of problem behaviors, man-
agement of rigid behaviors and special interests, and management of anxiety.
Content on comic strip conversations and social stories was based on the
work of Gray (1994a,b, 1998). Managing child problem behavior was based
on behavioral interventions described by Sanders and Dadds (1993). Con-
tent on managing special interests and anxiety focused on understanding
the needs of the child and approaching child support from the perspective
of prevention (Sofronoff et al., 2004). It was unclear if the anxiety manage-
ment strategies were tied to evidence-based approaches.
2.5. Treatment Outcomes

All 19 studies investigated the effects of a parent training intervention on
the challenging behavior of children with IDD. In addition to challeng-
ing behavior, several studies investigated the effects of parent training on
parenting behavior, parental competence, parenting stress, and depression
(Table 8.1). Below I summarize treatment outcomes across studies.
2.5.1. Challenging Behavior

All but two studies (Singh et al., 2006, 2007) measured child challenging
behavior through parent-reported measures. Of the 17 studies that included
parent-reported measures of child challenging behavior, all but three stud-

ies (McIntyre, 2008a; Nicholson et al., 2008; Williams et al., 2012) reported
significant reductions of parent-reported challenging behavior posttreatment.
Neither evaluation of the Sing & Grow intervention produced significant
reductions in parent-reported child challenging behavior (Nicholson et al.,
2008;Williams et al., 2012). McIntyre (2008a) did not demonstrate a signifi-
cant treatment effect on parent-reported child behavior using the Incred-
ible Years intervention. Five studies included direct observations of child
challenging behavior, with all showing significant reductions in observed
child problem behavior posttreatment (Bagner et al., 2010; McIntyre, 2008a;
Plant & Sanders, 2007; Singh et al., 2006, 2007).
2.5.2. Parenting Behavior

Six studies assessed changes in parenting behavior through self-reported
questionnaires (Bagner et al., 2010; Hames & Rollings, 2009; Nicholson
et al., 2008; Plant & Sanders, 2007;Whittingham et al., 2009;Williams et al.,
2012). All but Williams et al. (2012) reported positive effects on self-reported
parenting behavior. Six studies assessed parenting behavior through direct
observations (Bagner et al., 2010; McIntyre, 2008a,b; Nicholson et al., 2008;
Phaneuf & McIntyre, 2011;Williams et al., 2012) with all six reporting posi-
tive effects on observed parenting behaviors, including more positive inter-
actions (Bagner et al., 2010; Nicholson et al., 2008; Williams et al., 2012)
and fewer negative interactions (McIntyre, 2008a,b; Phaneuf & McIntyre,
2011).
2.5.3. Parental Competence, Self-Efficacy, and Confidence

Seven studies assessed parental competence, self-efficacy, or confidence in
parenting (Hudson et al., 2003, 2008; Nicholson et al., 2008; Okuno et al.,
2011; Plant & Sanders, 2007;Whittingham et al., 2009;Williams et al., 2012).
Hudson et al. (2003, 2008), Okuno et al., and Plant and Sanders reported
significant improvement in parenting self-efficacy postintervention. On the
other hand, Nicholson et al. and Williams et al. reported null effects. Whit-
tingham et al. reported a possible sleeper effect such that parenting self-
efficacy significantly increased from pretreatment to 6 months follow-up
assessment; however, there was no significant change from pretreatment to
posttreatment on parenting self-efficacy. Whittingham et al. suggested that
it may take parents a while to feel efficacious with their new parenting
skills. They hypothesize that over time, and with practice, parents feel more
competent.
2.5.4. Parenting Stress and Depression

Eight studies measured parenting stress (Bagner et al., 2010; Hudson et al.,
2003, 2008; McIntyre, 2008a,b; Plant & Sanders, 2007; Singh et al., 2007)
with mixed results. Bagner et al., Hudson et al. (2003, 2008), and Singh
et al. (2007) reported significant reductions in parenting stress from pre-
to posttreatment. In contrast, McIntyre (2008a,b) and Plant and Sanders
(2007) reported null findings on the effects of parent training on parenting
stress. Six studies measured parental depression (Hudson et al., 2003, 2008;
McIntyre, 2008a; Nicholson et al., 2008; Plant & Sanders, 2007; Williams
et al., 2012) with all but two (McIntyre, 2008a; Plant & Sanders, 2007)
reporting significant decreases in parental depression postintervention.
2.6. Strengths of Extant Literature

