Early intensive behavioral intervention for children with autism: parental therapeutic self-efficacy
Introduction
Compelling empirical data focus on outcomes in clinic-directed applied behavior analysis (ABA) and early intervention programs for children with autism (e.g., Lovaas, 1987; McEachin, Smith, & Lovaas, 1993). Within clinic-directed programs, parents are often encouraged to be a full member of the therapy team (Lovaas & Buch, 1997). However, increasingly parents are playing a more central role in the organization and delivery of ABA interventions. This is due, in part, to practical problems in obtaining services from suitably qualified ABA practitioners and the financial costs to families who are not in receipt of assistance from government-funded agencies (Jacobson, 2000, Johnson & Hastings, 2002). Data on programs where parents act as therapists, and on programs that are parent-directed, are generally encouraging (e.g., Sheinkopf & Siegel, 1998; Smith, Buch, & Gamby, 2000). However, treatment gains have typically been found to be less than those achieved in clinic-directed programs (Bibby, Eikeseth, Martin, Mudford, & Reeves, 2001; Smith et al., 2000).
The sources of variance in outcomes of parent versus clinic-directed ABA programs have received little systematic study. Mudford, Martin, Eikeseth, and Bibby (2001) observed that parent-directed programs in the UK often failed to meet standards of a model intervention (Lovaas, 1987). Specifically, children were often older than 40 months at intake, the average number of therapy hours per week was 32, no program was supervised on a weekly basis, and it was difficult to establish the credentials of those supervising the programs. In a subsequent analysis, these treatment variables were not significantly related to child outcomes (Bibby et al., 2001) apart from the child’s age at intake. Younger children had better outcomes, a pattern that has been found by other investigators (e.g., Fenske, Zalenski, Krantz, & McClannahan, 1985; Harris & Handleman, 2000).
Smith et al. (2000) also addressed dimensions of the quality of parent-directed programs. In a study of six young children with autism, observations of the discrete trial implementation performance of the children’s therapists were compared with the performance of therapists working in a clinic-based program. Although presentation of discriminative stimuli, discrete trials, and consequences was correct on the vast majority of occasions in both groups, the clinic therapists showed superior performance. Smith et al. (2000) suggest that such differences may explain why early success on children’s simple skills can be demonstrated in parent-directed programs but this is rarely translated into best outcomes in the longer term.
Although there has been some analysis of the impact on program outcome of child variables such as IQ, age at intake, and language ability (Fenske et al., 1985, Harris & Handleman, 2000, McEachin et al., 1993; Smith, Eikeseth, Klevstrand, & Lovaas, 1997), therapist variables have not been related directly to intervention efficacy. A working hypothesis would be that therapist behavior (e.g., adherence to treatment protocols) is a salient variable in contributing to the success of ABA programs for children with autism. This question is empirical and remains to be tested. Assuming that therapist performance is influential, it will also be important to consider factors that account for variation in therapist behavior or performance.
At present, there is no theory of therapist performance in ABA programs for children with autism. However, we might expect that child, program, and therapist variables will be salient (cf. Graziano & Katz, 1982). Each of these is considered in turn. First, behavioral researchers have shown for some time that child variables affect parent, teacher and staff behavior (e.g., Berberich, 1971; Emery, Binkoff, Houts, & Carr, 1983; Patterson, 1982, Sherman & Cormier, 1974). In particular, adults reliably behave in a manner that serves to avoid or escape severe behavior problems that function as aversive stimuli (Carr, Taylor, & Robinson, 1991; Taylor & Carr, 1992). In the context of ABA programs for children with autism, this negative reinforcement process may play a role but one would also hope that positive reinforcement of therapist behavior also occurs due to improvements in children’s adaptive behaviors.
Second, therapist performance is also likely to be affected by various program variables. These factors might include the quality of training provided, frequency and quality of supervision, support provided by therapy team members, and the underlying efficacy of the behavioral technology. By way of example, a key factor in determining performance of therapists applying various ABA techniques is continued monitoring and feedback by a supervisor (e.g., McConnachie & Carr, 1997). A third set of factors that may influence therapist performance relate to the therapists themselves. Aspects of therapists’ personality (e.g., extroverts may find it easier to apply social reinforcers), mental health/stress, and beliefs may all be important. For example, staff working in mental retardation services have been found to interact less positively with clients if they are experiencing increased stress or burnout (Lawson & O’Brien, 1994; Rose, Jones, & Fletcher, 1998). The integrity of ABA interventions may well be compromised under such conditions.
The present research addresses one therapist factor that may have an impact on their performance in ABA programs for children with autism: therapists’ beliefs about their self-efficacy in the therapeutic role. This factor may have benefits at the behavioral level. In particular, there are strong contingencies acting to punish therapist adherence to behavioral technologies. These include temporal distance between therapist behavior and positive changes in the child and social disapproval from members of the therapists’ verbal community (Allen & Warzak, 2000). It is possible that therapists’ belief in their efficacy in the therapeutic role will help to mitigate against these contingencies (e.g., improving the chances that they will adhere to the program long enough for their behavior to come under the control of child improvement contingencies). In this manner, therapeutic self-efficacy may interact with establishing operations set up by supervisors (cf. Allen & Warzak, 2000) such as: “You may experience some tantrums and other difficulties to start with, but these are signs that what you are doing is working. They will soon settle down if you continue with the program.” Although this is a speculative argument at the present time, the research is significant as one of only a very small number of studies of therapist factors that may account for some of the variance in therapist behavior and the outcomes of ABA programs for young children with autism.
In the present study, we evaluated the relationship between the severity of the child’s symptoms of autism, social support provided by the program team, and parents’ perceptions of their efficacy as a therapist on ABA early intervention programs. Specifically, we hypothesized that parent therapists would have lower levels of self-efficacy when they were working with children with more severe symptoms of autism and when they felt less supported by the program team. We also explored a potential mechanism for this hypothesized effect: that child-related stress might mediate the impact of symptom severity on therapeutic self-efficacy. In previous research in the developmental disabilities field, strong relationships have been found between stress variables and therapeutic self-efficacy (Hastings & Brown, 2002a, Hastings & Brown, 2002b). The present analysis focused on a sub-group of parents from a larger survey study of families where a young child with autism was engaged in an ABA program (Hastings & Johnson, 2001). These parents were acting as one of the therapists on their child’s program team. Thus, the present data are also significant as they represent the first systematic study of the perceptions of parents in this therapeutic role in ABA programs for children with autism.
Section snippets
Participants
Participants were drawn from a larger survey of primary parental caregivers of children with autism engaged in intensive ABA early intervention programs in the UK (Hastings & Johnson, 2001). One hundred and forty-one parents participated. In this paper, data are presented on a sub-sample where one or both parents were a part of the therapy team for their young child with autism. Due to the small number of fathers responding to the survey (11 from 141, nine of whom were a therapist for their
Results
Statistical analysis proceeded through two distinct stages. First, correlates of maternal therapeutic self-efficacy were explored. Thus, all of the demographic variables and other measures described above were analyzed for their univariate association with maternal therapeutic self-efficacy. Only three variables were associated with maternal therapeutic self-efficacy at p<.05: (1) Mothers of children with more severe symptoms of autism reported lower self-efficacy as a therapist (Pearson r
Discussion
This study is one of a very small number addressing therapist variables that may predict therapist performance in ABA programs for young children with autism, and the first to gather data from mothers acting as therapists on these programs. Mothers’ beliefs about their self-efficacy in the therapeutic role are related to child, program, and maternal variables. Specifically, more severe autism symptoms in the child, less supportive ABA program teams, and higher maternal stress were predictive of
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