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J Autism Dev Disord
DOI 10.1007/s10803-017-3339-2
ORIGINAL PAPER
Teaching Parents Behavioral Strategies for Autism Spectrum
Disorder (ASD): Effects on Stress, Strain, and Competence
Suzannah Iadarola1,7 · Lynne Levato1 · Bryan Harrison1 · Tristram Smith1 ·
Luc Lecavalier2 · Cynthia Johnson3 · Naomi Swiezy4 · Karen Bearss5 ·
Lawrence Scahill6
© Springer Science+Business Media, LLC 2017
Abstract We report on parent outcomes from a rand-
omized clinical trial of parent training (PT) versus psychoe-
ducation (PEP) in 180 children with autism spectrum disor-
der (ASD) and disruptive behavior. We compare the impact
of PT and PEP on parent outcomes: Parenting Stress Index
(PSI), Parent Sense of Competence (PSOC), and Caregiver
Strain Questionnaire (CGSQ). Mixed-effects linear models
evaluated differences at weeks 12 and 24, controlling for
baseline scores. Parents in PT reported greater improvement
than PEP on the PSOC (ES = 0.34), CGSQ (ES = 0.50), and
difficult child subdomain of the PSI (ES = 0.44). This is
the largest trial assessing PT in ASD on parent outcomes.
PT reduces disruptive behavior in children, and improves
Electronic supplementary material The online version of this
article (doi:10.1007/s10803-017-3339-2) contains supplementary
material, which is available to authorized users.
* Suzannah Iadarola
suzannah_iadarola@urmc.rochester.edu
Lynne Levato
lynne_levato@urmc.rochester.edu
Bryan Harrison
bryan_harrison@urmc.rochester.edu
Tristram Smith
Tristram_smith@urmc.rochester.edu
Luc Lecavalier
luc.lecavalier@osumc.edu
Cynthia Johnson
Cynthia.johnson@chp.edu
Naomi Swiezy
nswiezy@iupui.edu
Karen Bearss
kbearss@u.washington.edu
parental competence while reducing parental stress and
parental strain.
Keywords Autism spectrum disorder · Parent training ·
Parental stress · Parental competence
Introduction
Parents of young children with ASD face many challenges.
Children with ASD often require specialized care coordi-
nation across several providers and multiple meetings on
school placement. Parents may become isolated from friends
and family who may not understand the child’s behavior
and disability (Abbeduto et al. 2004; Kogan et al. 2008;
Rao and Beidel 2009). These parental challenges may be
influenced by the child’s age, timing of diagnosis, and level
Lawrence Scahill
Lawrence.scahill@emory.edu
1
University of Rochester Medical Center, Rochester, NY,
USA
2
Ohio State University, Columbus, OH, USA
3
University of Florida, Gainesville, FL, USA
4
Indiana University, Indianapolis, IN, USA
5
University of Washington, Seattle, WA, USA
6
Emory University, Atlanta, GA, USA
7
Department of Pediatrics, University of Rochester Medical
Center, 601 Elmwood Avenue, Box 671, Rochester,
NY 14642, USA
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of symptom severity (Greenberg et al. 2006; Hastings et al.
2005). Disruptive behaviors, including tantrums, noncompli-
ance, aggression, and self-injury are common, affecting as
many as 50% of children with ASD. These behaviors in the
child may amplify caregiving burden (Hastings et al. 2005)
and contribute to parental stress and strain (Boström et al.
2011; Hsiao 2016; Vasilopoulou and Nisbet 2016). Disrup-
tive behavior in the child may also erode parental compe-
tence, perceived self-efficacy, and problem-solving skills
(Benson 2014; Falk et al. 2014; Pottie and Ingram 2008;
Rezendes and Scarpa 2011). Interventions that reduce dis-
ruptive behavior may also reduce parental stress and strain.
In addition, the association between child behavior and
parenting stress may be bidirectional, with stress reducing
parents’ ability to address disruptive behavior (Greenberg
et al. 2006).
Several parent training (PT) interventions have been
developed (Smith and Iadarola 2015) to teach new skills,
address skill deficits, or decrease disruptive behavior in
children with ASD (Bearss et al. 2015; Strauss et al. 2012;
Tonge et al. 2014). Studies on PT for children with ASD
and disruptive behavior have shown decreases in child dis-
ruptive behavior (Postorino et al. 2017). Few studies have
reported on parental distress and related outcomes (e.g., self-
efficacy). Findings on parental outcomes in parent training
studies are inconclusive due to study design limitations or
small sample size (Coolican et al. 2010; Tonge et al. 2006;
Whittingham et al. 2009). Parent variables that moderate
or mediate the effect of PT on child disruptive behavior or
parental stress have not been examined (Smith and Iadarola
2015). Observational, cross-sectional studies suggest that
parental cognitions such as perceived efficacy (or related
cognitions such as perceived locus of control, perceived
competence, engagement, and problem-solving) are associ-
ated with lower parenting stress (Benson 2014; Falk et al.
