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Effects on Parental Mental Health of an Education and Skills = Training=20 Program for Parents of Young Children With Autism: A Randomized = Controlled=20 Trial

Journal=20 of the American Academy of Child and Adolescent = Psychiatry -=20 = Volume=20 45, Issue 5 (May 2006) - Copyright =A9 2006 = Williams &=20 Wilkins - About=20 This Journal

=20

Articles

Effects on Parental Mental Health of an Education and Skills = Training=20 Program for Parents of Young Children With Autism: A Randomized = Controlled=20 Trial

BRUCE TONGE M.D. ¹=20
AVRIL BRERETON = PH.D.=20 ¹=20
MELISSA KIOMALL = M.PSYCH.=20 ¹=20
ANDREW MACKINNON = PH.D.=20 ¹=20 ²=20
NEVILLE KING PH.D.=20 ¹=20
NICOLE RINEHART = PH.D.=20 ¹=20

¹ = At=20 the time of this study, all of the authors were with the Monash = University=20 Centre for Developmental Psychiatry, Clayton, Victoria, = Australia.=20
²=20 Andrew Mackinnon is now with the Centre for Mental Health Research, = Australian National University, = Canberra.

Accepted November 15, 2005.

Reprint requests to Dr. Avril Brereton, Monash = University=20 Centre for Developmental Psychiatry and Psychology, Monash Medical = Centre, 246=20 Clayton Road, Clayton, Victoria 3168, Australia: e-mail: = avril.brereton@med.=20 monash.edu.au.
⁰⁼²⁰

=A92006 by the American Academy of Child and Adolescent=20 Psychiatry.

^D=20

ABSTRACT

Objective: To determine the impact of a parent education and = behavior=20 management intervention (PEBM) on the mental health and adjustment of = parents=20 with preschool children with autism. Method: A randomized,=20 group-comparison design involving a parent education and counseling = intervention=20 to control for nonspecific therapist effects and a control sample was = used. Two=20 metropolitan and two rural regions were randomly allocated to = intervention=20 groups (n =3D 70) or control (n =3D 35). The parents of = consecutive=20 children with autism (2=BD=965 years old) from the autism assessment = services for=20 the intervention regions were then randomly allocated to either a = 20-week=20 manual-based parent education and behavior management intervention = (n =3D=20 35) or a manual-based parent education and counseling intervention = (n =3D=20 35). The main outcome measure of parental mental health was the General = Health=20 Questionnaire used pre- and postintervention and at 6-month follow-up.=20 Results: Both treatments resulted in significant and progressive=20 improvement in overall mental health at follow-up (F =3D 2, 97, = p =3D=20 .007) and mental health significantly improved over time in the 54% of = principal=20 caregivers who had the highest levels of mental health problems. The = parent=20 education and behavior management intervention was effective in = alleviating a=20 greater percentage of anxiety, insomnia, and somatic symptoms and family = dysfunction than parent education and counseling at 6-month follow-up.=20 Conclusions: A 20-week parent education and skills training = program for=20 parents of young children newly diagnosed with autism provides = significant=20 improvements in parental mental health and adjustment, justifying its = addition=20 to early intervention programs at least for parents with mental health = problems.=20 J. Am. Acad. Child Adolesc. Psychiatry, = 2006;45(5):561=96569.

Keywords:

: autism
: parents
: early intervention.

Autism is associated with burden and stress for parents (=20 Howlin et al., 2004 ). The demands placed on parents caring for a = child with=20 autism contribute to a higher overall incidence of parental stress, = depression,=20 and anxiety and adversely affects family functioning and marital = relationships=20 compared with parents of children with other intellectual, = developmental, or=20 physical disabilities (=20 Dunn et al., 2001 ; Yim=20 et al., 1996 ).

Mothers of children with autism are more likely to suffer from = depression=20 than mothers of children with intellectual disability (ID) without = autism and=20 mothers with typically developing children (=20 Bristol et al., 1993 ; Olsson=20 and Hwang, 2001 ; Yirmiya=20 and Shaked, 2005 ); however, they may also have a heritable = vulnerability=20 for depression (=20 Bolton et al., 1998 ). Therefore, autism treatment studies should = include=20 measures of parental mental health and family functioning (=20 Fisman et al., 2000 ; Koegel=20 et al., 1996 ; Tunali=20 and Power, 2002 ).

