Early Behavioural Intervention in Autism

Further Thoughts on Effects and Effectiveness

 

The first part of these summaries concerns the question whether behavioural approaches bring about true play in children, or simply evoke responses which have been attached to specific stimuli.

The next section concerns the impact upon the family functioning as a whole in the case of a child receiving intensive behavioural intervention, with implications for variations in such impact according to the pressures, benefits, and existing family resources.

There follows a revisiting of earlier research (now formally published) which compared the effectiveness of behavioural intentions, specialist nursery provision, and Portage in promoting intellectual, educational, and adaptive gains.

The final section describes an intervention, relevant to a number of developmental disabilities or behavioural problems, including autism, designed to help parents to manage and alleviate the observable symptoms of those conditions.

 

M.J.Connor                                                                                          November 2007

 

 

Behavioural Approaches to Teach Play 

 

A review of studies concerned with the outcomes of behavioural approaches to the teaching of play skills has been completed by Luckett et al (2007) who begin their report by highlighting a lack of spontaneous and varied play as a characteristic of autism.

 

These authors recognise the considerable body of research that now exists concerning the perceived effectiveness of behavioural approaches, including those directed towards enhancing play, and they note that the reports are frequently positive, indicating that young children with autism can be taught to play.

However, the question is raised whether these behavioural techniques really do bring about genuine play.  Is it more a matter of the children going through a repertoire of learned behaviours with the essence of true play missing (with the further danger that practitioners may lose sight of what play really is, and why children engage in play) ?

 

It appears very difficult to set down a universally agreed and all-embracing definition of play, and, instead, researchers (eg  Sayeed and Guerin 2000) contribute to an agreed list of attributes that reflect a disposition towards play. 

True play is seen as independent of the materials or activities or context involved, and more to do with the attitude of the child and his or her internal motivation. 

Related features include the voluntary nature of play, flexibility, spontaneity, some freedom from the constraints of reality, its pleasurable nature, its absorbing nature, and its continuation linked to the child’s internal locus of control rather than to some external management.

 

It may be argued that these characteristics of play are hardly compatible with teaching methods that involve a high level of imposed structure, repetition, and a systematic use of rewards.

 

Meanwhile, the current authors note that, in the case of autism, there has been attention afforded to the distinctiveness of functional and symbolic play.

Functional play is a matter of using objects in a standard way, appropriate to its normal use and function ....so a toy brush, for example, would be used to replicate sweeping actions.  Toys are miniature versions of the real thing.

Symbolic play, which emerges a little later in typical development, involves using some object in a novel and imaginative way, such as watching a cardboard box as if it were a television, or giving a bottle to a doll as if she were able to drink, or acting as if something is present such as moving one’s hands like someone steering a car.

The significance of limited or impaired symbolic play in autism has been interpreted by some researchers as highlighting a deficit in the capacity to represent mental states ... and which would also be relevant in respect of impaired social interaction and communication.

 

Another commonly studied element of autism is social play and it has been argued by Jordan (2003) that social and affective impairments in autism may be combined with cognitive impairments to form a state wherein the child cannot access the social or emotional or cultural experiences which are required to foster typical development.

 

Accordingly, two significant reasons exist for continuing attempts to enable children with autism to play.   Firstly, there is the developmental potential that play has for a range of skills, particularly those involved in social interaction and in communication.

Secondly, play can have some diversionary potential in that play may be used to take the place of other activities which are seen as maladaptive or undesirable or harmful.

 

Behavioural approaches can now involve a range of techniques, such as differential reinforcement, reciprocal imitation, video modelling, play scripts, etc.  Claims made for their effectiveness in respect of teaching play have been classified by Luckett et al either as soft (which hold that the increased behaviours at least resemble the play of typically-developing children); or as hard  (which hold that the children have been taught to play in a true, dispositional sense comparable to children without autism). 

 

These latter (hard) claims involve more than just a difference in observable behaviour, and refer to an actual change in a child’s whole approach and motivation.  However, the problem is that any emerging data are always behavioural, perhaps verbal, so that it is only possible to make inferences, not draw direct evidence, about changes in underlying mental states. 

