School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT)
Focused Question:
Does parent education improve compliance in children and adolescents with autism spectrum
disorder?
Prepared By:
Natasha Arastehmanesh, OTS & Evelyn Babaroudi, OTS
[email protected]
[email protected]
Department of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89014
Date Review Completed:
September 30, 2015
Clinical Scenario:
The prevalence of Autism Spectrum Disorder (ASD) has increased within the recent years
from 1 in 88 births in 2008 to 1 in 68 births in 2010 (Center for Disease Control and Prevention,
2014). ASD includes a spectrum of disorders including the previous DSM-IV autism disorder,
Aspergers disorder, childhood disintegrative disorder, and pervasive developmental disorder-not
otherwise specified (American Psychiatric Association, 2013). According to the DSM-V (2013),
ASD is characterized by persistent deficits in social communication, social interaction, and
restricted, repetitive patterns of behaviors, interests and activities. Symptoms are present in early
childhood, typically recognized within the first two years, and cause significant impairment in
everyday functioning, and not otherwise explained by intellectual disability or developmental
delay (What is Autism Spectrum Disorder?, n.d.). Core deficits in areas of social interaction
and communication can impede a childs ability to interact effectively with their surroundings
thereby limiting cognition and adaptive functioning. Furthermore, the majority of children with
ASD develop behavioral and emotional problems such as, tantrums, aggression, noncompliance,

property destruction, self-injury, and recklessness and hyperactivity (Bearss, Johnson, Handen,
Smith, & Scahill, 2013). Such challenging behaviors can increase parental stress and cause
feelings of hopelessness, as is commonly reported in parents of children with ASD (Bearss,
Johnson, Handen, Smith, & Scahill, 2013).
A wide range of interventions exist for children with ASD to help manage symptoms and to
address specific needs. Although medicine, such as antipsychotics, is commonly prescribed in
treating core symptoms, it is most effective when used in conjunction with another treatment
approach, such as early intensive behavioral intervention. Most early intensive behavioral
interventions utilize parent education and training as a component of intervention to actively
engage parents in decision making and the implementation of treatment. Populations that have
received dual intervention include ASD, attention deficit hyperactive disorder (ADHD),
intellectual disabilities, or typically developing children with disruptive behaviors.
Parent education has emerged as an effective tool in educating parents of children with ASD
about proper techniques for facilitating interaction with their child. Different disciplines have
recognized the potential of parent education in helping parents develop a better understanding of
their childs diagnosis and in promoting efficient social interaction and communication skills
with their child. Many parent education programs now exist across the country for parents of
children with ASD. Some parent education programs apply behavioral principles, while others
utilize a more non-traditional approach such as the practice of mindfulness meditation.
Regardless of the intervention approach, parent education and training is important as it helps
incorporate parents as co-therapists in intervention, and allows them to develop the strategies and
techniques necessary to reduce inappropriate behaviors, increase compliance, and improve the
overall quality of life and level of independence in the child. In order for children with ASD to
make continuous progress and to generalize skills to different contexts, it is imperative to
educate parents and to actively engage them in the process of treatment.

Summary of Key Findings:

Summary of Levels I, II and III:
Results from a randomized controlled trial (RCT) found that, despite treatment
assignment (medicine alone or parent training and medicine), children with more severe
noncompliance experienced an increased level of improvement than less impaired
children. The results of this study suggest that combined treatment (parent training and
pharmacotherapy) is superior to medication alone, and no measured baseline
characteristics (family income, mothers education, child IQ) predicted or moderated
this effect (Farmer et al., 2012, Level I). Another RCT found parent training to not be of
additional value versus usual general care given by parents of children with ASD. No
statistical significant was found for any of the primary (language), secondary (global
clinical improvement), or mediating (child engagement, early precursors of social

