Impact of a Contextual Intervention on Child Participation
and Parent Competence Among Children With Autism
Spectrum Disorders: A Pretest–Posttest
Repeated-Measures Design
KEY WORDS
 activities of daily living
 autistic disorder
 education
 parenting
 professional–family relations
 sensation
 sensory threshold
Winnie Dunn, PhD, OTR, FAOTA, is Professor and
Chair, Department of Occupational Therapy Education,
School of Health Professions, University of Kansas
Medical Center, 3033 Robinson Hall, Mailstop 2003,
3901 Rainbow Boulevard, Kansas City, KS 66160-7602;
wdunn@kumc.edu
Jane Cox, MS, OTR, is Clinical Assistant Professor,
Department of Occupational Therapy Education, University
of Kansas Medical Center, Kansas City.
Lauren Foster, OTD, OTR, is Clinical Assistant
Professor, Department of Occupational Therapy Education,
University of Kansas Medical Center, Kansas City.
Lisa Mische-Lawson, PhD, RRT, is Assistant
Professor, Department of Occupational Therapy Education,
University of Kansas Medical Center, Kansas City.
Jennifer Tanquary, MEd, is Research Program
Administrator, Department of Occupational Therapy
Education, University of Kansas Medical Center, Kansas
City.
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Winnie Dunn, Jane Cox, Lauren Foster, Lisa Mische-Lawson,
Jennifer Tanquary
OBJECTIVE. We tested an occupational therapy contextual intervention for improving participation in
children with autism spectrum disorders and for developing parental competence.
METHOD. Using a repeated-measures pretest–posttest design, we evaluated the effectiveness of a con-
textually relevant reflective guidance occupational therapy intervention involving three components: au-
thentic activity settings, family’s daily routines, and the child’s sensory processing patterns (Sensory
Profile). We used these components to coach 20 parents in strategies to support their child’s participation.
Intervention sessions involved reflective discussion with parents to support them in identifying strategies to
meet their goals and make joint plans for the coming week. We measured child participation (Canadian
Occupational Performance Measure, Goal Attainment Scaling) and parent competence (Parenting Sense of
Competence, Parenting Stress Index).
RESULTS. Results indicated that parents felt more competent and children significantly increased par-
ticipation in everyday life, suggesting that this approach is an effective occupational therapy intervention.
Dunn, W., Cox, J., Foster, L., Mische-Lawson, L., & Tanquary, J. (2012). Impact of a contextual intervention on child par-
ticipation and parent competence among children with autism spectrum disorders: A pretest–posttest repeated-measures
design. American Journal of Occupational Therapy, 66, 520–528. http://dx.doi.org/10.5014/ajot.2012.004119
F
amily-centered practice (Dunst, Bruder, Trivette, & Hamby, 2006) empha-
sizes practitioner–caregiver partnerships (McWilliam, 2010) and principles
such as use of family resources to generate solutions to family-identified goals,
family uniqueness, and interventions in authentic contexts (e.g., Dunn, 2011;
LaVesser & Berg, 2011). Twenty years of studies (e.g., Ackland, 1991; Dunst
et al., 2006) have shown that with professional support, parents and teachers
effectively promote positive child outcomes. Parent-implemented interventions
involve identifying everyday activities, settings, and child interests to support
child learning during everyday activities (Dunst, 2006). For example, daily
routines such as dressing, eating, sleeping, car rides, and playing (Doo & Wing,
2006; Dunst et al., 2006; King et al., 2003; Shani-Adir, Rozenman, Kessel, &
Engel-Yeger, 2009) can serve as intervention contexts that yield positive child
outcomes (e.g., Darrah et al., 2011; Law et al., 2011). Spagnola and Fiese
(2007) described the dinnertime routine to demonstrate how typical routines
can be sources of predictable, repeated learning opportunities.
Coaching is an evidence-based intervention method that is family centered
and promotes adult learning (McWilliam, 2010; Rush & Shelden, 2011).
Coaching occurs in family settings, promotes parent-directed goals and sol-
utions, and builds parents’ capacity to identify and implement interventions
during life routines (Dunst et al., 2006; Graham, Rodger, & Ziviani, 2010).
