Moving towards a more ecologically valid model of parent-implemented interventions in autism

research-article2014 AUT0010.1177/1362361314566739AutismStahmer and Pellecchia Editorial Moving towards a more ecologically valid model of parent-implemented interventions in autism Early intervention is critical for improving the long-term outcomes for children with autism (National Research Council, 2001). Training parents and other caregivers of young children with autism to implement treatment has been identified as a potential way to improve access to evi- dence-based interventions during the critical early years (Burrell and Borrego, 2012; McConachie and Diggle, 2007; Matson et al., 2009). Our field has a long history of success- fully teaching parents to increase communication and other skills in their children with autism in research settings using primarily single-subject or quasi-experimental designs. Several recent studies that include randomized trials have shown very promising results for teaching parents of very young children with autism to integrate evidence-based strategies into daily routines with positive effects on core symptoms of the disorder (Kasari et al., 2014; Rogers et al., al., 2014; Wetherby et al., 2014). 2014; Solomon et However, many other trials evaluating the effectiveness of parent-implemented interventions have failed to dem- onstrate the large effects seen in studies of therapist- implemented interventions (Carter et al., 2011; Green et al., 2010; Rogers et al., 2012). A recent meta-analysis compar- ing studies of parent- and clinician-implemented interven- tions for children with autism found significantly greater improvements in clinician-implemented studies with small to no effects in parent-implemented studies (Nahmias and Mandell, 2014). The disparity in outcomes between parent-implemented and clinician-implemented interventions may result from a variety of factors. First, manualized parent-implemented autism interventions can be complex and require extensive training and expertise to be implemented with high levels of fidelity (Rogers et al., 2012). Second, parents also have difficulty reaching the high levels of intensity typically provided in clinician-implemented trials, due to the many competing demands for their time. Third, parent- implemented interventions typically are designed to improve the child’s play, imitation, and communication skills, with outcomes measured using standardized assessments after relatively brief periods of time (Carter et al., 2011; Drew et al., 2002; Green et al., 2010; Kaiser et al., 2000). These standardized assessments may not capture improve- ments in these domains as well as the more specific meas- ures usedin single-subject studies. Developing outcome Autism 2015, Vol. 19(3) 259­–261 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1362361314566739 aut.sagepub.com measures that capture meaningful change is a critical failure of the field and has led funders like the Simons Foundation to prioritize this area of research (http://www. simonsfoundation.org/funding/funding-opportunities/ autism-research-initiative-sfari/2015-novel-outcome- measures-for-asd-clinical-trials/). In contrast to parent-implemented interventions for chil- dren with autism, those designed to address other child- hood psychiatric disorders traditionally focus on reducing children’s disruptive behavior and improving family func- tioning (Boggs et al., 2004; Reid et al., 2004). These inter- ventions have been shown to be effective in facilitating changes in both parent and child behavior, with demon- strated decreases in parental stress and improvements in parent–child interactions (Boggs et al., 2004; Eyberg, 1993). Unlike many autism interventions, these interven- tions for other disorders have more rigorously demon- strated effectiveness when community-based (rather than university-based) clinicians deliver them, suggesting that they may be more sustainable than proven efficacious parent-implemented autism interventions (Lyon and Budd, 2010; Reid et al., 2001). Although the needs of children with autism are in many ways distinct from the needs of children with other disorders, the needs of parents who are faced with the task of raising children with social– emotional challenges are similar across disorders. We who develop parent-implemented autism interven- tions could benefit by borrowing from the practices of parent-implemented interventions for other disorders (Brookman-Frazee et al., 2006). Practices such as frequent and direct coaching of targeted parenting skills and focus- ing on goals that are intended to reduce parental stress and improve family functioning may be essential additions for parent-implemented interventions for children with autism. We may need to move away from seeing parent- implemented intervention as replacing more intensive treatment delivered by trained professionals and toward examining the role of parent-implemented strategies in improving family functioning and stress, in addition to facilitating child development. Of fundamental importance is the need to improve paren- tal participation and implementation; this is especially true of under-resourced parents. Attrition in parent-implemented intervention studies is high, especially in studies that have Downloaded from aut.sagepub.com at UNIV CALIFORNIA DAVIS on June 24, 2015