communication, or parental skills) outcome variables, suggesting that the Focus parent
training was not of additional value to the more general care-as-usual (Oosterling et al.,
2010, Level I).
Another study found that parent training can be an effective intervention for parents of
children with Asperger syndrome. On each measured outcome variable the number of
problem behaviors, and rating of social skills, parents indicated significant improvement
following parent training for both intervention groups (1 day workshop and 6 individual
day sessions) while control group showed no significant improvement on any of the
outcome variables. The individual session group reported greater changes than the
workshop group on outcome variables (number of problem behaviors, reported intensity
of problem behavior, parent ratings of social skills, and usefulness of the components of
the workshop or sessions) (Soffronoff, Leslie, & Brown, 2004, Level I).
Level II
A controlled trial for children with suspected ASD, whose parents received either
immediate intervention or delayed access, found two main findings. First, parents were
able to learn strategies and techniques for facilitating their childrens communication
skills, particularly parents of children with a diagnosis of ASD. Second, the children
whose parents received the parent training course had larger reported vocabulary
(McConachie, Randle, Hammal, & Couteur, 2005, Level II).

Summary of Level IV and V:

Level IV
Results from a single case study pilot trial support feasibility and efficacy of a 24-week
parent training program for children with ASD and disruptive behaviors. Parents found
the intervention acceptable, and were able to attain knowledge and information in
relation to each sessions objective. Another single case study explored the effects of
mindfulness training on two mothers and the compliance of their children with attention
deficit hyperactive disorder (ADHD). Mindfulness training results in true listening
when we stop our internal conversations and simply hear what the other person is saying
to us (Singh et al., 2009, p. 164). In response to mindfulness training, researchers found
an increase in childrens compliance during the mothers training phase, followed by
even larger increases after the child received training in mindfulness. Upon follow-up,
an increase in compliance was still evident, suggesting strong response maintenance
(Singh et al., 2009). We believe findings from the study are difficult to generalize to a
larger population due to a small sample size (4 participants).

A case series study by Anan et al. (2008) explored the effects of a group parent-training
program for parents of preschoolers with ASD. Parents attended a 12 hour didactic
weekend workshop pertaining to hands-on behavioral principles and strategies to
interaction with children. In completion of the intervention program, implementation of
the Vineland Adaptive Behavior Composite and Mullen Early Learning Composite
revealed significant improvements in the short-term cognitive and adaptive functioning
skills of the children.
Another study examined the effects of mindfulness-based positive behavior support
(MBPBS) for mothers of adolescents with ASD. The researchers aimed to assess the
impact of intervention on adolescents behavior and parental stress. The intervention
was an 8-week program that used mindfulness-based practices in conjunction with
positive behavioral support. Results from the study indicated:
First parent-child dyad:
Aggressive behaviors decreased by 16% from baseline to training; 88% decrease from
training to practice.
Noncompliance behaviors per week decreased by 33% from baseline to training. 68%
decrease from training to practice.
Second parent-child dyad:
Aggressive behaviors per week decreased by 6% from baseline to training; 70% from
training to practice.
Noncompliance behaviors per week decreased 11% from baseline to training; 64%
decrease from training to practice.
Third parent-child dyad:
Aggressive behaviors per week decreased 10% from baseline to training; 85% from
training to practice.
Self-injurious behaviors per week decreased 17% from baseline to training; 51% from
training to practice.
Results indicate that parents successfully learned the PRT techniques and trained others
to implement the techniques presented during the program to significant caregivers.
Additionally, the childrens social communication and behaviors improved during
interactions with both parents and the significant caregivers. (Singh et al., 2014).
A single-case study examined the effects of a week-long parent education program for
families of children with ASD. The focus of the intervention was to educate and train
primary caregivers on how to effectively implement the techniques into daily
interactions with children, as well as train significant caregivers who work with their
children. During intervention, parents were introduced to pivotal response training