Parent training has long been regarded as an important component of = early=20 intervention programs for children with autism (=20 Harris, 1994 ). There is empirical evidence that parent training = contributes=20 to the effectiveness of behavioral treatments (=20 Schreibman, 2000 ; Schreibman=20 and Anderson, 2001 ) and, for example, enhances functional = communication in=20 young children with autism (=20 Moes and Frea, 2002 ) and may result in improved parent=97child = interactions=20 after pivotal response training (=20 Koegel et al, 1996 ). Although most research has focused on child = outcomes,=20 there are several equivocal studies of the effect on parental adjustment = of=20 parent training programs for parents of children with autism. The = EarlyBird=20 Programme (=20 Shields, 2001 ), offers a 3-month program of parent support groups, = behavior=20 management training, and individual early intervention for the child = with=20 autism. In a pilot study of this program, parents reported decreased = stress=20 after 3- and 6-month follow-up. A small, nonrandomized controlled study=20 (treatment n =3D 12; control n =3D 5) of The Scottish = Centre for=20 Autism program (therapist-supervised parent=97child sessions, behavior = management=20 parent training groups) found a nonsignificant reduction of parental = stress (=20 Salt et al., 2002 ). A randomized controlled trial of a parent = intervention=20 that focused on the development of joint attention skills and joint = action=20 routines in 12 children with autism compared with 12 children receiving = local=20 services only found no treatment effect at 12-month follow-up (=20 Drew et al., 2002 ).

Therefore, the aim of this article is to report on a large, = randomized=20 controlled study of the impact of a manual-based parent education and = behavior=20 management (PEBM) training intervention on the mental health and = adjustment of=20 parents with preschool children recently diagnosed with autistic = disorder.=20 Improvement in the child=92s adjustment may follow as a consequence but = is the=20 subject of a secondary study.

METHOD

Research Design

A parallel-group comparison design compared a PEBM intervention, a = parent=20 education and counseling (PEC) intervention to control for nonspecific=20 therapeutic effects, and a control sample. To avoid the likelihood of = exchange=20 of information between the parents attending the same regional early=20 intervention services, initial allocation between one of two = geographically=20 separate metropolitan regions and one of two rural regions was made by=20 computer-generated random numbers to either a treatment intervention = region or a=20 control region. Intervention subjects were then randomly allocated by = computer=20 to either the PEBM intervention (n =3D 35), or the PEC = intervention=20 (n =3D 35). The randomly selected metropolitan and rural control = regions=20 contributed 35 families.

Subjects

Children 2=BD−5 years old were obtained during the month after = diagnosis from=20 consecutive referrals to two metropolitan and two rural regional = assessment=20 services for young children suspected of having autism (N =3D = 107). All but=20 two families agreed to participate. The catchment areas comprise a broad = cross-section of social class and ethnic backgrounds. All of the = children lived=20 with their parents and attended a play group or preschool. Children in = the=20 treatment and control groups also received a similar early intervention = program=20 after the diagnosis of autism was made (mean 7.3 hours/week and 7.9 = hours/week=20 of intervention, respectively). The children had a strict DSM-IV=20 diagnosis of autistic disorder (=20 American Psychiatric Association, 1994 ) based on a standardized = clinical=20 interview (=20 Einfeld, 1992 ) for children with developmental disability and the = Autism=20 Diagnostic Interview-Revised (=20 Lord et al., 1994 ). Each diagnosis was confirmed using a screen = observation=20 or video record of the interview by an independent clinician. All of the = parents=20 had adequate English language skills to complete the questionnaires and=20 participate in the intervention programs.

Measures

Parent Measures.=20

Measures of parent and family functioning were taken pre- and = posttreatment=20 assessment and at 6-month follow-up. The primary measure of parental = mental=20 health was the General Health Questionnaire (GHQ-28; Goldberg=20 and Williams, 1988 ) a widely used, reliable, and valid = self-administered=20 adult screening test designed to detect psychiatric disorder in = community=20 settings (Cronbach a range, .82−.93; sensitivity, 0.79; and = specificity, 0.87).=20 The 28-item version has four subscales: somatic symptoms, social = dysfunction,=20 anxiety and insomnia, and severe depression. Secondary outcome measures = were the=20 Parenting Stress Thermometer, a visual analogue rating of general level = of=20 stress from 0 (none) to 4 (very, very much) and the McMaster Family = Assessment=20 Device (FAD; Epstein=20 et al., 1983 ), a self-administered 12-item general functioning = scale=20 measuring general family function. Reliability of the global functioning = scale=20 is high (intercorrelation coefficient [ICC] =3D 0.86, split-half =3D = 0.83), with=20 good construct validity obtained by assessing its relationship with 12 = family=20 variables from the Ontario Child Health Study (=20 Byles et al., 1988 ).