2014; Pottie and Ingram 2008; Rezendes and Scarpa 2011).
Although PT is a well-established intervention for dis-
ruptive behavior in non-ASD pediatric populations (Dretzke
et al. 2009), findings on parental outcomes are also limited
and equivocal. Common parent outcomes of interest include
perceived parenting ability and satisfaction (often referred
to as parental self-efficacy or parental competence) as well
as stress and internalizing symptoms (i.e., anxiety, depres-
sion, somatization). A meta-analysis reported medium effect
sizes (0.42–0.53) of PT on measures of parental stress and
competence (Lundahl et al. 2006). Associations between
parenting programs for disruptive behavior and reduced
stress, decreased depression, and increased locus of control
(Chacko et al. 2009; Danforth et al. 2006; Moreland et al.
2016) have also been documented. However, in two large-
scale studies of children with ADHD, parents reported no
reduction in stress after PT (Abikoff et al. 2007; Wells et al.
2000). Thus, although PT provides specific tools to help
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J Autism Dev Disord
parents manage disruptive behavior, it is not clear that PT
reduces parental stress and strain. Indeed, the task demands
of applying PT could contribute to parental stress (Karst and
Van Hecke 2012). It may be expected that parents who learn
and practice parent training techniques will achieve a greater
sense of competence. Whether increases in competence will
contribute to decreased parental stress and strain is not clear.
In prior work, we built a structured PT manual that inte-
grated behavior change strategies developed and tested in
single subject studies for disruptive behavior in children
with ASD (Johnson et al. 2007). We conducted a series of
studies showing that this program is acceptable to parents,
can be delivered with fidelity by trained therapists, and can
augment the therapeutic effects of medication (Aman et al.
2009; Bearss et al. 2013). In a rigorous test of PT, we con-
ducted a six-site, 24-week randomized controlled trial (RCT)
in 180 children with ASD and disruptive behavior, aged
3–7 (Bearss et al. 2015; Lecavalier et al. 2017; Scahill et al.
2016). Children were randomized to an 11-session, struc-
tured PT program or a 12-session parent education program
(PEP) that controlled for time and attention. PT was superior
to PEP in reducing parent-rated child disruptive behavior.
The positive response rate on the Clinical Global Impres-
sion Improvement Score completed by clinicians who were
blind to treatment assignment was 68.5% in PT compared
to 39.6% in PEP (39.6%). PT was also superior to PEP on
a standardized measure of child daily living skills (Scahill
et al. 2016). In a follow-up paper we identified that modera-
tors of positive child outcomes in PT versus PEP included
lower ADHD and anxiety symptoms and higher household
income (Lecavalier et al. 2017).
The current report focuses on parent outcomes in this
RCT. Our primary hypothesis was that self-reported paren-
tal competence would show significant improvement and
whether self-reported measures of parental stress would
show significant decreases in PT compared to PEP. Based
upon previous findings that parental cognitions may influ-
ence parental stress (Falk et al. 2014), we also explored
whether change in parental cognitions (i.e., competence)
would predict improvement in parental stress and caregiver
strain, as well as child disruptive behavior. The study design
allowed examination of these questions because it included
multiple parent self-report measures collected at midpoint
(week 12) and endpoint (week 24).
Methods
Design
The original RCT was conducted at six sites (Emory Univer-
sity, Indiana University, Ohio State University, University of
Pittsburgh, University of Rochester, and Yale University) from
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J Autism Dev Disord
September, 2010 to February, 2014. The trial was approved
by the institutional review boards at each site, and informed
consent was obtained from a parent or legal guardian. Partici-
pants who met eligibility criteria were randomly assigned to 24
weeks of PT or PEP using permutated blocks with concealed
allocation to investigators. Randomization was performed
within site and further stratified by educational intensity to
ensure that groups contained an equal number of participants
in high intensity school/therapeutic programming. High inten-
sity service was defined as 15 h or more per week of 1:1 or 1:2
specialized instruction for ASD. Therapists held a minimum of
a master’s degree and had been certified to deliver each study
intervention after completing training and demonstrating fidel-
ity (> 80% correct implementation of content in all sessions,
rated by a senior investigator). Therapists received weekly
local supervision and monthly during cross-site case reviews.