September/October 2012, Volume 66, Number 5
 Given that coaching focuses on building parents’
capacity to design their own solutions, we consider the
impact of contextual interventions on parental compe-
tence. Parents of children with autism spectrum disorders
(ASD) often experience more stress (Mori, Ujiie, Smith,
& Howlin, 2009), and home-based, parent-directed prac-
tices may reduce stress and increase competence (e.g., King,
Teplicky, King, & Rosenbaum, 2004).
Thus, to adequately address the needs of families
raising children with ASD, occupational therapists must
consider evidence-based interventions that reflect family-
centered care, occur in natural environments, and reflect
interests of families with children with ASD (Bruder,
2010). Knowing that children with ASD have more in-
tense sensory processing, we hypothesized that providing
contextual interventions within daily routines informed
by the child’s sensory patterns would improve parental
competence and child outcomes. We used Dunn’s (1997,
2001, 2008) model of sensory processing—which out-
lines four patterns of seeking, avoiding, sensitivity, and
registration—combined with occupational therapy using
a contextually relevant, guided approach to examine two
research questions: When parents participate in contex-
tual occupational therapy interventions,
1. Do children increase their participation in family
activities and routines?
2. Do parents increase their competence and de-
crease stress in their parenting role (i.e., parental
competence)?
Method
Research Design
We used a one-group repeated-measures pretest–posttest
research design to investigate whether contextually rele-
vant interventions led to (1) increased child participation
and (2) increased parental competence and decreased
perceived stress. We obtained approval from the Human
Subjects Committee at the University of Kansas Medical
Center. Parents provided informed consent; children ³
age 7 provided assent.
Participants
We recruited families who have children with ASD (based
on parent reports) ages 3–10 through schools and support
groups in a Midwestern suburban area. We selected
families on a first-come, first-served basis when parents
indicated that they had unmet needs in their family life
and when children had at least one sensory pattern out-
side typical (Sensory Profile [SP]; Dunn, 1999). We re-
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corded other family services but did not control for them.
We excluded children with typical sensory patterns.
Measures
Sensory Profile. In the SP, the caregiver answers 125
questions about the child’s sensory experiences on a
5-point Likert scale. The SP reports internal consistency
ranging from .41 to .91 and construct validity (.517–.796)
with the School Function Assessment (Coster, Deeney,
Haltiwanger, & Haley, 1988). Discriminant validity has
been reported in many studies over the past decade (Dunn,
Myles, & Orr, 2002; Engel-Yeger, 2008; Kientz & Dunn,
1997; Rogers, Hepburn, & Wehner, 2003; Shani-Adir
et al., 2009; Tomchek & Dunn, 2007; Watling, Deitz,
& White, 2001). The SP yields four processing scores
(seeking, avoiding, sensitivity, registration) and six sensory
scores (auditory, visual, proprioception, vestibular, tactile,
oral; Dunn, 1999).
Canadian Occupational Performance Measure. The Ca-
nadian Occupational Performance Measure (COPM; Law
et al., 1998) is an outcome-based assessment; caregivers
identify issues in self-care, productivity, and leisure. Pa-
rents rate performance and satisfaction (scores range from
1 to 10). Psychometric properties include internal con-
sistencies of .56 and .71, respectively, and test–retest re-
liability of .80 (Law et al., 1998; Law, Baum, & Dunn,
2005). Intervention goals come from parent-identified
issues. Change scores indicate met outcomes (Law et al.,
1998). Consistent with Darrah et al. (2011), we used the
COPM to support parents in developing functional
goals.
Goal Attainment Scaling. Goal Attainment Scaling
(GAS; Schaaf & Nightlinger, 2007) quantifies goal prog-
ress in everyday life. Miller, Schoen, James, and Schaaf
(2007) reported an interrater reliability of .67 with various
populations. To use GAS, one identifies current behavior,
creates incremental steps toward desired behavior, and
then evaluates level of goal attainment at the conclusion of
the intervention. Studies have indicated that GAS is an
effective posttest measure for parents to report behavior
change (Graham et al., 2010; Miller et al., 2007). For
this study, parents identified goals and therapists coached
parents in scaling them incrementally.
We recorded parents’ exact words and continued
asking reflective questions until GAS had five levels (we
used a 5-point scale for analyses). Parents indicated that
each step represented satisfactory progress (Graham et al.,
2010).