Child = Measures.=20

Measures of each child=92s development and severity of autistic = symptoms were=20 taken at the pretreatment assessment and 6-month follow-up and are = reported in a=20 companion paper. The main measure of child psychopathology was the = Developmental=20 Behaviour Checklist (DBC), a reliable and valid 96-item, = parent-completed=20 questionnaire with a total problem behavior score =B1 ICC =3D 0.80) and = an autism=20 screening algorithm, the DBC-Autism Screening Algorithm, which is = sensitive and=20 specific for the symptoms of autism (area under the curve =3D 0.80; = sensitivity,=20 0.86 [95% confidence interval 0.80=960.91]; and specificity, 0.69 [95% = confidence=20 interval: 0.62=960.76]; Brereton=20 et al., 2002 ; Einfeld=20 and Tonge, 2002 ). The Psychoeducational Profile-Revised (=20 Sehopler et al., 1990 ) is a developmental measure designed = specifically for=20 use with children who have autism. A total developmental score and = developmental=20 quotient are calculated, along with a profile of the child=92s = performance in=20 seven domains assessed relative to standardized age equivalents. Items = have been=20 empirically tested and have clinical validity. At the end of the = treatment=20 program, the patents completed a brief treatment acceptability and = consumer=20 satisfaction questionnaire (=20 Harrold et al., 1992 ).

Procedure

The study was approved by the Monash Medical Centre Human Research = Ethics=20 Committee and parents provided written consent.

Screening and Pretreatment Assessment.=20

After a DSM-IV diagnosis of autism was confirmed, the child = was=20 enrolled in the project and all other measures were taken. Families from = the=20 randomly allocated intervention regions were then randomly allocated to = either=20 the PEBM or the PEC group.

PEBM Skills = Training.=20

Parents in this treatment condition received a manual-based education = and=20 behavior management skills training package (=20 Brereton and Tonge, 2005 ). The program was broadly based on = multiple early=20 intervention and cognitive behavioral techniques previously tested for=20 acceptability with three families. Treatment sessions included education = about=20 autism; features of communication, social, play, and behavioral = impairments;=20 principles of managing behavior and change; teaching new skills; = improving=20 social interaction and communication; services available; managing = parental=20 stress, grief and mental health problems; and sibling, family, and = community=20 responses to autism. Sessions were skills based and action oriented = through the=20 provision of workbooks, modeling, videos, rehearsal (with child when = present),=20 homework tasks, and feedback.

PEC.=20

The aim of this treatment was to control for the nonspecific aspects = of the=20 PEBM intervention, in particular, therapist attention, understanding, = and=20 support. The educational material in the manual for PEC group discussion = sessions was the same as for the PEBM group; however, for the individual = sessions, no skills training or homework tasks were set and the emphasis = was on=20 nondirective interactive discussion and counseling.

Both treatments were delivered by special educators or psychologists = who had=20 experience working with children with autism and their parents. Ten = 90-minute=20 small group (four to five families) sessions alternated with ten = 60-minute=20 individual family sessions over a 20-week period. To sustain treatment=20 integrity: (1) therapists received training in the procedures for each=20 condition; (2) therapists were required to follow a manual that = delineates each=20 treatment on a session-by-session basis (=20 Brereton and Tonge, 2005 ); (3) a random 10% sample of therapy = sessions for=20 both conditions was videotaped for content review and intervention = adherence;=20 and (4) therapists received ongoing clinical supervision and training = throughout=20 the study. To safeguard against possible confounding because of = individual=20 therapist effects, therapists were rotated across treatment = conditions.

Nonintervention Control Group.=20

This group consisted of children with autism and their families from = the=20 randomly allocated control regions who received local early childhood = services=20 but no PEBM and PEC intervention. Parents were informed they were to be = part of=20 a follow-up study of autism and receive three 6-month assessments.

Posttreatment and Follow-up Assessments.=20

Subjects in all groups underwent reassessment at the completion of = the=20 treatment program (at 20 weeks after the initial assessment for the = control=20 group) and at 6 months after the completion of treatment using all of = the=20 pretreatment measures of child and parent/family functioning. These = measures=20 were completed by a clinician blind to the results of the pretreatment=20 assessments and to treatment group membership.