Parent ratings on child disruptive behavior were completed
every 4 weeks and every 12 weeks for parent measures. The
measures included several parent-report questionnaires. The
background, methods, and main child outcomes are reported
in detail in Bearss et al. (2015).
Participants
One-hundred-eighty children with ASD and moderate
or greater disruptive behavior between the ages of 3 and
7 years inclusive participated in the 24-week study. One
parent from each household was enrolled in PT or PEP and
was the informant on all outcome measures. Other parents
and family members with caregiving responsibilities were
invited to join therapy sessions. Eligibility required: an ASD
diagnosis, a score ≥ 15 on the Irritability subscale of the
Aberrant Behavior Checklist (described below), and a CGI
Severity (CGI-S) score ≥ 4. Additional interventions and
medications were required to be stable for 6 weeks, with no
planned changes for the course of the study. Children with
serious medical conditions or another psychiatric disorder
in need of treatment, receptive language skills ≤ 18 months
(as determined by standardized cognitive and developmen-
tal assessments), or those with current or past treatment in
structured PT for disruptive behavior were excluded. Clini-
cal diagnosis of ASD was based on DSM-IV-TR criteria
(American Psychiatric Association 2000) corroborated by
the Autism Diagnostic Interview-Revised (ADI-R; Rutter
et al. 2003) and the Autism Diagnostic Observation Sched-
ule (ADOS; Lord et al. 2002).
Measures
Characterization Measures
The Autism Diagnostic Observation Schedule (ADOS) is
an investigator-based assessment conducted in naturalistic
social situations demanding specific social, communication
and restricted/repetitive responses. Behaviors are scored in
the areas of social communication, social relatedness, play
and imagination, and repetitive behaviors. An ADOS score
above the cutoff for either autism or autism spectrum disor-
der was used to support the diagnosis of ASD.
The Autism Diagnostic Interview, Revised (ADI-R), is a
structured parent interview that is designed to obtain rel-
evant information about a child’s early communication and
language development, social development and play, and
unusual interests and behaviors. The ADI-R was conducted
with parents to corroborate the information collected dur-
ing the ADOS and was also used to confirm diagnosis for
eligibility.
Developmental/Cognitive Functioning The Stanford-
Binet Fifth Edition (SB-V; Roid 2003) or the Mullen Scales
of Early Learning (MSEL; Mullen 1995) were used to assess
cognitive functioning. The abbreviated SB-V was attempted
with all children. The Mullen was administered to children
who were unable to the abbreviated SB-V. Standard scores
obtained from these measures were used to determine eli-
gibility and to characterize the cognitive functioning of the
sample.
Outcome Measures
Parenting Stress Index-Short Form (PSI; Abidin 1995) The
PSI is a 36-item measure completed by parents of children
3 months to 10 years of age designed to assess parental
stress. Each item is rated on a 5-point scale (from “Strongly
Disagree” = 0 to “Strongly Agree” = 5). The PSI yields a
total stress score and subscale scores across three factors:
parental distress, parent–child dysfunctional interaction, and
difficult child characteristics. Example statements include, “I
feel trapped by my responsibilities as a parent,” “Sometimes
I feel my child doesn’t like me and doesn’t want to be close
to me,” and “I feel that my child is very moody and easily
upset.” The PSI has good test–retest reliability (ICC = 0.77)
and internal consistency (IC; 0.91 (Barroso et al. 2016)).
A PSI total score of ≥ 88 (85th percentile) is considered
clinically significant. This measure was used to differentiate
among subtypes of stress, including stress related to child
behavior and interactions, as well as stress related to the
parents’ internal emotional state.
Caregiver Strain Questionnaire (CGSQ; Brannan et al.
1997) The CGSQ is a 21-item, parent self-report on the
burdens associated with raising a child with ASD and
perceived interference with family activities. Parents rate
caregiver strain on items such as “Interruption of personal
time,” “Financial strain,” and “Feeling sad or unhappy” on
a 1–5 scale (“Not a problem” to “Very much a problem”).
This measure yields objective strain, internalized strain, and
externalized strain subscales and a global score. The CGSQ
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demonstrates acceptable-to-high internal consistency for
objective strain (0.91), externalized strain (0.74), internal-
ized strain (0.86), and the global score (0.93). The subscales
are negatively correlated with established measures of fam-
ily functioning, such as the Family Assessment Device. The
original sample from Brannan et al. (1997) included parents
of children with unspecified emotional/behavioral disorders
and reported mean scores of 2.0 (objective strain), 3.4 (inter-
nalized strain) and 2.3 (externalized strain).