 

The review by Luckett et al themselves is concerned with the hard claims, and their approach involved an assessment of the degree to which the measures that are the basis for the claims relate to the accepted list of attributes of true play. 

The review of data was completed by means of a search across databases to access all published findings concerned with autism and behavioural approaches to teach play.  The articles were assessed and were allocated to the hard claim category if they described teaching children with autism to play without any qualification about the precise behaviours and skills taught, or in a way comparable to children without autism, or in a way that indicated a change in a child’s approach as internally motivated, flexible, voluntary, enjoyable, spontaneous, active engagement, and paying attention to the process rather than to some end product.

 

In respect of functional play, there were 4 studies where the reported interventions matched the hard claim criteria and described an increase in play in the children or young people. A range of behavioural methods were involved, including differential reinforcement, discrete trial training, and self-management training.  Two of the articles provided evidence for developments in at least some of the elements of play as a disposition;  and they reported generalisation of the behaviours to toys or settings other than those used in the training which would imply at least a degree of internal motivation, flexibility, and voluntariness.  

 

The sets of findings concerned with appropriate play were those which went beyond observable behaviours and referred to some change in the child’s intentional state. 

The problem with many of the reports, as perceived by the current authors, is that typical play, or what was intended by the play, or what was meant by the play, all involved an interpretation by someone other than the children, hence precluding the elements of spontaneity or flexibility that are the characteristics of true play.  Elements such as creative use of toys, or appropriate use of toys, or participation in games were described, but with no information about how these elements should be assessed.  The issue is still that of going behind the observable behaviour and gaining some insight into the underlying mental state or attitude. 

Further, if it is suggested by one research team (Nuzzolo-Gomez et al 2002) that children’s preferences for playing with toys rather than some other activity reflected the reinforcement available from the toys offered, the question is raised about the extent to which the preferences can be said to be voluntary rather than conditioned responses.

 

An inverse relationship between play and stereotyped behaviours was discussed by a number of the reviewed studies, with the suggestion that stereotypical acts have a quasi play function and can be replaced by play behaviours .... and it was acknowledged by the review team that that at least some of the behaviours seen in children with autism, and described as stereotypic, could meet some of the criteria for true play in being spontaneous and internally motivated, and focused upon process rather than any product (while also, presumably, being engaging and enjoyable).  

It was commented that such features were rather less characteristic of the play activities that replaced the stereotyped behaviours, raising the question of the value of the exercise !

 

This question may be answered at least partially in terms of the cosmetic appeal in that the taught play behaviours are more socially acceptable than the behaviours they replace.  The current authors accept that gaining more socially appropriate behaviour can be a legitimate goal in itself if the children in question may subsequently be more accepted by peers in integrated settings.  It is also accepted that self stimulatory behaviour, engaged in to the exclusion of other activities, will inhibit learning opportunities.  However, there is some anxiety lest replacing behaviours deemed as inappropriate will upset the balance of behaviours and deny the children access to a playful engagement even if it is atypical.  

 

In respect of symbolic play, six studies were identified as claiming to have increased such play, sometimes defined as pretend or make-believe play. 

For example, Ingersoll and Schreibman (2002) claimed that children could be taught  imitative pretend play using behavioural approaches, and that a number of the children increased their spontaneous pretend play.  Social behaviours such as joint attention were also seen to increase.

The problem is that this study was an unpublished presentation so that one could not directly assess the supportive evidence for the claims made.  

Meanwhile, a summary of one of the other studies described how play remained qualitatively distinguishable from the play of typically-developing children.

 

Of the remaining four articles, each reported results that appeared consistent with development of play as a disposition. 

However, questions arise in respect of real spontaneity in one case where the children showed continuing self prompting .... although it is acknowledged that the children’s reduced reliance upon self-administering of rewards could suggest some degree of enhanced internal motivation.  Once again, there is the difficulty of making a judgement about the quality of change in disposition on the basis of observed behaviour.

