Parent training key to reducing behavioral problems in autistic children, study finds

(image courtesy The Ohio State University Wexner Medical Center)

Children with autism spectrum disorder (ASD) have a significant reduction in behavioral problems when parents are given specific training, found a large multi-center study published Tuesday in JAMA.

Working with the parents of 180 children between ages 3 and 7 with autism and behavioral problems, investigators from the six participating universities randomly assigned them to a 24-week parent-training program or a 24-week parent-education program.

The parent-education program was the study’s “placebo” group. Typically, during behavioral studies, the control group consists of participants who are put on a wait list who don’t initially receive any intervention.

“We brought what you’d typically see in a drug trial to behavioral interventions, which has never been done,” study author Luc Lecavalier, Ph.D., a professor of psychiatry at The Ohio State University Wexner Medical Center, told FoxNews.com.“[This is] the largest randomized control trial ever done in the field of autism when it comes to a behavioral intervention, a non-psychopharmaceutical intervention.”

Researchers found that serious behavior problems were reduced by 47 percent for the parent-training group, compared to about 31 percent for parent-education participants. Overall progress responses were recorded by a blinded clinician. At week 24, 70 percent of the parent-training group’s children showed a positive response, compared to 40 percent of those of the parent-education group. Six months after the trial ended, participants were reevaluated and 79 percent of the training group maintained improvement.

“What was unique about this study is that we packaged known techniques into a manual that we then pilot tested for feasibility, and it was well-received by parents,” Lecavalier said.

Educating and training parents
The parent-training group went through 11 sessions in addition to optional sessions and telephone boosters. First, they were taught how to detect clues for children’s disruptive behavior. For example, a child is told he has bath time, throws a tantrum and does not have a bath. The child has learned to avoid bath time by having a tantrum. Parents are then taught about preventative measures, such as establishing a schedule and using a visual timer to encourage positive responses, reinforcement strategies and how to ignore undesirable behaviors.

Caring for an child with ASD is stressful, Lecavalier noted, and parents do the best they can, but simply don’t know how to manage it, and react by yelling or some behavior that worsens the situation.

“We try to get in there and tell them ‘There’s a reason why he hits himself or he hits you, let’s try to identify that and see if we can change the antecedent and consequences, which in turn will modify the behavior,’“ he said.

There’s no “recipe” for decreasing self-injurious behavior, which can change from day to day, but teaching parents to figure out the causes from the get-go can shape the child’s development, he added.

In the second part of the study, parents were taught compliance training, adaptive daily living skills— such as teaching a child to brush his teeth— and how to implement changes in different environments, such as from home to school.

In between lessons, parents were given homework to practice the techniques.

“We’re teaching the parent how to change their behaviors so they will interact differently with their child,” Lecavalier said.

The parent-education group, the active control group of the study, had 12 sessions during which they were provided with information covering topics such as the causes of autism, how to read a psychiatric or medical report, how to advocate for services at school, and known family stressors that accompany a child with autism. While the information was useful, they were not explicitly told how to deal with tantrums and other aberrant behaviors.

A group of about 25 highly-trained therapists from each facility followed a specific written script for both study groups and were supervised by video. Researchers noted that the low attrition rate for participants was 10 percent.

This low attrition rate for both groups shows the parents’ recognition of the positive effects of both the training and education.

“Getting the message out there will help parents understand the importance— it’s not just a parenting class, but an intervention they can do with their children,” Dinah Godwin, a social worker at the Meyer Center for Developmental Pediatrics at Texas Children's Hospital, told FoxNews.com.

Many of the families were fairly newly diagnosed and the average age was 4.5 years, Lecavalier noted.

“We targeted young kids because that’s where they have the most potential for change. [We believe that] behavior is learned, the longer you wait to change, the harder it is; it’s easier to change tantrums or aggressive behavior in a 4-year-old doing [therapy] for a year than a 12-year-old,” he said.

Creating a structure that is focused on parents is important to empower families, experts agree, as most therapies, such as medications, are child-focused.

“So often we see that lots of families see it as a child’s behavior problem and… it’s difficult for parents to accept that they can influence it in a positive way, without necessarily taking the blame, so to speak, for behavior problems,“ Stacey Broton, a social worker for the Autism Center at Texas Children's Hospital, told FoxNews.com. “Even though they’re not necessarily causing it, they can still help manage and prevent behavioral issues with some strategies.”

Better than medicine?
In the future, researchers hope to study older children, but their next step is to understand who does well with training intervention and who does not. They also plan to disseminate their training programs to see if this could be done on a wider scale, with different moderators, such as nurses, psychologists, even people in a school setting.

Another element of their findings to consider, Lecavalier noted, is that children in their study had similar scores at the endpoint as did children in a previous study they published six years ago looking at the effects of antipsychotic medication, risperidone. According to their survey, taken 10 years ago, roughly one-fifth of children with ASD took an atypical antipsychotic, such as risperidone. Lecavalier estimated that that figure is currently higher.

The children went from being in the clinically significant range for behavior problems at baseline to being out of clinical range at the end of medication treatment. While the children in this study were older and more impaired than the preschool children in the current study, Lecavalier said the comparison puts the new findings in context.

Another element of their findings to consider, Lecavalier noted, is that children in their study had similar scores at the endpoint as did children in a previous study they published six years ago looking at the effects of antipsychotic medication, risperidone. According to their survey, taken 10 years ago, roughly one-fifth of children with ASD took an atypical antipsychotic, such as risperidone. Lecavalier estimated that that figure is currently higher.

The children went from being in the clinically significant range for behavior problems at baseline to being out of clinical range at the end of medication treatment. While the children in this study were older and more impaired than the preschool children in the current study, Lecavalier said the comparison puts the new findings in context.

“This might mean if we intervene early, these kids will not have to take medication down the road,” he said. “This is a very big deal because these medicines are potent, very potent, and work, but have side effects. A lot of parents don’t want to give them to their child.”

Lecavalier hopes to study the economic impact of the new study’s findings to see what cost savings would be associated with children who are exposed to behavioral treatment early in life.

Along with Ohio State, other participating centers included Emory University, Indiana University, Ohio State University, University of Pittsburgh, University of Rochester and Yale University.

“The take-home message is that well-trained therapists can train parents on specific behavior management techniques that could be implemented by parents on their own, which will significantly and clinically reduce behavior problems of their child with autism,” Lecavalier said.