Parenting Stress Index–Short Form. The Parenting
Stress Index–Short Form (PSI–SF; Abidin, 1995) is a 36-
item self-report measure (responses are made on a 5-point
521
 Likert scale) of parent responses to life events. Validity
and reliability are reported in the manual, along with a
.94 correlation between the short and long form. Recent
reliability estimates ranged from .84 to .93 for the Pa-
rental Distress subscale (Zaidman-Zait et al., 2010). In-
ternal consistency between subtests and the total score
was .90 and remained the same 1 yr later (Haskett,
Ahern, Ward, & Allaire, 2006). Haskett et al. (2006) also
reported discriminant validity by comparing the PSI–SF
with six measures of emotional health, parental percep-
tions of child adjustment, and parenting behaviors of
parents who were or were not abusive; five comparisons
yielded significant differences, with Cohen’s ds (indi-
cating effect size) ranging from 0.22 to 2.02.
Parenting Sense of Competence Scale. The Parenting
Sense of Competence Scale (PSOC; Ohan, Leung, &
Johnston, 2000; Rogers & Matthews, 2004) is a 17-item
scale (responses range from 1 5 strongly agree to 6 5
strongly disagree) that measures parental self-efficacy and
satisfaction on the basis of factor analyses. Gilmore and
Cuskelly (2008) accounted for 50% of variance among
1,200 parents with these factors. Graham et al. (2010)
reported that the PSOC was an effective measure of
change.
The COPM, GAS, PSI–SF, and PSOC formed the
Outcomes Measures Battery (OMB).
Intervention
Two occupational therapists provided 10 intervention
sessions per family; sessions lasted approximately 1 hr
(total 5 10 hr) over 12–15 wk. The intervention reflected
principles of context therapy (Darrah et al., 2011) and
contained three intervention characteristics: activity set-
tings, daily life routines, and sensory processing patterns.
Figure 1 illustrates the relationships among intervention
characteristics and outcomes (successful child participa-
tion, increased parental competence).
Parents identified goals and selected activity settings in
which they needed support on the basis of their priorities
and interests (e.g., home, park, grocery store). Activity
Figure 1. Illustration of contextual intervention and outcomes.
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settings distinguish this intervention from traditional
therapy, which might occur in clinic interactions with
therapists. Evidence has indicated that children get more
practice and develop and generalize skills when inter-
ventions are embedded within routines (e.g., getting
dressed, playing, sitting in grocery cart; Dempsey &
Dunst, 2004; Law, Garrett, & Nye, 2004).
We used SP data, expertise about sensory process-
ing, and task analysis to consider the impact of each
child’s sensory patterns on routines and settings. In
conversations with parents, we linked sensory processing
principles to their family’s routines and settings, so that
parents learned how their children’s sensory processing
patterns might affect participation. One parent who had
successfully used visual schedules with an older child
made one for her younger child’s morning routine but
found that it did not help. The therapist coached, “Let’s
look at your daughter’s sensory patterns and see if we
can see why the visual schedule didn’t work.” Through
coaching, the mother realized her daughter’s auditory
strengths and decided to try a kitchen timer instead,
because that approach took advantage of the daughter’s
strength in auditory processing. The timer prompted her
daughter to get out of the shower and move through her
routine.
During the first intervention session, therapists met
with parents to review their priorities from the COPM,
GAS, and activity configurations (i.e., outline of family’s
daily schedule) to provide the settings and routines
components of the contextual interventions. Using SP
findings, therapists coached parents to design interven-
tion plans for Week 1. At each subsequent visit, they
discussed what had happened since the last visit. When
closing each session, parent and therapist made a joint
plan detailing the family’s strategies; the plan reflected
how sensory knowledge informed the strategies in au-
thentic settings and life routines for that week.
We followed coaching principles outlined by Rush
and Shelden (2011) and consistent with context therapy
(Darrah et al., 2011) to guide intervention planning.
Therapists used reflective statements and questions to
invite parents to discuss possible ways to achieve those
goals. Therapists avoided yes–no questions; rather, they
fostered insights. For example, they would ask, “How
does he wash his face now?” (awareness); “What other
times does he get things on his face; how does he act
during those other times?” (analysis); “I wonder how we
could use successful past strategies to change his routine?”
(alternatives); and “What supports do you need to try
that?” (action). Therapists did not offer expert advice or
directives. Instead, they continued to ask questions to
September/October 2012, Volume 66, Number 5
 uncover what the child’s participation would look like
(e.g., “If his performance was a little better, what would
he be doing instead?”) and make comments until parents
identified specific characteristics that would represent
progress or goal achievement for them.