 

In another case, some of the hardest claims involved the development of creative and spontaneous play following the use of pivotal response training;  and the critique by Luckett et al recognised advances in complexity and creativity in symbolic play in the sample of children in question ... although the advances had tailed off by the 3-month follow-up in three of the seven children.

Interactions were more positive, but initiations remained low. 

The findings do suggest spontaneity, internal motivation etc, but there remained the caveat to this generally positive outcome in that the children performed best with the familiar therapist and the familiar toys used in training, and there was limited generalisation towards playing with peers.  Nor was evidence presented about levels of play when the children were alone as opposed to interacting with therapist or parents.  

 

In a further case, socio-dramatic play was the target, using pivotal response training; and parents and teachers assessed the outcomes in terms of role playing, persistence, make-believe transformations, social behaviour, and verbal communication.

Positive gains were identified in the sample of three children and performance was seen to generalise to new toys and, to a lesser extent, to new playmates. 

These results did suggest voluntariness, internal motivation, flexibility, etc; but poorer performance when playing with parents, and a continued preference for two of the children for parallel play, suggested that engagement required some specific elicitation; and the researchers in question qualified their claims by conceding that the play of the children did remain qualitatively different from typically developing children, especially in the case of one child who maintained stereotyped and non-interactive behaviours.                                     

 

The fourth and final study cited here used discrete trial training to target “appropriate” behaviours (such as putting a cup to a doll’s mouth for her to drink), and it was found that the increased responses did generalise to other pretend actions suggesting, again, some voluntariness, flexibility, spontaneity and freedom from constraints of reality. 

 

When it came to social play, three studies were identified as meeting the criteria for hard claims.

The strongest claims emerged from the work of Perry et al (1995) who used Lovaas-style ABA techniques to develop social play and who described the two siblings in question as “recovered” to the extent of no longer meeting any criteria for pervasive developmental disorder or showing any idiosyncracies of behaviour or language to separate them from peers.

However, a critical commentary on this study cast doubt on the initial diagnoses of autism as well as arguing that the strength of their claims was not in proportion to the level of evidence available .... and for the purposes of this current review, insufficient detail was offered to determine whether a true dispositional change had occurred. 

 

A second study sought to incorporate the ritualistic behaviour of children into their  participation in board games thus to increase sibling social play of the three children involved.  Their findings did indeed suggest that there were degrees of voluntariness, internal motivation, and enjoyment in their approach to playing with their siblings. 

 

The third study used in vivo modelling and imitation to teach cooperative play, and all six of the children involved gained a degree of cooperative play that generalised to new settings and new partners.  However, Luckett et al were reluctant to see the results as indicating enhanced play in a dispositional sense. “Cooperative play” was a matter of rigid turn-taking which seemed to preclude spontaneity and flexibility; nor was there any evidence for genuinely novel responses as opposed to the reproduction of modelled responses. 

Nevertheless, it was accepted that the findings did suggest a degree of flexibility and voluntariness.

 

In their final summary and discussion, Luckett et al reiterated their finding of 13 articles making hard claims for promoting play in children with autism.  8 of these were seen to produce results consistent with the cited elements of true play and to suggest that behavioural approaches could sometimes be effective in changing children’s disposition towards play. 

 

However, while the approaches described were behaviourally oriented in being highly structured and using reinforcement to shape behaviours, the authors held that the procedures adopted were somewhat differentiable from the typical behavioural “canon”.   For example, use was made of peer support to aid turn-taking; or there was reliance upon reinforcement from the activity or the materials themselves rather than upon any extrinsic reinforcement right from the start; or self monitoring was a key; or there was a reliance upon the rules of the games rather than on rules set out by the therapist.  

The issue of the confounding of behavioural and dispositional interpretations was restated, and reference was made to some confusion concerning the processes underlying generalisation.

 

Their conclusion included the comment that marketing of behavioural approaches may respond to concerns lest such approaches simply achieve rote responses by arguing that the skills learnt undergo a transition from initial rigidity to ultimate fluency and spontaneity, but that no such phenomenon was evident in any of the articles currently reviewed.

