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Investigators plan to publish the parent training manuals to share intervention techniques for managing behavioral problems. Image Credit: Yale News

Parent training reduces autism behavioral problems

Young children with autism spectrum disorder, who also have serious behavioral problems, show improvement when their parents are trained with strategies to manage tantrums, aggression, self-injury, and non-compliance.

The findings from this parent training study by Yale and Emory University researchers were published recently in the Journal of the American Medical Association (JAMA).

Autism spectrum disorder (ASD) is a chronic condition starting in early childhood. Marked by impaired social communication and repetitive behavior, ASD affects 0.6 to 1% of children worldwide. In young children it is often complicated by moderate to severe behavioral problems.

“Serious behavioral problems interfere with everyday living for children and their families. Decreasing these serious problems results in children more able to manage everyday living.”

Lawrence Scahill PhD, senior author on the study, professor, Yale University School of Nursing and Child Study Center.

A 24-week trial was conducted by the Research Units on Behavioral Intervention (RUBI) Autism Network, a six-site National Institute of Mental Health consortium, dedicated to developing and testing behavioral treatments for ASD children.

"Parent training has been well studied in children with disruptive behavior disorder. Our study shows that parent training is also helpful for improving behavioral problems such as irritability and non-compliance in young children with ASD," adds Denis Sukhodolsky PhD, assistant professor Yale Child Study Center, who provided oversight for the multi-site study.

RUBI investigators randomly assigned 180 children ages 3 to 7 with ASD and behavioral problems to either a 24-week parent training program, or a 24-week parent education program. Parent education provided up-to-date and useful information about ASD, but no instruction on how to manage behavioral problems.

“In a previous report from this trial, we showed that combined treatment was superior to medication alone in reducing serious behavioral problems. In the current report, we show that combination treatment was better than medication alone on measures of adaptive behavior. We note that both groups — medication alone group and the combined treatment group — demonstrated improvement in functional communication and social interaction. But the combined group showed greater improvement on several measures of everyday adaptive function.”

Lawrence Scahill PhD

Based on their findings, Scahill and his team are now conducting a study that uses parent training as a stand-alone strategy in treating younger children with ASD. This study is being conducted at Yale and four other medical centers across the United States. Investigators plan to publish the parent training manuals as a way to share this intervention with the public.

"Parent education was an active control condition," said James Dziura, associate professor in the Department of Emergency Medicine at Yale, who led the study along with Cindy Brandt MD. "Both groups showed improvement, but parent training was superior on measures of disruptive and noncompliant behavior."

Abstract
Importance Disruptive behavior is common in children with autism spectrum disorder. Behavioral interventions are used to treat disruptive behavior but have not been evaluated in large-scale randomized trials.

Objective To evaluate the efficacy of parent training for children with autism spectrum disorder and disruptive behavior.

Design, Setting, and Participants This 24-week randomized trial compared parent training (n = 89) to parent education (n = 91) at 6 centers (Emory University, Indiana University, Ohio State University, University of Pittsburgh, University of Rochester, Yale University). We screened 267 children; 180 children (aged 3-7 years) with autism spectrum disorder and disruptive behaviors were randomly assigned (86% white, 88% male) between September 2010 and February 2014.

Interventions Parent training (11 core, 2 optional sessions; 2 telephone boosters; 2 home visits) provided specific strategies to manage disruptive behavior. Parent education (12 core sessions, 1 home visit) provided information about autism but no behavior management strategies.

Main Outcomes and Measures Parents rated disruptive behavior and noncompliance on co-primary outcomes: the Aberrant Behavior Checklist–Irritability subscale (range, 0-45) and the Home Situations Questionnaire–Autism Spectrum Disorder (range, 0-9). On both measures, higher scores indicate greater severity and a 25% reduction indicates clinical improvement. A clinician blind to treatment assignment rated the Improvement scale of the Clinical Global Impression (range, 1-7), a secondary outcome, with a positive response less than 3.

Results At week 24, the Aberrant Behavior Checklist–Irritability subscale declined 47.7% in parent training (from 23.7 to 12.4) compared with 31.8% for parent education (23.9 to 16.3) (treatment effect, −3.9; 95% CI, −6.2 to −1.7; P < .001, standardized effect size = 0.62). The Home Situations Questionnaire–Autism Spectrum Disorder declined 55% (from 4.0 to 1.8) compared with 34.2% in parent education (3.8 to 2.5) (treatment effect, −0.7; 95% CI, −1.1 to −0.3; P < .001, standardized effect size = 0.45). Neither measure met the prespecified minimal clinically important difference. The proportions with a positive response on the Clinical Global Impression–Improvement scale were 68.5% for parent training vs 39.6% for parent education (P < .001).

Conclusions and Relevance For children with autism spectrum disorder, a 24-week parent training program was superior to parent education for reducing disruptive behavior on parent-reported outcomes, although the clinical significance of the improvement is unclear. The rate of positive response judged by a blinded clinician was greater for parent training vs parent education.

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In addition to Yale and Emory University, which is the lead site, the RUBI Autism Network includes Indiana University, Ohio State University, University of Pittsburgh, and University of Rochester.

Other authors on the study include Karen Bearss, Cynthia Johnson, Tristram Smith, Luc Lecavalier, Naomi Swiezy, Michael Aman, David B. McAdam, Eric Butter, Charmaine Stillitano, Noha Minshawi, Daniel W. Mruzek, Kylan Turner, Tiffany Neal, Victoria Hallett, James A. Mulick, Bryson Green, Benjamin Handen, Yanhong Deng, and Lawrence Scahill.

Citation: JAMA doi:10.1001/jama.2015.3150 http://jama.jamanetwork.com/article.aspx?articleid=2275445

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