Parenting Sense of Competence (PSOC) The PSOC
(Gibaud-Wallston and Wandersman 1978) is a 17-item,
parent self-report reflecting parental satisfaction and effi-
cacy. The satisfaction subscale measures parental motivation
and frustration (e.g., “Even though being a parent could be
rewarding, I am frustrated now while my child is at her/
her present age”). The efficacy subscale measures perceived
capacity to change the child’s behavior (e.g., “I meet my
own personal expectations for expertise in caring for my
child”). The PSOC also yields a Total Competence score,
with higher scores reflecting higher competence. In a norma-
tive community sample of mothers (Gilmore and Cuskelly
2009), subscale mean scores of Satisfaction (22.72) and Effi-
cacy (22.03) were reported.
Aberrant Behavior Checklist (ABC; Aman et al. 1985)
is a reliable and valid 58-item parent-rated scale with dem-
onstrated sensitivity to change (Kaat et al. 2014). Each item
is rated from 0 (not a problem) to 3 (severe in degree). The
ABC contains five subscales: Irritability (15 items), Social
Withdrawal (16 items), Stereotypic Behavior (7 items),
Hyperactivity/Noncompliance (16 items), and Inappropri-
ate Speech (4 items). It was completed at baseline and every
4 weeks thereafter. For the current analysis, we used only
the Irritability subscale, which was the primary outcome
measure in the RCT.
Treatments
Parent Training (PT)
PT consisted of 11 core sessions of 60–90 min delivered
individually that included direct instruction, video vignettes,
practice examples, and role playing between parent and ther-
apist. Weekly homework assignments gave the participat-
ing parent opportunities to practice the strategies learned
in session with the child in natural settings. The program
included two home visits and up to two optional sessions.
Sessions were conducted over 16 weeks. Therapists followed
a treatment manual that included scripts and suggestions for
engaging the family. Fidelity to the manual was assessed
with a session-specific checklist of the required elements
of the session. The PT intervention instructed parents on
the application of behavioral strategies to manage behavio-
ral problems in the home and community. Session content
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J Autism Dev Disord
focused on the situations and events that preceded disruptive
behavior (antecedents) and the environmental responses that
reinforced the behavior. Briefly, the PT program included
use of visual daily schedules, positive reinforcement,
planned ignoring as well as techniques to promote compli-
ance and daily living skills.
Psychoeducation Program (PEP)
PEP was an active condition to control for time and therapist
attention. It was also a structured intervention consisting of
12 individually-delivered sessions and one home visit. The
manual covered useful topics for parents of young children
with ASD, including etiology of ASD, educational plan-
ning, advocacy, and information on how to select effective
treatments. As with PT, PEP was delivered over 16 weeks
and included regular fidelity checks. Unlike PT, PEP did not
include any direct instruction in behavioral management.
Each session comprised didactics, discussion, and informa-
tional handouts at the end of each visit (see Bearss et al.
2015 for more detailed information about PT and PEP).
Statistical Analysis
Treatment Effects
Mixed-effects linear regression models were used to evaluate
within-group changes over time from baseline to week 24
(endpoint) and between-group differences at week 12 (mid-
point) and week 24 for total scores on the PSI, CGSQ, and
PSOC. Exploratory analyses examined subscales on each
measure. Fixed effects included treatment group, time, site,
intervention intensity (i.e., whether the child was receiv-
ing more or less than 15 h of direct, individual service per
week), and time-by-treatment. Within-group effects were
ascertained by regressing the PSI, CGSQ, and PSOC scores
against time. For between-group effects, the average slopes
of the regression lines were compared (PT versus PEP).
Effect sizes were calculated on each measure by taking the
difference in the least squares means at weeks 12 and 24
and dividing by the standard deviation at baseline for the
entire sample. We assumed that missing data were missing
at random (Little 1988).
Exploratory Analyses
Structural equation modeling (SEM) was employed to evalu-
ate the relationships between change in PSOC in the first 12
weeks and change in the PSI, CGSQ and ABC Irritability
subscale in the next 12 weeks. SEM permits examination
of the model while simultaneously controlling for shared
variance across measures and informants at each assessment
wave. Within the SEM framework, latent difference scores
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J Autism Dev Disord
(LDS; McArdle 2009) were calculated to model true change
in predictors and outcomes over time. The LDS scores gen-
erated for the PSOC (the predictor of change from baseline
to week 12) and outcomes (change in PSI, CGSQ and ABC-I
from week 12 to week 24). This method accounted for base-
line scores on each variable.