Taken as a whole, recent empirical studies investigating the effects of par-
ent training interventions suggest positive effects on reducing child chal-
lenging behavior in children with IDD. The effects on parenting behavior
and mental health are less clear. Of note is that all studies included in this
chapter primarily focused on parent training interventions to reduce chil-
dren’s challenging behavior. Thus, several parent training intervention stud-
ies aimed at enhancing parent mental health and reducing parenting stress
were omitted if they did not also focus on children’s challenging behavior
(e.g. Keen, Couzens, Muspratt, & Rodger, 2010; Tonge et al., 2006). Cer-
tainly the literature base on the effects of parent training interventions on
parent mental health in families with children with IDD is growing.
There are a number of strengths inherent in the current body of litera-
ture reviewed. Below I highlight several strengths, including the interna-
tional literature base, tailoring for children with ASD and their families, use
of evidence-based behavior management strategies, and the multimethod
assessment.
2.6.1. International Literature Base

The 19 studies reviewed in this chapter represent research from four coun-
tries. Eight studies were conducted in the US (Aman et al., 2009; Bagner
et al., 2010; McIntyre, 2008a,b; Phaneuf & McIntyre, 2011; Research Units
et al., 2006, 2007). Seven studies were conducted in Australia (Hudson et al.,
2003, 2008; Nicholson et al., 2008; Plant & Sanders, 2007; Sofronoff et al.,
2004; Whittingham et al., 2009; Williams et al., 2012). Three studies were
conducted in the UK (Hames & Rollings, 2009; Kleve et al., 2010; Pillay
et al., 2011), and one study was conducted in Japan (Okuno et al., 2011).
Although each parent training intervention had a slightly different approach,
curriculum, design, and goal, all interventions incorporated at least some
similar content in terms of basic child development and learning principles.
These commonalities, along with the growing international evidence base,
suggest widespread uptake of parent training practices for use with families
of children with IDD and challenging behavior.
2.6.2. Tailoring Interventions for ASD

Given the sharp increase in the estimated prevalence of ASD, more treat-
ments are needed that incorporate empirically supported strategies tailored
to the specific needs of children with ASD and their caregivers. Of the 19
studies reviewed in this chapter, six were designed exclusively for use with
parents of children with ASD. Several modifications were made to these
treatments to tailor them for the needs of children with ASD. In particular,
Aman et al. (2009), Okuno et al. (2011), Pillay et al. (2011), and Whittingham
et al. (2009) all provided content on using schedules and visual displays
to prevent challenging behavior. Sofronoff et al. reported on the incor-
poration of psychoeducation surrounding Asperger syndrome, comic strip
conversations and social stories into the parent management intervention.
Whittingham et al. reported on the incorporation of comic strip conver-
sations and social stories to the SSTP program. Aman et al. (2009) and
the Research Units on Pediatric Psychopharmacology [RUPP] Autism
Network (2007) included content on functional communication training.
Pillay et al. (2011) provided information to help parents understand the
social cognitive differences in children with ASD.These carefully developed
parent training protocols are especially well suited to address the needs of
families of children with ASD and challenging behavior.
2.6.3. Evidence-Based Behavior Management Strategies

The clear majority of reviewed parent training interventions for children
with IDD and challenging behavior are based on principles of operant and
social learning theories and draw on strategies from the field of applied
behavior analysis.To highlight this point, all intervention components in the
RUPP PT intervention have empirical support for use with children with
disabilities and challenging behavior ( Johnson et al., 2007). At the heart of
behavioral parent training programs is altering the parent–child interactions
so that children’s positive behaviors are reinforced and reinforcement is
withheld for children’s negative or inappropriate behaviors. Furthermore, a
number of behavioral parent training programs for children with disabilities

focus on training parents to implement teaching programs and implement
behavior plans, all the while empowering parents to partner with profes-
sionals in the intervention plans in support of their child’s well-being.
2.6.4. Multimethod Assessment

A final strength in the extant empirical literature base on parent training
interventions for children with IDD is the inclusion of multimethod assess-
ments to characterize the sample and measure outcomes. More than half of
the studies (n = 10) included parent self-report measures as well as direct
observation of parent or child behaviors. Assessments that involve direct
observations with blinded evaluators strengthen the conclusions that can be
drawn from the results of the study and lend additional ecological validity
and generalization to the data.
2.7. Limitations and Future Directions

Although these studies have a number of strengths, there are several notable
limitations, which taken as a whole, limit the inferences that can be drawn
from the findings. Below I outline several study limitations including study
design, attrition, sample size, moderators and mediators, assessment of gen-
eralization and maintenance, and assessment of treatment integrity.
2.7.1. Study Design