Luckett et al accept that children may be enabled to approach activities with a playful disposition, but that this is not amenable to recognition by an observer.  In any event, the aim of their review was to assess evidence for claims that there can be developments in children’s disposition to play, and they cannot conclude that dispositional change did not occur.  They can only state that the authors in question did not provide substantive evidence for the claims they were making to this effect.

 

The Impact of Home-Based Early Intervention on Families  

 

Trudgeon and Carr (2007) begin their survey of parental experiences of behavioural interventions by describing the accumulating evidence for positive gains from such approaches, especially when initiated in early childhood. 

However, while the evidence may provide general support for the effectiveness of early and intensive behavioural intervention, it is noted in the NIASA report (2003) that there remain questions about which specific elements of the intervention or precisely which level of intensity will bring about maximal gains for any given child.

 

A brief literature review by the current authors indicates that early intensive behavioural intervention (EIBI) can bring about considerable gains in language, social communication, cognitive skills, and adaptive functioning. 

The common characteristics of successful programmes appear to include early initiation (during the preschool period), an intensity level of at least 25 hours per week, maintenance of the programme for a minimum of a year, and supervision by staff with postgraduate training and experience in the use of these methods for children with autism.

 

These authors continue by describing how EIBI typically takes place in the child’s home and, while there is usually overall direction from a consultant, the arrangements  are likely to be the responsibility of the parents, and this highlights the potentially considerable pressures upon the parents (and other family members). 

Further, manuals and guidelines are available by which to assist parents in the practical issues surrounding the maintenance of programmes, but they do not usually refer to the emotional demands that accompany their organisation and day to day management.

 

What evidence does exist concerning the wider impact of EIBI is described as limited to questionnaire studies and anecdotal reports concerned with stress.

For example, Hastings and Johnson (2001) surveyed a sample of 141 parents involved in Applied Behavioural Analysis programmes in the UK and found that parental stress levels were predicted by a number of psychological variables, such as the formation of coping strategies, access to social support, and positive beliefs about the likely effectiveness of the intervention.  The severity of the autistic features was also predictive of stress, but variables such as the child’s age at the start of the programme, the duration of the programme, and whether the parents acted directly as therapists, were not found to be significant.  Hastings and Johnson noted that the most facilitating feature was the supportiveness of the tutors, and that barriers were most commonly reported to involve the recruitment of therapeutic teams and their management.

 

The aim of the study by Trudgeon and Carr themselves was to expand the current evidence concerning the impacts upon families who are running EIBI programmes in terms both of the positive features and of potential stressors.  

 

Their participants were 16 parents (9 mothers and 7 fathers) representing 9 families each of which included one child diagnosed with autism for whom an intensive early programme based upon ABA principles was being conducted at home.  Each family had been running the programme for at least 3 months, with the child engaged for at least 30 hours per week, and receiving supervision from an experienced consultant.

A semi-structured interview was conducted with the parents covering the establishment of the EIBI, effects upon family life, perceived benefits and disadvantages, and facilitating and inhibiting issues.

 

The findings were described as presenting a picture of mixed impacts in that the stress and anxiety associated with the demands of the programme were accompanied by support associated with the perceived benefits.  

 

The example was given of the sense of an invasion of privacy resulting from the constant presence of tutors in the home; and the organisation of the tutor team was frequently reported to be a source of stress.  However, those tutors were also frequently cited as a source of practical and emotional support.

 

A common concern arose in those families where the child with autism had at least one sibling for whom, the parents acknowledged, there was less than a fair share of time and attention.

Balancing and positive impacts were reported to include positive relationships between the siblings and gradually increasing access to social and leisure activities as a result of the progress of the child with autism.  The effects of running the programme were also largely positive as a result of feelings of being empowered to do something practical and of encouragement at signs of progress. 

 

It is recognised that the sample of participants was small so that it is necessary to be cautious about attributing the emerging themes to a wider population of families involved in EIBI.  However, Trudgeon and Carr report that their findings are consistent with existing evidence that the running of such programmes is not necessarily associated with a net stressful impact; rather, the potential stress can be mitigated by various sources of support.

