Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: a randomized clinical trial

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.

Trial registration: clinicaltrials.gov Identifier: NCT01233414.

Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Aman reported having received research contracts, consulted with, or served on advisory boards of Biomarin Pharmaceuticals, Bristol-Myers Squibb, Confluence Pharmaceutica, CogState Clinical Trials, Coronado Biosciences, Forest Research, Hoffman LaRoche, Johnson and Johnson, MedAvante, Novartis, Pfizer, ProPhase, and Supernus Pharmaceuticals. Dr Handen reported having received research contracts with Curemark, Roche, and Eli Lilly. Dr Scahill reported having served as a consultant for Neuren, Coronado, Roche, MedAdvante, and Shire Pharmaceuticals. No other disclosures were reported.

Figures

Figure 1.. Flow of Patients Through Trial of Parent Training vs Parent Education in Autism Spectrum Disorder

ABC-I indicates Aberrant Behavior Checklist–Irritability subscale; ASD, autism spectrumdisorder; CGI-I, Clinical Global Impression–Improvement scale. a Response was rated by an independent evaluator using the CGI-I. Scores of much improved or very much improved were used to define positive response; all other scores indicated negative response.

Figure 2.. Least Squares Means and 95% CI for Parent-Rated ABC-Irritability at Baseline Through Week 24

ABC indicates Aberrant Behavior Checklist.

Figure 3.

Percentage and 95% CI of Children With a Ratingof Much Improved or Very Much Improved on the Clinical Global Impressions–Improvement Scale During the 24-Week Trial