(PRT) techniques to embed in daily routines. (Symon, 2005). Results indicate that
parents successfully learned the PRT techniques and generalized them into their
interactions with their children at home. They were also able to train other caregivers to
implement the techniques presented during the program. Additionally, the childrens
social communication and behaviors improved during interactions with both parents and
the significant caregivers.
Level V
The case report describes a 4-session parenting intervention (primary care stepping
stones triple p) targeting compliance and cooperative play in an 8-year-old girl with
Aspergers disorder and ADHD combined type. Significant reductions in child behavior
problems, improvements in parenting confidence, and decreases in the use of
dysfunctional parenting styles was found.
Contributions of Qualitative Studies:
N/A

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT: Short-term and cost-effective parent training
programs are vital to implement in clinical and community-based practice of OT. Given the
plethora of research displaying positive effects of parent training, it is vital for OTs to
incorporate parent training into their interventions for children with ASD. Parent training will
ensure that what is taught in therapy will continue to be implemented in the home and
community setting. OT clinical services try to incorporate parents in intervention, but many
times parents find time and financials as barriers to participate. Through implementing brief
parent training programs in the clinical and community-based settings, therapists can actively
engage parents in the delivery of treatment. This opportunity will help reduce parental stress and
allow the child to gain functional independence.
Program development: Given the increased prevalence rate of autism (30% higher than estimates
reported in 2012) (CDC, 2014), it is important to implement supportive parent-education
programs that can help parents utilize effective strategies and techniques to increase compliance
and decrease parental stress. However, parent training can be expensive and consist of sessions
that may take weeks to several months to complete. Many parents do not have the available

resources and time to partake in a program that is extensive in nature. Implementing a parent
training program that is short, cost-effective, and readily available will address these
shortcomings and provide a valuable and insightful experience for both parent and child, further
increasing family quality of life (Bearss, Johnson, Handen, Smith, & Scahill, 2012, Level I).
Societal Needs: Given the complex nature of ASD, and the different interventions and supports
that children typically receive, parents often experience increased levels of stress and a need for
additional support. Coping with these challenging behaviors associated with ASD often requires
patience, maintenance, and attention. Implementing a brief cost-effective parent training program
producing effective results fits the needs and demands of parents of children with special needs.
It is increasingly important to implement parent training education programs for families of
children with ASD in order to generalize techniques implemented in therapy. Parent education
programs can effectively help educate parents on how to cope with disruptive behaviors and can
potentially help increase compliance by providing education including techniques and strategies
to foster a healthy relationship. Due to financial and time constraints, attending workshops that
are extensive and lengthy may not be a feasible options for parents. Therefore, short term and
cost-effective programs will help address societal needs. The use of parent training may shorten
the amount of visits the child will need on a weekly basis and therefore fit societal needs.
Healthcare delivery and policy: Parents of children with ASD are often the first to notice that
their child is exhibiting atypical behaviors. These concerns typically lead parents to seek medical
advice from healthcare professionals such as pediatricians, and psychologist/psychiatrists. These
healthcare professionals are the first to evaluate symptoms of ASD. With this being said, they
can play a key role in promoting evidence-based parenting interventions for parents in need of
assistance or in conjunction with pharmacotherapy. Therefore, educating primary care health
care professionals on the effects of parent training programs in helping parents deal with
disruptive behaviors will be of beneficial value.
Education and training of OT students: Educating and training OT students on how to structure
and lead a parent workshop should be introduced to first year OT students. One intervention
approach OT students can encourage their patients on is the teach-back communication
strategy. It is an opportunity to check for client understanding, and if necessary re-teaching
pertinent information. This approach has been shown to be effective in all health care settings,
and further optimizes patient learning, comprehension, and satisfaction. Teach-back method
promotes health care literacy and promotes enhanced communication skills between patient and
health care provider (Tamura-Lis, 2013).
Refinement, revision, and advancement of factual knowledge or theory: All studies reviewed
during this process indicate the use of parent education as an intervention approach to parents
and subsequently their children with ASD. It has shown a trend towards increasing compliance

and decreasing disruptive behaviors. It is believed that parent education programs will help
address parental stress, caregiver interaction, and promotion of new and generalized skills to
increase compliance and overall quality of life. Parent satisfaction was noted in all studies. This
theory should be advanced through more research through randomized control trials including
larger sample sizes. Also studies should examine the effect of parent education on children with
varying symptoms from mild to severe. Further research should include more rigorous research
designs such as follow up data and increased sample size.