Of the 16 group design studies reviewed, more than half did not include a
control or comparison group, making it impossible to rule out the impact
of history or maturation on child and parent outcomes posttreatment
(Campbell & Stanley, 1963). As the body of evidence supporting the efficacy
of parent training on challenging behavior in children with IDD expands, it
will become important to compare parent training to other evidence-based
interventions, such as individual therapy and medication management. The
only study to compare parent training with another active intervention
was the RUPP medication trial described by Aman et al. (2009). Aman
et al. randomized children with PDD and challenging behavior to receive
either medication (risperidone) alone or a combined treatment of medica-
tion plus behavioral parent training. Given the documented effects of ris-
peridone on the challenging behavior of children with PDD (Canitano &
Scandurra, 2008), Aman et al. (2009) assumed that one important aspect of
treatment for this population was medication management. Parent training
was evaluated to determine the additive benefits, above and beyond the
positive effects of medication. This design is similar to several studies con-

ducted on the effects of stimulant medication and parent training in chil-
dren with ADHD (e.g. Ercan, Ardic, Kutlu, & Durak, 2012). Although the
state of our science is not as well established as the ADHD treatment lit-
erature, comparative treatment designs will become increasingly important
for evaluating the effects of multiple treatments on challenging behavior in
children with IDD.
2.7.2. Attrition
Attrition ranged from 0% to 87% in the studies included in this chapter. In
some cases families participated in intervention but did not complete assess-
ments. In other instances families withdrew from parent training without
completing intervention. Both scenarios influence the inferences that can be
drawn from study findings. Nevertheless, accurately tracking and reporting
attrition information is imperative in treatment studies, as is reporting the
measures taken to retain participants in treatment or follow-up assessments.
Attrition may be minimized if steps are taken to increase client treatment
engagement. Treatment engagement describes the process by which clients
connect with and actively participate in intervention (Thompson, Bender,
Lantry, & Flynn, 2007). Although treatment engagement is separate from
treatment attendance, these concepts are related in that one must attend
treatment sessions in order to engage in therapy. Future studies should take
measures to reduce attrition as well as take meaningful steps to boost family
engagement with parent training interventions.
2.7.3. Sample Size

With few exceptions, the sample sizes in the included studies were relatively
small (median n = 51). Small studies are important for documenting the
feasibility of methodology and for piloting treatment or assessment pro-
cedures. Small studies, if carefully designed, can also provide an evidence
base for conducting larger scale evaluation. Two noteworthy examples of
scaling up treatments are the RUPP PT studies and the Signposts inter-
vention development. In the RUPP studies, pilot testing was conducted
to determine the feasibility of parent training procedures ( Johnson et al.,
2007; Research Units on Pediatric Psychopharmacology [RUPP] Autism
Network, 2007) before scaling up for a larger efficacy trial (Aman et al.,
2009).The Signposts intervention was evaluated in an efficacy trial (Hudson
et al., 2003) before implementing on a wide scale (Hudson et al., 2008).
Future investigation should systematically evaluate the feasibility, efficacy,
and effectiveness of interventions through the use of single-subject experi-

ments, small pilot studies, larger controlled efficacy trials, and wide-scale
implementation studies.
2.7.4. Power, Moderators and Mediators

Related to sample size is the issue of power to detect significant treatment
effects. Power is influenced by type I and type II error, sample size, and the
magnitude of treatment effects (Cohen, 1992). Thus, when the sample size
is small, power to detect small to medium treatment effects is compromised.
When power is low, it is virtually impossible to conduct analyses that exam-
ine moderators and mechanisms of treatment outcomes. Larger scale studies
that are adequately powered can explore variables predictive of treatment
outcomes as well as explore variables that account for changes in dependent
measures. For example, it could be hypothesized that parent training inter-
ventions are effective in reducing children’s challenging behavior because
of changes in parenting and parent–child interactions. Parenting behavior
is assumed to mediate, or partially mediate, the relation between treatment
and outcome, yet these assumptions are not often empirically tested in the
IDD parent training literature. Likewise, studies that examine subgroup
differential outcomes or explore variables predictive of treatment outcome
(moderational analyses) are rare in the IDD literature. Although studies of
treatment moderators and mediators are in the IDD parent training litera-
ture, three exceptions are worth highlighting. Two papers from the RUPP
PT studies report on moderators and mediators of treatment outcomes for
children with PDD and challenging behavior. Farmer et al. (2012) reported
on the original sample (described by Aman et al., 2009) and conducted
moderational analyses examining demographic variables and noncompli-
ance on treatment outcomes. Farmer et al. found that more noncompli-
ance at baseline, regardless of treatment group assigned (medication alone vs
combined medication and parent training), predicted better outcomes post-
treatment. Scahill et al. (2012) reported on the original RUPP PT sample
and investigated the effects of treatment on children’s adaptive behavior.
Scahill et al. concluded that a reduction in children’s challenging behav-
ior promotes improvements in adaptive behavior. Although not tested in
a meditational model, this relation could be investigated empirically in a
larger sample with great power. Hudson, Reece, Cameron, and Matthews
(2009) reported on moderational analyses using a subsample of participants
with complete pre- and posttreatment data from the large-scale implemen-
tation trial (Hudson et al., 2008). Child gender, age, and disability diagnosis
were explored as possible moderators of treatment outcomes. Results from

moderational analyses suggest main effects for the Signposts parent train-
ing intervention but no significant moderators of treatment (Hudson et al.,
2009). Studies examining moderators and mediators are important in
enhancing our knowledge of intervention effectiveness for subgroups and
for enhancing our understanding of underlying mechanisms of treatment
outcomes.
2.7.5. Generalization and Maintenance