Maintaining Fidelity of Contextual Intervention
Two occupational therapists provided interventions to 10
families each. Therapists attended statewide training in
coaching, which involved 4 days of training with 6 mo of
follow-along coaching (Rush & Shelden, 2011). As di-
rector of a statewide evidence-based practice project, the
senior researcher, Winnie Dunn, collaborated to develop
materials used in the statewide training. After intensive
training with simulated practice, therapists implemented
coaching strategies with actual families and obtained
feedback from experienced coaches. They kept coaching
logs and analyzed them for reflective questioning strate-
gies. This process continued until logs contained re-
flective questions and comments and did not contain
directives. The intervention was manualized for future
publication.
The research team met weekly to review research
procedures and provide coaching to therapists; recordings
from visits served as references for these meetings. The
therapists also met weekly to ensure they were providing
consistent intervention.
Data Collection
During testing, parents and therapists completed the
OMB. The same therapist provided testing and inter-
ventions to families. Intervention therapists were blind to
parents’ responses on the PSI–SF and PSOC; parents
completed them, and other team members entered and
scored their forms. They were not blind to parents’ results
on the GAS and COPM, which they needed to guide
interventions.
Figure 2 details data collection timelines. During
TEST 1 (the initial visit after consent), therapists re-
viewed the study and completed the OMB and an activity
configuration about daily routines of interest to the
family. During baseline (4 wk), families continued usual
Figure 2. Timeline for data collection.
a
During testing periods, therapists administered the Outcome Measures Bat-
tery: Canadian Occupational Performance Measure, Goal Attainment Scaling,
Parenting Stress Index–Short Form, and Parenting Sense of Competence
Scale.
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routines and services. They completed the OMB at TEST
2, and therapists scheduled intervention sessions.
During the intervention period, therapists met with
parents (face to face or by phone) according to their needs
and at their convenience (10 sessions). During these
sessions, therapists coached families to support their
children using three intervention characteristics. TEST 3
occurred after 10 intervention sessions. During sustain-
ability (4 wk), therapists and parents did not meet; families
continued routines and services from other sources. Fi-
nally, during TEST 4 therapists and parents completed the
OMB again.
Data Analysis
We used a within-subject (repeated-measures) analysis of
variance with post hoc testing to determine effects for time
(Figure 1). We made four comparisons:
1. TEST 1–TEST 2 (baseline): Do outcomes change
over a 4-wk period without additional intervention?
2. TEST 2–TEST 3: Is the intervention effective?
3. TEST 3–TEST 4: Are effects sustained without
contact?
4. TEST 1–TEST 4: Are there overall changes from first
to last meeting?
With four pairwise comparisons, Holm’s sequential
Bonferroni procedure controlled for familywise error
rates (Green & Salkind, 2011). With this correction, we
set p < .0125 as our significance level. We used poly-
nomial contrast calculations to identify the source of
significant differences when there was overall significance.
Results
Sample Characteristics
Participants were parents of 17 boys and 3 girls, ages 3–10 yr
(mean 5 6.5 yr). Twelve children had autism, 1 had As-
perger syndrome, and 7 had ASD and another diagnosis
(e.g., developmental delay, attention deficit hyperactivity
disorder, depression). Physicians diagnosed 11 participants;
a team diagnosed the other 9 participants. Ten children took
supplements (e.g., melatonin, homeopathics) or medication
(e.g., citalopram).
Nineteen mothers and 1 father served as participants.
Two families had one child; others had 2–6 children.
Eighteen families were suburban; 2 families were urban.
One family was Latino, 17 were White, and 2 reported
more than one ethnicity. Families reported household
income levels (1, <$30,000; 5, $30,000–$75,000; 14,
>$75,000). All parents had some college education. All
children received other services.
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 Sensory Profile Patterns
For 10 children, all four quadrant scores were 1–2 stan-
dard deviations greater than those of their peers without
autism. Nine children had three or four quadrants in the
more-than-others categories. One child had only Regis-
tration in the more-than-others category.
Intervention Characteristics
The contextual intervention characteristics (active ingre-
dients) were activity settings and routines and the child’s
sensory patterns. Parents selected activity settings—home
(74%; e.g., bedroom, bathroom, transitions) and com-
munity (22%; e.g., church, parking lots, stores)—and
routines—self-care (49%; e.g., dressing, eating, sleeping,
hygiene) and leisure (37%; e.g., playing, watching TV).
