Parent inclusion in Early Intensive Behavioral Intervention: The influence of parental stress, parent treatment fidelity and parent-mediated generalization of behavior targets on child outcomes

https://doi.org/10.1016/j.ridd.2011.11.008Get rights and content

Abstract

Although early intensive behavior interventions have been efficient in producing positive behavior outcome in young children with Autism Spectrum Disorder, there is a considerable variety in the children's progress. Research has suggested that parental and treatment factors are likely to affect children's response to treatment. The purpose of the current study was to examine the interrelating factors that impact children's progress, highlighting the influence of parent inclusion in treatment provision captured by parental stress, how faithfully the parents followed the treatment protocols and the intensity of treatment provided at home. Twenty-four children received cross-setting staff- and parent-mediated EIBI, including continuous parent training and supervision. A comparison group of 20 children received eclectic intervention. Standardized tests were carried out by independent examiners at intake and after six months. The intervention group outperformed the eclectic group in measures of autism severity, developmental and language skills. Parent training and constant parent-mediated treatment provision led to reduced challenging behaviors from the children, increased treatment fidelity and child direct behavior change as measured by performance in correct responding on behavior targets. Variables of treatment progress and potential predictors of child outcome were analyzed in detail and mapped with regard to their relationships drawn from multiple regression analysis. Particularly, the study highlights an association between parental stress and staff treatment fidelity that interferes with decision making in treatment planning and consequently with positive behavior outcome. Such results provide important scientific and clinical information on parental and treatment factors likely to affect a child's response to treatment.

Highlights

► Parent treatment inclusion does not increase the parental stress levels. ► High level of staff treatment fidelity reduces the parental stress levels. ► High level of parent treatment fidelity predicts a better child outcome. ► Parent training and constant parent-mediated treatment provision reduces challenging behaviors.

Introduction

Although research has convincingly demonstrated that EIBI is effective in improving cognitive, communication, adaptive and social abilities in children with Autism Spectrum Disorders (ASD) in clinical and community-settings (Cohen et al., 2006, Eldevik et al., 2006, Eldevik et al., 2009, Eikeseth et al., 2002, Eikeseth et al., 2007, Howard et al., 2005, Perry et al., 2008, Reed et al., 2007, Remington et al., 2007, Smith et al., 2000), there is considerable variability in the extent to which the children progress. In fact, concerns have been voiced concerning such variability in child outcomes and a recognition of the need for individualization of treatment schedules and approaches in autism has been growing (Sherer & Schreibman, 2005). There have been promises that relating variables regarding the pre-treatment profile of the child and treatment variables to later child outcome will enable professionals to match individual children to specific treatment programs. The inherent heterogeneity of the Autism Spectrum Disorder with a variety of different symptom clusters ranging from severe to minor impairments, naturally complicates the scientific and clinical goal of identifying such predictors likely to affect a child's response to treatment. Well-established factors include the child's age at the initiation of treatment, with younger children yielding better outcomes (Granpeesheh et al., 2009, Harris and Handleman, 2000, Perry et al., 2011). Cognitive ability at intake has a moderate relation to outcome (Eikeseth et al., 2002, Eikeseth et al., 2007, Hayward et al., 2009, Sallows and Graupner, 2005), and children with better adaptive behaviors at intake tend to achieve better outcomes, and more language skills at intake accurately predict “rapid responders” to treatment (Remington et al., 2007, Sallows and Graupner, 2005).

The predictive value of autism symptom severity in determining developmental trajectories rarely has been investigated. Nevertheless, autism severity has been proven to account for additional explanation of different child outcomes (Darrou et al., 2010, Sutera et al., 2007). Studies that address treatment factors such as intensity of intervention have revealed inconsistent results, with one group claiming that comprehensive and high-intensity treatments produce better outcomes (Reed et al., 2007), and others suggesting that intensity does not necessarily correlate with outcome (Darrou et al., 2010, Luiselli et al., 2000).