Review Process:

A search was completed to determine a population (ASD), intervention (parent training),

and outcome (increased compliance) (PIO) for the focus question.
PIO was articulated, submitted for review, and approved by instructor.
Inclusion and exclusion criteria was developed and submitted for instructor review.
Selected articles that met the inclusion criteria were reviewed and critically evaluated.
Upon an extensive search, articles were chosen and were submitted for approval and
feedback from instructor to create the critically appraised topic.
Upon feedback, evidence tables were created and summarized for review and returned
with feedback.
Finally, evidence table was summarized into a critically appraised topic.

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:
Children and adolescents (0-19 years old) with autism spectrum disorder, intervention or
treatment program implemented by an occupational therapist, or any professional qualified
such as psychologist or trained therapist, child may present with similar features to autism but
may not have diagnosis (social interaction, verbal communication, restrictive repetitive
behavior), has comorbid disabilities.
Exclusion Criteria:
Studies not available in English, articles published before the year 2005, adults with autism or
any population other than children and adolescents, studies not available in full text.

Search Strategies:
Categories
Patient/Client Population

Key Search Terms

Autism Spectrum Disorder

Intervention

Parent training, Parent education

Outcomes

Compliance

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Databases and Sites Searched

Google Scholar, EBSCO, CINHAL, PubMed
Quality Control/Peer Review Process:

Students formulated PICO question and received instructors approval

PICO question, literature review, evidence table, scholarly articles, and critically
appraised topic (CAT) were reviewed by course instructor with feedback/comments to
ensure accuracy and thorough analysis of research reviewed
Upon revision of evidence table by course instructor, CAT was completed by students.
Constructive criticism from course instructor was taken into consideration.

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:

Level of
Evidence
I
II
III

Study Design/Methodology of Selected Articles

Systematic reviews, meta-analysis, randomized
controlled trials
Two groups, nonrandomized studies (e.g., cohort,
case-control)
One group, nonrandomized (e.g., before and after,
pretest, and posttest)

Number of Articles
Selected
3
1
0

IV

Descriptive studies that include analysis of outcomes

(single subject design, case series)
V
Case reports and expert opinion, which include
narrative literature reviews and consensus statements
Other
Qualitative Studies
TOTAL:
Limitations of the Studies Appraised:

5
1

10

Levels I, II, and III

Not possible to rule out Type II error. Trial was not designed to determine the effect of
moderators and/or predictors of outcome. (Farmer et al., 2012, Level I).
Limitations include small sample size and not all criteria met for a perfectly
designed randomized controlled trial. Authors did not formally check on
treatment integrity to verify if treatment was conducted in the manner that was intended
(Oosterling et al., 2010, Level I).
Small sample size and subjectivity in results due to parent report (Soffronoff, Leslie, &
Brown, 2004, Level I).
Limitations include small sample size, non-randomized group allocation, short followup time, and the delayed control group was receiving some degree of individual services
from their speech and language therapists while waiting, therefore there was not a no
intervention control group (McConachie et al., 2005, Level II).
Levels IV and V
Lack of control group making it difficult to separate effects of treatment from effect of
time or attention on disruptive behavior or noncompliance. Reliance on un-blinded
parent and clinician ratings to measure change in child behavior. This study excluded
lower functioning children, this is a limitation because often the parents of these
children need more support to help their children live their lives to the fullest (Bearss,
Johnson, Handen, Smith, & Scahill, 2013, Level IV).
Experimental control (to demonstrate effects of training need 3 baseline but this study
only had 2) (Singh et al., 2010, Level IV).
Authors did not examine dependent variables, study groups were not randomized,
authors were not blind to childrens pre- or post-intervention status, and authors did not
provide a long-term follow-up (Anan et al., 2008, Level IV)