The third characteristic was the child’s sensory pat-
terns. When creating joint plans, therapists referenced
sensory patterns: seeking (21%), avoiding (1%), sensi-
tivity (10%), registration (13%), and two or more pat-
terns (55%). They used sensory system information:
auditory (13%), visual (26%), touch (20%), movement
(17%), body position (13%), and other (e.g., oral; 11%).
Children’s Participation
For the COPM, results indicated a significant time effect
for Performance (Wilks’s L 5 .137, F [4, 16] 5 27.408,
p < .001, h2 5 .863) and Satisfaction (Wilks’s L 5 .181,
F [4, 16] 5 19.546, p < .001, h2 5 .819). Polynomial
contrasts for COPM indicated a significant linear effect
for Performance scores (F [1, 19] 5 90.907, p < .001,
h2 5 .858). Comparisons 2 and 4 were significant (both
ps < .001). Ratings changed from 3.6 to 7.0 (10-point
scale). Polynomial contrasts for COPM Satisfaction in-
dicated a significant linear effect (F [1, 19] 5 66.502, p <
.001, h2 5 .816). Comparisons 2 and 4 (both ps < .001)
and Comparison 1 (p 5 .011) were significant. Ratings
changed from 3.2 to 7.0 (10-point scale). Figure 3 il-
lustrates changes across time periods.
For GAS, results indicated a significant time effect as
well (Wilks’s L 5 .070, F [4, 16] 5 66.328, p < .001, h2 5
.930). Polynomial contrasts indicated a significant
linear effect (F [1, 19] 5 215.963, p < .001, h2 5
.927). Comparisons 2 and 4 (both ps < .001) were
significant. The average change for goals was 2 points
(4-point scale; Figure 3).
Parental Competence
For the PSI–SF, results indicated a significant time effect
(Wilks’s L 5 .436, F [4, 16] 5 6.037, p < .007, h2 5
.564). Polynomial contrasts for subtests indicated a sig-
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Figure 3. Mean scores for child outcomes across testing periods
(n 5 20 children, 44 goals).
Note. COPM 5 Canadian Occupational Performance Measure; GAS 5 Goal
Attainment Scaling.
nificant linear effect for defensive responding (7 items;
F [1, 19] 5 17.049, p 5 .001, h2 5 .516) and parental
distress (12 items; F [1, 19] 5 13.031, p 5 .002, h2 5
.449). Comparison 4 was significant (ps 5 .001). For
defensive responding, parents began the study at the 96th
percentile and ended the study at the 70th percentile on
the basis of PSI–SF scoring criteria. For parental distress,
parents went from the 85th percentile to the 50th
percentile.
PSOC results indicated that parents experienced
a significant improvement in efficacy. The analysis of
variance indicated a significant time effect (Wilks’s L 5
.335, F [4, 16] 5 10.065, p 5 .001, h2 5 .665). Poly-
nomial contrasts indicated a significant linear effect (F [1,
19] 5 22.078, p < .000, h2 5 .580). Only Comparison 4
was significant (p < .001), with parents increasing their
sense of efficacy from the first visit to the last. Compared
with a normative Australian sample (Gilmore & Cuskelly,
2008), parental efficacy levels in this study were 2 standard
deviations higher than average. Parental satisfaction did
not change in our study; however, when compared with
Gilmore and Cuskelly’s (2008) data, parental satisfaction
in our study was about average.
Discussion
We found that a 10-session contextual intervention was
effective in improving children’s participation and pa-
rental competence among families with children with
ASD. We provided interventions by meeting with parents
to discuss their goals and supporting them in identifying
new ways to achieve their goals. Our intervention shares
core principles of context therapy as reported in Darrah
et al. (2011); for example, work centers on parents within
the family’s authentic environments and activities. We
focused on building the family’s capacity to achieve its
own goals. Findings indicated that this brief intervention
September/October 2012, Volume 66, Number 5
 (10 sessions) had a strong positive impact on parents and
children.