Models (see Fig. 1) examined (a) the extent to which
change in parental competence (PSOC) predicted change
in outcome measures (PSI, CGSQ, and ABC-I) and (b)
whether this predictive relationship significantly differed
across the two treatment groups (PT and PEP). (McArdle
2009). Structural equation models were estimated using the
Amos 18.0 software system (Arbuckle 2006). To maximize
statistical power, we used full-information maximum likeli-
hood (FIML) in AMOS and included the full sample in the
analyses (Enders 2001). The model adequately represented
the data, χ2 (2) = 3.53, p = .17, RMSEA = 0.07. To test for
treatment-related differences, AMOS’s critical ratio (CR) of
Differences was used. Pairwise parameter comparisons cal-
culated the difference between the two estimates divided by
the estimated standard error of the difference. The resulting
difference statistic is normally distributed and tested against
the z-score distribution (CR > 1.96). Therefore, the CR pro-
vides an explicit test of the modifying effect of treatment
group.
Results
Parent respondents were primarily female (93%), in their
mid-30s (see Table 1). Children were 79% male, with a mean
age of 4.2 years (SD = 1.1), and 74% had an IQ of 70 or
above on the SB-V.
Treatment Effects
Table 2 presents data on parent outcome measures at base-
line and week 24 within each treatment group. Baseline
Fig. 1  Model predicting change
in parental stress and strain and
child irritability, as predicted by
change in parental competence
Treatment
Group (PT
versus PEP)
scores on the PSI were elevated. On the CGSQ, scores were
similar or elevated compared to the sample described in
Brannan et al. (1997). Scores on the PSOC were comparable
or higher than those reported in community samples. Over
time, both PT and PEP showed improvements in the PSI,
CGSQ, and PSOC. On the PSI total score, PT showed a 14%
reduction, and PEP showed 9.3% reduction. On the CGSQ
global score, PT showed 17.2% reduction, and PEP showed
7.1% reduction. For PSOC total score, PT showed 16.4%
increase, and PEP showed 7.4% increase. See Supplemental
Materials for figures of the total score and subscale scores
for the PSI, CGSQ, and PSOC.
Table 3 shows differences in least squared means from
baseline to weeks 12 and 24 between PT and PEP. PT did
not show a significant advantage over PEP on the PSI total
score, the parent–child interaction or the child distress scales
at week 12. On the PSI difficult child factor, however, PT
produced greater reductions than PEP at week 12 and week
24. The reduction in the PSI total score was greater in PT
than PEP at week 24, but the difference was not significant.
At week 12 and week 24, PT was superior to PEP on the
CGSQ global score and Internalized subscale. There was
no difference in CGSQ Externalized or objective strain sub-
scales at week 12. The CGSQ Objective subscale reached
significance at week 24. On the PSOC, parents in the PT
group reported greater gains than parents in PEP at week
12 on the satisfaction subscale but not the efficacy subscale
or total score. Improvement was significantly greater in PT
compared to PEP on the PSOC total score and the efficacy
subscale at week 24. The difference on the satisfaction sub-
scale was no longer significant.
Exploratory Analyses
The LDS models confirmed findings from the mixed-effects
linear models that parents in both treatment groups showed
significant change in competence from baseline to week
12 (PT: β = .68, p < .001; PEP: β = .49, p < .001). Pairwise
Change in
Parent
Competence
Change in
Parent
Stress/ Strain
and Child
Competence Competence
at Baseline Irritability
at Week 12
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J Autism Dev Disord

Table 1  Participant characteristics change in stress and strain from week 12 to 24 did not sig-
No. (%)
nificantly differ across groups (z = 1.15 and z = 0.74, respec-
tively). Similarly, parents in both groups reported significant
Parent training Parent education
change in child disruptive behavior on the ABC-I from week
(n = 89) (n = 91)
12 to week 24 (PT: β −0.54; PEP: β −0.50, p < .001), and
Study center there was no difference across treatment groups (z = 0.983).
Emory/Yale University 17 (19.1) 18 (19.8) This exploratory analysis examined whether change in
Indiana University 14 (15.7) 14 (15.4) competence predicted change in stress, strain, or child irri-
Ohio State University 19 (21.4) 20 (22.0) tability, and whether treatment groups differed. The results
University of Pittsburgh 19 (21.4) 18 (19.8) revealed that change in competence did not significantly pre-
University of Rochester 20 (22.5) 21 (23.1) dict change in PSI total score, CGSQ global score, or child
Parent demographics disruptive behavior (ABC-I). Furthermore, the magnitude
Gender of primary informant of this relationship did not significantly vary across groups.