 

For example, in respect of family relationships, the degree of support available from the wider family appeared significant in determining whether the effects of a programme would have an overall positive or negative impact.  Where such support is available, the parents are enabled to maintain a more positive outlook and their own relationship is safeguarded; but where there is little or no access to family support, the demands on the parents will be greater and more stress will be applied to their relationship.

The parents’ own resources appear significant in that the majority of the parents in this study had a higher than average level of educational achievement with the speculative  implication  that the advantages of home-based EIBI may be greater among parents with educational advantages who may also have the various skills by which to manage tutor teams and to contribute to the programmes.  

 

Meanwhile, some parents differentiated the stress of coping with the child’s autism and stress resulting from the demands of the programme, with the implication that emerging evidence of the programme’s effectiveness (for example, in improving the child’s degree of sociability) can reduce the stress from both sources. 

However, the authors note that the children in this current study were diagnosed with autism of a mild to moderate level, and it may be that the interaction between factors such as level of severity, parental feelings of efficacy, emergence of coping strategies, etc, would be different in the case of children with autism beyond a mild or moderate level. 

 

They recognise, therefore, that the views of this particular sample of parents may not be generalisable to parents with different family circumstances, different educational levels, and with children whose autism is of a different degree of severity.

 

(One might, at this point, remember the comments of Lovaas himself during a presentation to a London conference [1997] to the effect that an ABA programme, by its very intensity, can be a sources of stress upon parents with “burn-out” a real possibility; and that not all children will achieve significant benefits, with implications for monitoring progress and for a consideration of alternative intervention if observed progress is not a mitigating factor for the pressures involved in the programme.  Lovaas recognised the variability among children with autism, and how, without individual and matched intervention, such children may remain unable to learn.)

 

Trudgeon and Carr conclude by restating how home-based EIBI programmes can place high demands upon the personal and material resources of families. 

The corollary is that the success of the programmes may be predictable from the observed extent of these resources.

Meanwhile, NIASA (op.cit) warns that the current level of evidence does not identify support for home-based programmes rather than school-based delivery of any particular form of behavioural intervention, and that a fruitful theme for further research would be that of the relative impacts of home-based versus school-based EIBI by which to identify how equitable access to this form of intervention may best be achieved.

 

Real World Effectiveness of Early Interventions  

 

One of the studies included in the review by the above authors (Trudgeon and Carr) was that of Reed, Osborne, and Corless which appeared in its initial form in 2004. 
This study is also described in the review of the present author in the notes “ Ongoing Thoughts about Early Intervention in Young Children with Autism” (MJC : November 2004).

 

This study has now been published in a peer-reviewed journal (Reed et al 2007) and it seems logical briefly to highlight this research once more given that it can now be more formally cited. 

 

The starting point for the work was the perceived lack of quantitative evaluations of the efficacy of educational approaches for young children with autism despite their increasingly common usage.

These authors further noted that the significance of many of the studies that have been completed is limited as a result of the use of retrospective (archive) data rather than data emerging from prospective evaluation and direct comparison of the progress of children in different intervention groups.

 

Reference is made to the frequency with which Applied Behavioural Analysis (ABA) is discussed in the literature, and to the questions and criticisms that have been expressed in regard to the research report of Lovaas (1987) which stimulated this  renewed attention to early and intensive behavioural intervention.

 

The Reed et al study set out to assess effectiveness of this approach and of alternative approaches in the “ real world “ ... ie, among community-based rather than clinic-based participating children, representative of those referred to local services, and likely to present with relatively severe levels of autism and limited language development.

The three interventions compared were ABA, special nursery placement, and Portage programmes. 

A fuller description of the methodology and results are set out in the original article

(and in the November 2004 summary), but the basic outcomes can be described as demonstrating the effectiveness of the ABA approach, and of specialist nursery placement, in fostering intellectual and adaptive development. 