Intervention Characteristics
Because our intervention focused on families in natural
environments, it is not surprising that the bulk of activity
settings were home (74%) and community (22%). This
study illustrated that although children received special
services through school, families continued to have sig-
nificant needs for support in their daily lives. In general,
therapy services for self-care are not the scope of practice
for school personnel. Self-care represented nearly half of
goals, and playing represented 24% of goals. Although all
families focus on self-care and playing at home and in the
community, the increased intensity of managing daily life
with children who are vulnerable (e.g., those with ASD)
may require more attention. Other researchers have
reported that family life revolves around ASD and that
families have only fleeting moments of feeling like a family
(DeGrace, 2004). Occupational therapists might consider
how to reform services for school-age children to include
family needs.
Parents talked about intervention characteristics as
they told us how the joint plans had worked the previous
week. In early team meetings, we discussed what we
thought parents could do to achieve their goals. Because
our intervention was not an expert approach, therapists
did not give parents these ideas. We asked ourselves how to
support parents to identify strategies in their own lives and
gain insight into their situation. We presumed that parents
had the resources to achieve their goals (strengths ap-
proach) and that we were responsible for providing re-
flective feedback and questions to reveal their capacity and
resources. Using this reflective support, parents identified
and implemented strategies that we could not have
imagined. For example, one parent wanted her son to
behave better after school. In coaching sessions with each
other, we thought he needed a snack. However, in sub-
sequent weeks, this mother realized through reflective
discussions and joint plans that giving her son attention for
a few minutes after school fostered his playing alone until
dinner. Had we given our expert advice, we would have
misguided this family.
Sometimes it was helpful to understand why plans
did not work. One mother used music for morning
routines because her son loved music, but it did not
motivate him to get out of bed. In joint planning, the
mother wondered whether he was hungry; he was also
motivated by sweet flavors, so she decided to provide
sweet breakfast foods.
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Children’s Participation
Study findings indicate significant improvements in
children’s performance (COPM and GAS). Parents ex-
hibited positive perceptions of their children’s participa-
tion through the sustainability period, suggesting that
families discovered successful methods for managing their
daily lives.
Families set 44 goals (mean 5 2.4 goals, range 5 1–5
goals). When they felt satisfied, parents identified new
goals based on GAS. Sometimes parents discontinued goals
because they realized during coaching what the basis of
their child’s behavior was or determined that the behavior
was appropriate. For example, one mother decided to
address playing and realized that traditional playing
routines were not enjoyable for her son. She discovered
that he preferred helping to fold laundry. By redefining
what was satisfying, she recognized his strengths and
interests.
Parents asked for help in many areas, including
dressing, eating, getting shots, riding in cars, and
transitioning from bus to home. Therapists listened
carefully to parents’ explanations about goal areas and
guided discussions so that together they specified levels
of behavior for GAS. Therapists asked questions such
as, “What would it look like if she cared for her own
hair properly?” Although this process took time, ask-
ing reflective questions to specify measurement levels
on GAS invited parents to think about what aspects of
routines were going well and which needed adjustments.
For children’s outcomes, Comparison 2 revealed
changes from the intervention period, and Comparison 4
indicated overall changes from the beginning to the end
of the study; outcomes at both time points improved
significantly. No changes occurred during waiting peri-
ods, confirming that children’s participation did not
change during baseline (Comparison 1) and remained
high after the study (Comparison 3). Parents said they
benefited from dedicated time to talk about their family
and being accountable to someone for trying things each
week.
There was one exception: The COPM Satisfaction
score improved during Comparison 1. Perhaps during
baseline, parents became more aware of satisfaction factors
regarding their child’s participation and so had a different
perspective when intervention began because they had
thought about it for 4 wk. During the second visit, pa-
rents and therapists may have been more comfortable
with their new relationships. Parents expected to say what
was wrong with their children; because our approach
525
 emphasized strengths, TEST 1 may have reflected dis-
satisfaction, thereby dampening initial scores.
Parental Competence
On the PSI–SF, parents reported significantly lower
distress and less defensive responding (e.g., “I feel trapped
by my responsibilities as a parent”). Additionally, pa-
rental distress was at the 50th percentile at study’s end.
Considering that these parents are handling challenging
daily lives with children who have ASD, this finding is
notable. As parents continued to reflect on their lives and
identify strategies to support their family, perhaps they
began to understand their own capacity to find solutions
for situations that were overwhelming before inter-
vention. These findings are consistent with those of
other studies of parent empowerment (e.g., Nachshen &
Minnes, 2005).