Female 79 (88.7) 87 (95.6)
Male 10 (11.3) 4 (4.4)
Mother age (years) 35.4 (6.6) 35.9 (6.1) Discussion
Father age (years) 38.4 (7.7) 38.5 (7.2)
2-parent family 77 (86.5) 81 (89.0) To our knowledge, this is the largest randomized controlled
Education study to date of PT in children with ASD and disruptive
Some high school 1 (1.1) 0 behavior. Here we examined the impact of PT on multiple
High school degree 9 (10.1) 5 (5.5) parent outcomes, including parental stress, caregiver strain,
Some college 28 (31.5) 26 (28.6) and parental competence. The improvements in parent
College diploma 22 (24.7) 37 (40.7) self-reports in both groups suggest non-specific treatment
Advanced degree 29 (32.6) 23 (25.3) effects (e.g., therapist attention). However, there may also be
Family income unique effects for each intervention: increased proficiency in
<$20,000 8 (9.0) 7 (7.7) behavioral strategies in PT and increased knowledge about
$20,001–$40,000 19 (21.3) 17 (18.7) ASD in PEP. Still, the larger improvements for PT suggest
$40,001–$60,000 17 (19.1) 19 (20.9) that addressing child behavior was an especially effective
$60,001–$90,000 15 (16.9) 21 (23.1) intervention component. Although both groups improved,
>$90,000 29 (32.6) 27 (29.7) PT showed greater increase on perceived parental compe-
Child demographics tence than PEP. Compared to PEP, PT also showed greater
Gender reduction in several indices of parental strain and stress due
Female 10 (11.2) 12 (13.2) to the challenges of raising a child with ASD and disruptive
Male 79 (88.8) 79 (86.8) behavior. Effect sizes ranged from small to medium. Positive
Age (years) 4.8 (1.2) 4.7 (1.1) effects for difficult child behavior, global caregiver strain,
IQ and satisfaction with parental competence were evident at
< 70 13 (14.6) 16 (17.6) week 12, suggesting that change in parent self-reported out-
≥ 70 66 (74.2) 68 (74.7) comes occurred during the first half of treatment. This is
Missing 10 (11.2) 7 (7.7) consistent with the differential improvements between treat-
Ethnicity ment groups that also emerged for child outcomes at week
Black/African-American 9 (10.1) 6 (6.6) 12 (Bearss et al. 2015). Other dimensions, such as parental
Asian/Pacific Islander 2 (2.3) 6 (6.6) efficacy, overall parental competence, and externalized car-
White/Caucasian 78 (87.6) 78 (85.7) egiver strain, required the full 24 weeks to show differential
Other 0 1 (1.10) change. These findings contribute to the growing evidence
for PT in ASD and lend support to the broader finding that
PT reduces disruptive behavior in many different child popu-
parameter comparisons indicated that parents in the PT lations (Dretzke et al. 2009; Postorino et al. 2017; Skotarc-
group reported significantly greater gains on the PSOC than zak and Lee 2015).
the PEP group during the first 12 weeks of the interven- The PSI difficult child subscale, which includes disruptive
tion (z = 2.72, p < .01). Parents in both groups also reported behavior problems, was significantly different between treat-
significant decrease in stress (PT: β = −0.38, p = .009; PEP: ment groups at week 24. Given that disruptive behavior is the
β = −0.39, p = .006) and strain (PT: β = −0.50, p < .001; PEP: target of PT, this finding is not surprising. On the PSI total
β = −0.45, p < .001) from week 12 to week 24. However, score and other PSI factors (parental distress, parent–child

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J Autism Dev Disord

Table 2  Parenting stress, parent competence, and caregiver strain raw scores by group and timepoint
Parent training (PT) Parent education (PEP)
(n = 89) (n = 91)
Baseline Week 12 Week 24 Baseline Week 12 Week 24

Parenting Stress Index-short form total 106.2 (19.0) 96.5 (20.7) 91.4 (19.6) 103.5 (17.9) 96.9 (17.6) 93.9 (19.4)
Parental distress 33.3 (8.6) 30.7 (8.8) 28.9 (8.1) 32.7 (8.8) 29.9 (8.1) 28.7 (9.6)
Parent/child difficult interaction 29.1 (7.3) 26.8 (7.4) 25.4 (7.0) 28.6 (7.7) 26.8 (7.0) 25.7 (6.8)