 

However, it was also noted that none of these interventions (according to the ratings of presenting symptomatology) produced what could be seen as “recovery”; although it was acknowledged that the current ABA outcomes may be differentiable from those of the Lovaas study because of the shorter duration of the intervention, or the community rather than clinic setting, or the greater severity of the autism among the participating children. 

In any event, it was held that a typical and community-based intervention over a 9 month period produced no signs of an emergence from the symptoms of autism. 

 

These authors highlighted, further, the effectiveness of the special nursery placement in fostering intellectual and educational progress, and, particularly, in adaptive behavioural functioning, contrary to results cited in previous research which included a nursery control group.   The authors could not specify why gains were observable here and not in other studies, but speculated that it may be a matter of particular group-teaching style, the permutation of methodologies adopted, or differentiability between the groups of participating children .... issues worthy of subsequent investigation.

 

The effectiveness of the ABA approach (compared to Portage) in fostering intellectual and educational progress was thought likely to reflect the emphasis upon individual working, while the success of the nursery in promoting adaptive behaviour (compared to Portage) was thought to reflect the group teaching and shared activities.  The implication drawn was that any early programme for young children with autism would best include a combination of relatively intense one to one working and group activities.

 

Limitations to this present study were acknowledged to include the non-random allocation of children to intervention groups, and the lack of opportunity directly to monitor the strictness of adherence to the behavioural programmes implemented in the children’s homes.  It was also accepted that the research did not set out to identify precisely which elements of an intervention underlie observed benefits. 

Nevertheless, it was concluded that both ABA intervention and specialist nursery intervention produced gains (as great as many cited in previous and longer term clinic-based interventions); but that the current findings did not provide any evidence of recovery from autism.

 

(The present writer – MJC – would simply comment that the results do not suggest that Portage is not a valid and very effective system for intervention and support in respect of a range of special needs.  However, practice requires an evidential basis, and the evidence from this current study may be interpretable as reinforcing the benefits of specificity in interventions for young children with autism.  In other words, the intervention needs to be targeted to the particular nature of autism and the autistic symptoms (and to their particular permutation in any given individual). 

The intervention would best be fitted to the observed needs of the child, and fine tuning of the elements of any programme by which to maximise this match maintained via ongoing monitoring.  Fitting a child to a programme may be less effective, especially if the programme is not autism-specific.  

The potential benefits of, for example, ABA are observable; but it is somewhat dangerous to predict or assume that the progress reported in a child or group of children receiving a given style of programme will be precisely replicated in another child or group of children, who may not be directly comparable in terms of exogenous or endogenous characteristics, who are treated in a different setting, who are treated by different tutors/therapists, and whose programme may differ in even subtle ways from that of the model.  The generalisable significance of features such as early initiation of intervention, adequate duration, and optimal intensity are recognised; but what precisely is effective in the way of methodologies may differ across cases. This issue becomes all the more salient when one begins to consider further confounding variables such as intervention fidelity ...or “therapy drift”. 

Thus, determining effectiveness in any given case requires adequate baseline assessment, a clear description of the programme content and strategies, and repeated follow-up assessments. Reported outcomes in the literature can act as a starting point, but hardly as a wholly reliable predictor.)

 

The Parents Plus Programme

 

The Parents Plus Programme is an initiative of the Irish Health Services by which to provide support and practical guidelines for parents whose (pre-school) children present with developmental or behavioural disabilities. 

 

Quinn et al (2007) begin their report of an evaluation of this programme by citing converging evidence for significant behavioural problems among a proportion of young children who have developmental disabilities which may be persistent, and still evident in later childhood or adolescence. 

Such problems among children in the age range of 4 to 7 years may include oppositionality, non-compliance, and aggression.

 

In the face of these relatively common problems, various programmes by which to enable parents to apply management strategies have been produced; and the scope of such programmes, including video-modelling packages, has been extended to include children with no identified developmental disability but presenting with conduct problems.  