Parents reported significant improvements in parental
efficacy. According to Rogers and Matthews (2004), the
PSOC Efficacy scale assesses capability and problem-
solving ability (e.g., “If anyone can find the answer to
what is troubling my child, I am the one”). Efficacy may
be inversely related to distress, because distress reduced
and efficacy increased significantly. Parents demonstrated
efficacy by reporting how the joint plan worked, planning
with the therapist, and offering their own suggestions
about how to make adjustments to achieve goals.
Sometimes, parents made adjustments to joint plans
without direct therapist support. Parents also demon-
strated efficacy when they had “aha” moments during
coaching conversations; for example, 1 parent said she
realized that going to his brother’s soccer game was not
fun for her son and that they were all more satisfied when
she went to the game and got him a babysitter. Before the
study, she thought that she was neglecting him by leaving
him at home.
Efficacy levels were also notably stronger than those of
98% of typical parents (Gilmore & Cuskelly, 2008).
Perhaps parents who must pay vigilant attention develop
a stronger sense of themselves as parents. This example
may be one of an “uber” strength, a characteristic of the
person that has required his or her attention and so be-
comes both a unique feature of the person’s identity and
a strength because of the attention the person has given to
its development (Dunn, 2010).
Efficacy levels were significantly improved only for
Comparison 4 (i.e., from the beginning to the end of the
study). Perhaps parents need time to feel less distressed and
more confident. These data suggest that parents need time
to process their child’s progress, contextual factors, and
their own reactions to their child’s behavior. Sometimes
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professionals can feel rushed with families because of
caseloads and other responsibilities; this intervention
takes time to implement and achieve results. Perhaps
parents’ experience of trying strategies with their children
and achieving goals they set allows them to build their
competence.
Although parents’ satisfaction ratings did not change
(PSOC), they maintained high satisfaction as parents
(70%). The Satisfaction scale reflects parental emotions
(Rogers & Matthews, 2004); parents’ scores indicated
that they have relatively low levels of frustration and
anxiety about parenting. Even with the intense life they
experience with their children, these parents indicated
that they were satisfied with being a parent.
Parents made plans every week; not all strategies were
effective. Therapists completed an intervention docu-
mentation form at each session that included a question
about how effective parents felt with joint plans. Across all
plans, parents said joint plans worked well 26% of the
time, were “okay” 23% of the time, and were not effective
51% of the time. Because efficacy improved and distress
diminished, perhaps the iterative problem-solving process
led to changes for parents. An expert approach might
bypass the growth that is possible when a parent has to
consider how to meet a goal.
Study Limitations
Because families volunteered, we might have had families
who were more motivated to follow through with plans.
Therapists collected test data with families they served,
which may have affected results because they had de-
veloped a relationship and were invested in positive
outcomes. However, comments such as those reported
here suggest that parental insights had a strong part to play
in the outcomes. In future studies, we will need to specify
the details of the intervention process using transcripts
from sessions and from coaching meetings; until then,
a provider may not have enough information to imple-
ment these interventions and achieve similar outcomes.
Future Research
We need to establish clear fidelity parameters so we can
replicate interventions and findings with other providers.
We need to conduct additional studies to build evidence
for contextual interventions; even this small sample
yielded good power and effect size estimates, suggesting
that this approach has promise. Parents and therapists both
felt meeting in person at first was helpful, so identifying
the most salient features of the intervention process so we
can train experienced occupational therapists and faculty
will be critical to moving this evidence into practice.
September/October 2012, Volume 66, Number 5
 Implications for Occupational
Therapy Practice
The results of this study have the following implications
for occupational therapy practice:
• This study contributes evidence that families are
strong resources for managing their own lives. By pro-
viding a structure for problem solving (intervention
characteristics) and reflective guidance (coaching), we
supported parents in finding unique ways to achieve
prioritized goals.
• Interventions focused solely on supporting families to
achieve their prioritized goals lead to significant im-
provement in children’s participation in ways that pa-
rents found useful.
• Using coaching with parents to find strategies to
achieve their goals leads to the parents feeling more
competent in their parenting role.
• Linking sensory patterns to daily life activities and
settings provides a structure for problem solving. s
Acknowledgments
We are grateful to the families who participated in this
study; their insights lit the way to better practices for all
families. We acknowledge the Kansas Center for Autism
Research and Training for providing funding. We also
acknowledge the Department of Occupational Therapy
Education at the University of Kansas for providing an
environment of discovery, supporting all of us to think big
about possibilities for occupational therapy practice and
research.
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