These inconsistent results lead to questions about factors that may promote or impede children's progress and, as such, modify the actual effectiveness of specific treatment models. It is suggested that there may be other factors, such as the amount of parental involvement in teaching throughout the child's day, complementary to hours of professional service delivery that may impact outcomes (Luiselli et al., 2000). Although it was shown that staff-provided EIBI results in decreased parental stress and improved outcome with the children, the comparison parent training comprised both less child and less parent work load (Smith et al., 2000). In contrast, Sallows and Graupner (2005) did not find marked differences between clinic- and parent-directed treatments with children improving regardless of treatment condition. It was shown that high parent treatment fidelity via parent training leads to the maintenance of the child's mastery of skills and lasting behavior changes in children with ASD (Vismara, Colombi, & Rogers, 2009). It was also demonstrated that parental stress decreases in parents who are providing low-intensity treatment, but increases in high-intensive treatment provision (Brookman-Frazee, 2004, Keen et al., 2010). This may lead to reduced positive child outcomes solely in high time-input treatments (Osborne, McHugh, Sounders, & Reed, 2008a). Further, parent stress does not solely influence outcomes in parent-mediated interventions: higher initial parent stress is also associated with less adaptive behavior outcome in staff-provided intervention (Shine & Perry, 2010). The professor for the current study was to evaluate to what extent the parent inclusion in treatment provision accounts for an appropriate implementation of teaching strategies as such predicts or counteracts the facilitation of child's behavior improvement across clinical and community setting. Specifically, we aimed:

  • (1)

    To evaluate the impact of the EIBI model compared to an Eclectic intervention on child outcomes after six months of treatment and to monitor the level of parental stress in the two cases.

  • (2)

    To examine the progress of parent treatment fidelity and treatment provision after six months of inclusion in EIBI treatment, and to reproduce the child's six months direct behavior progress in child challenging behaviors and as performance in (a) producing correct responses to newly introduced behavior targets and (b) producing correct responses in generalization and maintenance probes.

  • (3)

    To investigate the interrelating factors that affect children's performance and outcome measures after six months of parent-mediated EIBI treatment, highlighting the impact of parent inclusion in treatment provision as indexed by parental stress, parent treatment fidelity and the intensity of treatment provided at home.

Section snippets

Procedures

In order to achieve the study aims, a set of hierarchical steps were followed. Drawing conclusions regarding interrelating factors that influence child and parent outcome, requests the efficiency of a specific treatment to produce positive outcomes. Therefore, the applied treatment model was compared with an eclectic treatment approach via intra- and between group analysis across a six-month time-span. The relative influence of parental stress on child outcomes after six months was measured in

Results

Study aim [1]: To evaluate the impact of the EIBI model compared to an Eclectic intervention on child outcomes after six months of treatment and to monitor the level of parental stress in the two cases.

Discussion

With regard to the first study question, our results prove an advantage for children following the staff and parent-mediated EIBI. These children showed a significant decrease in autism symptom severity, gains in mental developmental state and early language production, improvements that were not achieved by children following Eclectic interventions. Indeed, group comparisons in score change over time on early language skills demonstrated that children following both the EIBI and the Eclectic

Role of funding source

The project was conducted between the Association “Una Breccia nel Muro”, the Children's hospital Bambino Gesù, and the relief organization Don Calabria under the sponsorship of the Foundation Vodafone Italy, and private financial contributions of Anima, Foundation BNL, Federalalberghi, Insurance Consulting Group, Azienda Romana Mercat, Hotel Hilton, Sky, Promusic, Ms. Adelaide Mazzeo and Mr. Mauro Paissan.

The sponsors and contributors did not have any role in the collection, analysis, and

Acknowledgements

The authors would thank to the families following the approach of our Autism Treatment and Research Centre “Una Breccia nel Muro” and all staff working for the Association “Una Breccia nel Muro” that have spent extensive effort in order to implement the EIBI model. Particularly, we thank Vanessa Mancini for her commitment to the study and the reliable analysis of children daily data record. We thank Prof. John Morton and Dr. Joe Hettinger for their support and invaluable help in editing the

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