A review of a sample of those programmes seen to be appropriately designed and controlled has led to the ongoing conclusion that group-based training in behavioural strategies for parents can be effective in reducing the presenting behavioural problems and in reducing parental stress, thus producing positive parent-child relationships and family functioning. 

 

The Parents Plus Programme (Sharry and Fitzpatrick 1998) is reported to be the only group-based behavioural training programme available to parents in Ireland.

This is a practical, video-based course designed to assist parents in dealing with behavioural problems in children aged between 4 and 11 years.  The schedule involves eight weekly sessions of two hours each, using scenarios presented via video recordings of positive parent child interactions where problem behaviour is either averted or managed.

Particular topics include the use of parental attention to alter behaviour, play, the use of reinforcement, praise and encouragement, rule setting and helping children to keep them, active ignoring, time out, and problem solving with children.

While the overall model takes a cognitive-behavioural slant, the programme is flexible in matching parental strengths, and involves a collaborative mode of operation. 

 

Two evaluations of earlier versions of Parents Plus have been completed. 

Behan et al (2001) found that parents who completed the course described greater gains in respect of behavioural goals than those on the waiting list for places on the programme.  Externalising behaviour problems in the children had significantly decreased, as had the level of stress associated with interactions between parents and children. 

Sharry et al (2005) worked with parents of children aged up to 6 years and described a significant reduction in parent-reported conduct problems and hyperactivity in the children, and in their own stress levels.   Further, ratings by observers indicated marked improvement in parent-child interactions. 

 

The aim of the study by Quinn et al was to evaluate the effectiveness of the Parents Plus Programme for families with pre-school children presenting with developmental disabilities and significant behavioural problems.

 

41 parents of children with such disabilities in the age range 4 to 7 years were the participants, all drawn from four area clinics providing early intervention for children with significant cognitive developmental delay.  22 parents (of 16 children) formed the target group; and 19 parents (of 25 children) on the waiting list for the Parents Plus Programme formed the control group.

The majority of parents had a child whose primary diagnosis was an intellectual disability, with a minority of children in each group identified with autistic spectrum disorder. The most common behaviour problems were temper tantrums, non-compliance, over-activity, and impulsiveness, which, in all cases, had persisted over at least a year, leading to parental stress and a restriction upon the families’ social activities.  

While part of the Parents Plus Programme, or awaiting a place, all the participants continued to receive routine services for their children such as speech and language therapy and physiotherapy, and support from mental health professionals and social workers. Most of the children attended pre-school educational groups for 2 or 3 sessions per week. 

 

Pre- and post intervention assessments were completed to gain measures of the children’s behaviour problems, parental and family adjustment, and family stress processes, with use made of a range of published instruments including the Strengths and Difficulties Questionnaire, Child Behaviour Checklist, Family Assessment Device, Parental Distress Scale, etc.

Target and control parents competed the rating scales before and after implementation of the programme; and the target group completed the ratings on a third occasion ten months after the end of the programme.

The programme was reduced to 6 weekly sessions in the light of the existing commitments or travel problems of some families, with the sessions about effective use of rewards and solution-building omitted because they were directed towards older children.

 

The results indicated that, following the running of the programme, a comparison of target and control group mean scores indicated that the parents who had worked through the programme showed a better adjustment to the challenges faced with these gains maintained at the follow-up assessment. 50% of the children were shown to have made clinically significant improvements in their behaviour; and the target group of parents reported a high level of satisfaction with the programme. 

 

However, despite differences in the mean scores, ratings highlighted ongoing problems in respect of the children’s behaviour in both groups (ie the extent of differences between groups in respect of a shift in observed behaviour from the clinical range to the sub-clinical range did not reach statistical significance), and there remained some impacts upon family functioning or vulnerability to stress. 

Nevertheless, parents reported that the most important skills gained via the programme were the recognition of the need to remain calm, to use praise and encouragement and active listening to elicit pro-social behaviour, and to adopt an active ignoring style in the face of challenging behaviours.  The single most important gain was reported to be a sense of confidence and competence in their parenting style.

