Randomized comparative efficacy study of parent-mediated interventions for toddlers with autism.

Young children with autism spectrum disorder (ASD) display significant impairments in early social communication skills. These include the initiation of joint attention gestures (e.g., showing toys to others, pointing to share, and coordinated eye gaze between objects and people) and the ability to jointly engage in social interactions with others (Adamson, Bakeman, & Deckner, 2004; Kasari, Freeman, & Paparella, 2006; Sigman, Mundy, Sherman, & Ungerer, 1986). These impairments uniquely discriminate children with ASD from children with other developmental delays and typical children of similar mental age (Mundy, Sigman, Ungerer, & Sherman, 1987). Given the large literature on the importance of these skills as predictors of later development, early interventions have increasingly targeted these skills, especially for very young children (Kasari, et al., 2005). The foundational nature of these skills for the ability of children to develop relationships with others leads researchers to consider parents as important mediators of change and potential targets of intervention. However, the current evidence for parent-mediated interventions for children with ASD is mixed. For example, experimental low intensity, three-month, short-term parent-mediated interventions for very young children who are at risk for ASD have not demonstrated significantly greater change in parent and child outcomes relative to community-based, treatment-as-usual interventions (Carter et al., 2011; Rogers et al., 2012). Longer -term interventions of nine months have shown greater effects for children who begin intervention before age two years (Wetherby et al, 2014). However, for older children with confirmed diagnoses of ASD, these same types of interventions of 12–24 sessions over 3 to 6 months have improved parent responsiveness and child outcomes to a significantly greater extent when compared to treatment-as-usual community groups (Green et al., 2010; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010) or an alternative treatment (Kasari et al, 2014). What might account for these age-related differences? One notion is that older children display more readily apparent delays relative to other children. Thus, parents are better able to recognize the specific needs of their children. Another speculation is that children who have confirmed diagnoses are often receiving a range of intervention services in the community, thereby increasing the difficulty in identifying the augmenting effects of parent-mediated interventions against the background of more intensive treatments. Currently, we are unclear on the absolute dose needed and the best methods for teaching parents to achieve the most optimal child outcomes. Other factors may also affect parent and child outcomes. Increased stress and worry have been well documented for parents of children with ASD and suggest the need for specific interventions to address parental mental health concerns (Schieve, Blumberg, Rice, Visser, & Boyle, 2007). The increased stress may result from many sources: distress from the impact of their child’s diagnosis, the strain of additional parenting roles and demands, including expectations that they deliver interventions to their young child, as well as time lost from work, and increased medical costs associated with caring for a child with ASD (Cidav, Marcus, & Mandell, 2012). Early interventions that provide parenting strategies through psychoeducational programs have significantly decreased parental stress in these families (Feinberg et al., 2014; Tonge et al., 2006). Although effects of psychoeducational approaches on child outcomes are rarely tested, a recent study found that a parent education and counseling program that included behavior management strategies helped to improve child adaptive behaviors (Tonge, Brereton, Kiomall, Mackinnon, & Rinehart, 2014). Thus, the combination of counseling and education for ASD-specific parenting strategies may be effective for improving both parent and child outcomes. Individual child characteristics can also affect treatment outcomes. These individual characteristics may include a wide range of features such as language ability, cognition, and severity of ASD. This heterogeneity may account for findings that parent-mediated interventions have had very limited effects on child outcomes. Child treatment gains have been limited to particular subgroups, such as those entering the intervention with the greatest impairment, or those identified as displaying greater pre-intervention object interest (Carter et al, 2011; Siller, Hutman & Sigman, 2013). Overall, there is a need to identify other parent-mediated interventions for young children with ASD that are more robust in significantly improving parent and child outcomes. This comparative efficacy study attempts to advance intervention research by testing whether a parent-mediated intervention involving direct parent coaching with the child is more efficacious than a parent-education model (without direct involvement of the child) in improving parent and child outcomes. The study treatments were added to existing early intervention services, controlling for type and dose of these services. All of the children were toddlers with ASD, between the ages of 22 and 36 months, and attended the same 30-hour per week, early-intervention program. Families attending the early-intervention program were randomized to receive either one hour per week of parent training based on a manualized parent psychoeducation program for parents of children with autism (Psychoeducational Intervention -PEI; Brereton &Tonge, 2005) or a hands-on manualized, parent-mediated program aimed at improving core deficits in their toddlers (Joint Attention Symbolic Play, Engagement, and Regulation-JASPER, UCLA, 2005, unpublished manual). Controlling for the overall dose of intervention, we compared the approaches on the primary outcome of joint engagement between parent and child. Joint engagement, as defined, requires the active and reciprocal engagement of both parent and child. Secondary measures included child-initiated joint attention, functional and symbolic play types (reflecting play flexibility and diversity), play level, and generalization of joint engagement to the child’s classroom. We hypothesized that improvements in child engagement with objects and people, joint attention gestures, and play skills would be significantly greater in the JASPER condition as compared to the PEI condition. Because one focus of the PEI condition is on reducing parent stress, we also hypothesized that stress would be reduced to a greater extent for parents in the PEI condition relative to the JASPER condition. Child and parent measures were collected prior to intervention (Pre-Treatment), at the end of intervention (Post-Treatment), and at 6 months follow-up.