Small sample size, authors did not provide follow-up data, and use of a convenience
sample of parents and adolescents with ASD (Singh et al., 2006, Level IV).
Small sample size, study did not include families from diverse backgrounds, primary
caregivers were self-selected, well-educated, and married, and length of intervention
was short (Symon, 2005, Level IV).
Limitation includes small sample size (Tellegen & Sanders, 2012, Level V).
Other

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Articles Selected for Appraisal:

Anan, R. M., Warner, L. J., McGillivary, J. E., Chong, I. M., & Hines, S. J. (2008). Group
intensive family training (GIFT) for preschoolers with autism spectrum
disorders. Behavioral Interventions, 23(3), 165-180.doi: 10.1002/bin.262
Bearss, K., Johnson, C., Handen, B., Smith, T., & Scahill, L. (2013). A pilot study of parent
training in young children with autism spectrum disorders and disruptive
behavior. Journal of autism and developmental disorders, 43(4), 829-840. doi:
10.1007/s10803-012-1624-7
Farmer, C., Lecavalier, L., Yu, S., Arnold, L. E., McDougle, C. J., Scahill, L., ... & Aman, M. G.
(2012). Predictors and moderators of parent training efficacy in a sample of children with
autism spectrum disorders and serious behavioral problems. Journal of autism and
developmental disorders, 42(6), 1037-1044. doi: 10.1007/s10803-011-1338-2

McConachie, H., Randle, V., Hammal, D., & Le Couteur, A. (2005). A controlled trial of a
training course for parents of children with suspected autism spectrum disorder. The
Journal of pediatrics,147(3), 335-340. doi: 10.1016/j.jpeds.2005.03.056
Oosterling, I., Visser, J., Swinkels, S., Rommelse, N., Donders, R., Woudenberg, T., ... &
Buitelaar, J. (2010). Randomized controlled trial of the focus parent training for toddlers
with autism: 1-year outcome. Journal of Autism and Developmental Disorders, 40(12),
1447-1458.doi: 10.1007/s10803-010-1004-0
Singh, N. N., Lancioni, G. E., Winton, A. S., Karazsia, B. T., Myers, R. E., Latham, L. L., &
Singh, J. (2014). Mindfulness-Based Positive Behavior Support (MBPBS) for mothers of
adolescents with autism spectrum disorder: effects on adolescents behavior and parental
stress. Mindfulness, 5(6), 646-657. doi: 10.1007/s12671-014-0321-3
Singh, N. N., Singh, A. N., Lancioni, G. E., Singh, J., Winton, A. S., & Adkins, A. D. (2010).
Mindfulness training for parents and their children with ADHD increases the childrens
compliance. Journal of Child and Family Studies,19(2), 157-166. doi: 10.1007/s10826009-9272-z

Sofronoff, K., Leslie, A., & Brown, W. (2004). Parent management training and Asperger
syndrome a randomized controlled trial to evaluate a parent based
intervention. Autism, 8(3), 301-317. doi: 10.1177/1362361304045215
Symon, J. B. (2005). Expanding interventions for children with autism parents as
trainers. Journal of Positive Behavior Interventions, 7(3), 159-173. doi:
10.1177/10983007050070030501
Tellegen, C. L., & Sanders, M. R. (2012). Using primary care parenting interventions to improve

outcomes in children with developmental disabilities: A case report. Case reports in

pediatrics, 2012. doi: 10.1155/2012/150261

Other References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Centers for Disease Control and Prevention. (2014). Autism Spectrum Disorder (ASD). Retrieved
from http://www.cdc.gov/ncbddd/autism/index.html
National Institute of Mental Health. (n.d.). What is Autism Spectrum Disorder? Retrieved from
http://www.nimh.nih.gov/health/topics/autism-spectrum-disordersasd/index.shtml#part_145441
Tamura-Lis, W. (2013). Teach-back for quality education and patient safety. Urologic
nursing, 33(6), 267. doi: 10.7257/1053-816X.2013.33.6.267

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05