Less than half (n = 9) of the studies in this chapter included follow-up assess-
ments to examine the extent to which treatment effects maintained over
time. Follow-up assessments were conducted between 3 and 12 months post-
treatment. Follow-up assessments are useful in determining maintenance of
effects but can also be used to determine cost-effectiveness of intervention
and prevention of later mental health disorders. Studies that include longi-
tudinal assessments are costly and time-consuming; however, these studies
greatly enhance our understanding of treatment effects over time, particu-
larly if the goal is to prevent onset of behavior disorders. Likewise, exami-
nation of generalization of treatment effects is important in determining
the skill transfer across settings, caregivers, and materials. Given that many
parent training interventions are conducted in clinic or community settings,
the extent to which parents generalize skills to the home environment is
crucial. Only one study (Nicholson et al., 2008) assessed generalization of
parent training strategies to the home, and this was done through parent
report. Clearly, additional studies are needed to determine the generalization
and long-term maintenance of parent training treatment effects in reducing
child challenging behavior and promoting positive parenting practices.
2.7.6. Treatment Integrity

Treatment integrity refers to the extent to which the intervention is imple-
mented as intended (McIntyre, Gresham, DiGennaro, & Reed, 2007). Con-
clusions about study efficacy are compromised without knowledge of the
accurate implementation of intervention. Over half of the studies included
in this chapter did not specify treatment integrity data. Future studies should
document the treatment integrity of interventions as well as explore if all
components of an intervention are necessary to yield positive treatment
outcomes. Careful assessment and analysis of treatment integrity data may
shed light on critical components of parent training interventions necessary
to produce positive treatment effects.
3. CONCLUSIONS
A review of key study features and outcomes of 19 studies published
between 2003 and 2012 suggest that there is a growing evidence base for
the use of parent training interventions for reducing challenging behavior
in children with IDD, including autism and related disorders. A smaller
body of evidence suggests effects on parenting behavior and mental health.
Questions remain about the durability and generalization of findings, mod-
erators and mediators of change, and strategies for enhancing therapeutic
alliance and engagement with an aim to reduce attrition.
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Laura Lee Mcintyre

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Parent Training Interventions to

International Review of Research in Developmental Disabilities, Volume 44 © 2013 Elsevier Inc.

2.7. Limitations and Future Directions 270

2. REVIEW OF PARENT TRAINING INTERVENTIONS

demographic information on caregivers (Hudson et al., 2003; McIntyre,

2.2. Dependent Measures

2.3. Study Design

comparison group and contrasted it with a combined parent training and

2.3.1. Generalization, Maintenance, Consumer Satisfaction, and

2.4. Parent Training Interventions

delivered parent training interventions used manualized procedures, there

2.4.1. Incredible Years

2.4.2. Stepping Stones Triple P

2.4.3. Signposts for Building Better Behavior

Signposts is designed to teach parents strategies for reducing challenging

2.4.4. RUPP Parent Training

2.4.5. Sing & Grow Music Therapy

theory, childhood development, and behavioral parent training interven-

2.4.6. Mindfulness Training

2.4.7. Parent–Child Interaction Therapy

treatment. CDI focuses on increasing positive interactions between the par-

2.4.8. Autism Spectrum Conditions—Enhancing Nurture and

2.4.9. Parent Training with Smaller Groups and Shorter Schedules

2.4.10. Video Modeling Parent Training

2.4.11. Parent Management Training for Asperger Syndrome

2.5. Treatment Outcomes

2.5.1. Challenging Behavior

parent-reported measures of child challenging behavior, all but three stud-

2.5.2. Parenting Behavior

2.5.3. Parental Competence, Self-Efficacy, and Confidence

2.5.4. Parenting Stress and Depression

2.6. Strengths of Extant Literature

2.6.1. International Literature Base

2.6.2. Tailoring Interventions for ASD

2.6.3. Evidence-Based Behavior Management Strategies

number of behavioral parent training programs for children with disabilities

2.6.4. Multimethod Assessment

2.7. Limitations and Future Directions

2.7.1. Study Design

positive effects of medication. This design is similar to several studies con-

2.7.3. Sample Size

and effectiveness of interventions through the use of single-subject experi-

2.7.4. Power, Moderators and Mediators

were explored as possible moderators of treatment outcomes. Results from

2.7.5. Generalization and Maintenance

2.7.6. Treatment Integrity

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