Difficult child 43.6 (6.9) 38.9 (8.4) 37.0 (8.1) 42.2 (6.8) 40.1 (7.2) 39.1 (8.0)
Caregiver strain questionnaire global 2.9 (0.6) 2.5 (0.6) 2.4 (0.6) 2.8 (0.6) 2.5 (0.6) 2.6 (0.6)
Objective strain 2.9 (0.7) 2.5 (0.7) 2.4 (0.7) 2.8 (0.7) 2.5 (0.7) 2.6 (0.7)
Internalized strain 3.4 (0.7) 2.8 (0.8) 2.6 (0.8) 3.3 (0.7) 2.9 (0.74) 2.9 (0.9)
Externalized strain 2.2 (0.6) 2.0 (0.5) 1.9 (0.49) 2.0 (0.6) 2.0 (0.6) 2.0 (0.6)
Parenting sense of competence total 61.4 (11.8) 68.3 (10.4) 71.5 (9.7) 63.5 (10.7) 66.9 (11.8) 68.2 (12.2)
Satisfaction 35.2 (7.4) 38.7 (6.8) 40.1 (6.1) 36.7 (6.6) 38.1 (7.8) 39.2 (7.5)
Efficacy 26.2 (6.6) 29.6 (5.4) 31.4 (5.3) 26.8 (5.9) 28.7 (5.9) 29.0 (6.2)
Aberrant behavior checklist—irritability 23.7 (6.4) 16.1 (7.3) 11.9 (6.5) 23.9 (6.2) 18.7 (7.4) 16.6 (7.6)

Table 3  Differences between Change from baseline to week Change from baseline to week
parent training and parent 12* 24*
education program in least
square means, p values, and LSM-Diff p Effect size LSM-Diff p Effect size
standardized effect sizes for
change from baseline at 12 and Parenting Stress Index-short form total −3.50 .15 0.19 − 4.51 .07 0.25
24 weeks Parental distress − 0.21 .83 0.02 − 0.52 .63 0.06
Parent/child difficult Interaction − 0.41 .65 0.05 − 0.52 .56 0.07
Difficult child −2.75 .008 0.40 −3.02 .004 0.44
Caregiver strain questionnaire global − 0.16 .05 0.32 − 0.29 < 0.001 0.50
Objective strain − 0.14 .14 0.20 − 0.28 .005 0.40
Internalized strain − 0.27 .01 0.35 − 0.38 < 0.001 0.49
Externalized strain − 0.01 .89 0.90 − 0.14 .08 0.23
Parenting sense of competence total 2.41 .07 0.21 3.76 .01 0.34
Satisfaction 1.41 .04 0.20 1.32 .08 0.19
Efficacy 0.97 .18 0.15 2.40 .001 0.38

Effect sizes represented as Cohen’s d

LSM-Diff difference in least square means (PT-PEP)
*All trends show an advantage for PT over PEP

dysfunctional interaction), both groups improved and there
were no significant differences between groups. The greater
improvements in parental competence and parental stress
for PT over PEP suggest that decreases in child disruptive
behavior are associated with positive parent outcomes.
Although the PEP group improved over time, PT was
superior to PEP on measures of difficult child behavior, car-
egiver strain, and parent perceived competence at week 24.
The finding that psychoeducation programs, such as PEP,
can improve child outcomes (Bearss et al. 2015; Kasari et al.
2015) suggests that a better understanding of the behavior in
children with ASD may promote reductions in parental stress
and strain, although this implication cannot conclusively
be drawn from the data. However, our results suggest that
providing parents with specific tools to reduce disruptive
behavior reduces parental stress and strain, and improves
parental competence. Furthermore, the task demands of
applying parent training did not appear to contribute to
parental stress.
The finding that a decrease in child disruptive behavior
via PT promotes improvement in parental competence, are
consistent with previous research in non-ASD populations
(Dretzke et al. 2009). We used structural equation models
(SEM) to explore the predictive role of improved parent
competence in PT on parent and child outcomes. Our pre-
diction that improved parental competence would predict
subsequent reduction in parental stress and strain as well
as disruptive behavior in the child in PT versus PEP was

13
Licenciado para - Isabela - 08983525924 - Protegido por Eduzz.com
not confirmed. We observed significant increases on the
PSOC in the PT group from baseline to week 12, but this
did not significantly predict more change on the PSI total
score, CGSQ global score or the ABC-I from week 12 to
week 24. A limitation of this analysis is that, although
SEM controls for shared variance across measures, these
measures are not entirely separate constructs and were
highly inter-correlated in our sample, reducing our ability
to separate change in competence from change in stress
and strain.