 

The limitations of the study were acknowledged to include the small sample sizes and the non-random allocation to treatment and control groups, and the use of video scenarios concerned with typically-developing children when parents reported that they would have preferred video material tailored to their specific needs and incorporating children with developmental disabilities. 

 

The authors concluded that, despite these limitations, the results were encouraging and supported the growing view of the potential effectiveness of parent programmes; and that, for at least some families of pre-school children with developmental disabilities and behavioural problems, a programme such as Parents Plus would be a valuable addition to routine early intervention. 

 

(It could be suggested – MJC – that these findings, including the quoted comments of the parents themselves, also support the view that it is very important to follow up a child’s identification with some disability by rapid access to practical support in order that parents can experience a sense of efficacy.  It appears, further, that the opportunity to work alongside parents with similar concerns, and to share and discuss experiences and strategies, will enhance the impact of the intervention.

These results could also be taken as reinforcing the view that the support needs to be ongoing and not limited to a short and finite programme, and that benefits are likely to be most significant when the supportive programmes are specific to the particular and individual needs of the child and to his or her particular family context.)

 

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M.J.Connor                                                                                          November 2007

                     

REFERENCES

 

Behan J., Fitzpatrick C., Sharry J., Carr A., and Waldron B.  2001   Evaluation of the Parents Plus Programme.   The Irish Journal of Psychology  22  238-256

 

Hastings R.  and Johnson E.  2001   Stress in UK families conducting home-based behavioural interventions for their young child with autism.   Journal of Autism and Developmental Disorders  31  327-336  

 

Ingersoll B. and Schreibman L.  2002   The effect of reciprocal imitation.   Paper presented at the 2nd International Meeting for Research on Autism.  Orlando, Florida.        

 

Jordan R.  2003   Social play and autism spectrum disorders.   Autism  7(4)  347-360

 

Lovaas O.  1987   Behavioural treatment and normal educational and intellectual functioning in young autistic children.   Journal of Consulting and Clinical Psychology   55  3-9  

 

Lovaas O.  1997   Presentation to the P.E.A.C.H. Conference “ Early Intervention in Autism ”.  London (Imperial College) : September 12^th and 13^th, 1997 

 

Luckett T., Bundy A., and Roberts J.  2007   Do behavioural approaches teach children with autism to play, or are they pretending ?   Autism  11(4)  365-388

 

NIASA (2003)   National Autism Plan for Children : National Initiative for Autism.  London : National Autistic Society

 

Nuzzolo-Gomez  R., Leonard M., Ortiz E., Rivera C., and Greer R.  2002   Teaching children with autism to prefer books or toys over stereotypy or passivity.   Journal of Positive Behaviour Interventions  4(2)  80-87

 

Perry R., Cohen I., and Decarlo R.  1995   Case study : deterioration, autism, and recovery in two siblings.   Journal of the American Academy of Child and Adolescent Psychiatry  34(2)  232-237

 

Quinn M., Carr A., Carroll L., and O’Sullivan 2007   Parents Plus Programme 1 : evaluation of its effectiveness for pre-school children with developmental disabilities and behavioural problems.   Journal of Applied Research in Intellectual Disabilities  20  345-359

 

Reed P., Osborne L., and Corless M.  2007   The real-world effectiveness of early teaching interventions for children with autism spectrum disorder.   Exceptional Children  73(4)  417-433  

 

Sayeed Z. and Guerin E.  2000   Early Years Play : A Happy Medium for Assessment.   London : Fulton

 

Sharry J. and Fitzpatrick C.  1998   Parent Plus Programme; A Practical and Positive Video-Based Course for Managing and Solving Discipline Problems in Children.   Department of Child and Family Psychiatry, Mater Misericordiae Hospital, Dublin.   

 

Sharry J., Guerin S., Griffin C., and Drumm M.  2005   An evaluation of the Parents Plus Early Years Programme.   Clinical Child Psychology and Psychiatry  10  316-336

 

Trudgeon C. and Carr D.  2007   The impacts of home-based early behavioural intervention on families of children with autism.   Journal of Applied Research in Intellectual Disabilities  20  285-296