The positive child and parent outcomes demonstrated in
this trial add to the empirical support for PT and suggest
that PT is ready for wider application for young children
with ASD and disruptive behavior. Challenges ahead include
identification of barriers that may hinder the broader appli-
cation of PT in community settings. One obvious challenge
is training a wide range of practitioners (e.g., psychologists,
special educators, social workers and child psychiatric nurse
practitioners), which would require institutional commitment
to provide space and funding. Evaluation of ancillary effects
on families (e.g., parenting styles, sibling behavior), child
behavior in other settings (e.g., classrooms), and longer-
term outcomes could help indicate whether PT has broader,
clinically significant effects. Given the improvements in both
PT and PEP, a blended intervention that includes content
from both approaches may yield additive effects, but would
also increase the number of treatment sessions. Alternative
approaches such as group PT or PT by telehealth also war-
rant further development.
The present findings should be considered in light of
several limitations. Primary outcomes on child behavior
and parent outcomes are based on parent report. We did
not measure objective outcomes, such as physiological
markers of parental stress. However, parental perception
of stress and caregiver strain is testimony from parents
directly facing the challenges of raising a child with ASD
and disruptive behavior. We also note that parents were
not blind to group assignment. Perceptions about the two
treatments may have influenced their ratings. To date, few
studies with other measures of parental stress and well-
ness (e.g., physiological recordings) have been reported
in PT studies, and this is an area in need of future devel-
opment. We also note the use of multiple comparisons,
which inflated the probability of Type I error. Finally, the
parents who participated in this study were mostly white,
middle and upper-middle class, and were well-educated.
Accordingly, our findings may not necessarily extend to
racially or ethnically diverse or under-resourced parents,
who may face additional daily stressors not directly related
to parenting. Implementation studies are needed to extend
the reach of PT to more diverse and under-resourced
populations. Despite these limitations, this study demon-
strated the superiority of PT on reducing child disruptive
13
J Autism Dev Disord
behavior, improving child adaptive behavior, decreasing
parental stress and strain and improving parental sense of
competence.
Acknowledgments We would like to thank our team for their con-
tributions to this project: Jill Pritchett at Ohio State University; Laura
Simone at Yale TrialDB; Yanhong Deng, Saankari Anusha Challa,
Denis Sukhodolsky, James Dziura, and Allison Gavaletz at Yale; Car-
rie McGinnis at Indiana University; Rachael Davis, David McAdam,
Bridget Reynolds, Melissa Sturge-Apple, and Amit Chowdhry at Uni-
versity of Rochester Medical Center. We also thank the Data and Safety
Monitoring Board: Gerald Golden, M.D. (retired pediatric neurologist),
Christopher Young, M.D. (Medical Director of Wellmore Behavioral
Health, Waterbury, CT and Martin Schwartzman father of a child with
autism).
Funding This work was funded by the National Institute of Men-
tal Health by the following grants: Yale University/Emory University
MH081148 (principal investigator: L. Scahill); University of Pitts-
burgh/University of Florida MH080965 (principal investigator: C.
Johnson); Ohio State University MH081105 (principal investigator:
L. Lecavalier); Indiana University MH081221 (principal investigator:
N. Swiezy); University of Rochester MH080906 (principal investigator:
T. Smith). Additional support was provided by MH079130 (princi-
pal investigator: D Sukhodolsky), the National Center for Advancing
Translational Sciences of the National Institutes of Health under Award
Numbers UL1 TR000454 (Emory University), UL1 TR000042 (Uni-
versity of Rochester), UL1 RR024139 (Yale University) and the Mar-
cus Foundation. We thank the families who participated in this study.
Author Contributions SI participated conceived of the current study
analyses, participated in its design and coordination, and drafted the
manuscript; LL conceived of the current study analyses and drafted the
manuscript; BH participated in the study design, performed the statisti-
cal analyses, and assisted in drafting the manuscript; TS conceived of
the original study, participated in its design and coordination, assisted
with data interpretation and helped to draft the manuscript; LL con-
ceived of the original study, participated in its design and coordination,
assisted with data interpretation and helped to draft the manuscript; CJ
conceived of the original study, participated in its design and coordi-
nation, assisted with data interpretation and helped to draft the manu-
script; NS conceived of the original study, participated in its design
and coordination, assisted with data interpretation and helped to draft
the manuscript; KB conceived of the original study, participated in its
design and coordination, assisted with data interpretation and helped to
draft the manuscript; LS conceived of the original study, participated
in its design and coordination, assisted with data interpretation and
helped to draft the manuscript. All authors read and approved the final
manuscript.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict
of interest.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from all indi-
vidual participants included in the study.
Licenciado para - Isabela - 08983525924 - Protegido por Eduzz.com

J Autism Dev Disord

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