Data Analysis

Principal = Caregiver=20 Measures.=20

To assess the impact of the intervention posttreatment and at = follow-up,=20 primary (GHQ total and its four subscales [somatic symptoms, anxiety and = insomnia, social dysfunction, and severe depression]) and secondary = (stress=20 thermometer ratings and FAD total) outcome measures were analyzed using = analysis=20 of covariance. Group (PEBM, PEC, control) was the between-subjects = factor with=20 the corresponding pretreatment scores serving as a covariate. This = method of=20 accounting for pretreatment status is generally the most powerful of the = available alternatives (see Prison=20 and Pocock, 1992 ). This approach and its alternatives assume that = the=20 benefit of the intervention is constant=97in other words, unrelated to = parents=92=20 initial levels of distress (=20 Fig. l a). However, because participants were recruited for the = trial based=20 on their child=92s status rather than their own distress, wide variation = was=20 observed on these measures pretest. This included parents with =93floor = value=94 or=20 low scores who have little scope for reduction of their scores than more = distressed parents. This effect can be assessed by testing for the = presence of=20 an interaction between the pretest covariate and treatment condition. = When a=20 significant interaction is found, the Johnson-Neyman (J-N) technique (=20 Huitema, 1980 ) may be used to establish the value of the pretest = score=20 beyond which the treatment was significantly superior to the control = condition=20 (=20 Fig. 1 b).

=20 Figure 1. Hypothetical relationship = between=20 pre- and posttest scores, a, No interaction between pretest and = treatment group=20 leading to a constant effect of treatment independent of pretest score, = b,=20 Significant interaction between the pretest and treatment groups. The=20 Johnson-Neyman (=20 Huitema, 1980 ) procedure determines the range of pretest scores = associated=20 with a statistically significant effect of treatment.

RESULTS

Intervention Effects: Principal Caregiver Measures

Results are presented for the principal caregivers in the PEBM = treatment=20 (n =3D 35), PEC treatment (n =3D 33), and control group = (n =3D=20 35). Two PEC group principal caregivers did not complete the parent = training.=20 One family moved interstate for work and the other attended 10 sessions = before a=20 change in employment prevented attendance. The parents attended = virtually all of=20 the group sessions. On the rare occasion that one parent was unable to = attend,=20 the other was present. Individual sessions were rescheduled if necessary = so that=20 none was missed. All of the parents in treatment and control groups = participated=20 in follow-up; hence, there was no attrition. Status as principal = caregiver was=20 defined as the parent who spent the most time caring for the child; in = all but=20 four families, this was the mother. The other caregiver (usually the = father) was=20 encouraged to attend sessions and approximately 50% in both groups = attended.=20 Meetings were held at times convenient for the families. Child care was=20 available. There were no significant differences between control and = treatment=20 groups for socioeconomic status as determined by the Australian Standard = Classification of Occupations (=20 Australian Bureau of Statistics, 1997 ;=20 t₁₀₃ =3D −0.19, p =3D .85) = or parental age=20 (t₁₀₃ =3D 1.16, p =3D .25). = There were no=20 significant differences between the intervention groups and the control = group=20 for child developmental quotient (t₁₀₃ = =3D −1.10,=20 p =3D .27) or gender (χ² =3D 0.64, = p =3D .42)=20 or for DEC overall symptoms of disturbed behavior (total behavior = problem score;=20 t₁₂₁ =3D −1=9652, p =3D = .13) or specific=20 autism symptoms (DEC=97 Autism Screening Algorithm;=20 t₁₀₁ =3D −1.73, p =3D .08; = Tables=20 1 and 2=20 ).

**TABLE 1** -- Frequencies, = Means, and=20 SDs of Principal Caregiver=92s Age and Socioeconomic = Status
	PEC, n =3D = 33	PEBM,n =3D = 35	Control, n = =3D=20 35
Principal caregiver age, = yr
Range	25=9642	28=9643	26=9642
Mean	33.3	35.2	33.3
SD	4.7	3.8	4.2
Principal caregiver = SES
Range	2=968	2=968	2=968
Mean	5.1	4.1	4.7
SD	2.1	1.8	2.1
Note:PEC =3D parent = education and=20 counseling; PEBM =3D parent education and behavioral management; = SES =3D=20 socioeconomic status.

**TABLE 2** -- Frequencies, = Means, and=20 SDs of Children=92s Pretreatment Age, Sex, PEP-R Developmental = Quotient, DBC=20 TBPS, and DBC-ASA
	PEC, n =3D = 33	PEBM, n =3D = 35	Control, n = =3D=20 35
Child age, mo
Range	30=9665	23=9665	33=9670
Mean	45.3	45.3	49.4
SD	8.9	8.5	10.0
Sex, %
Male	87.9	77.1	88.6
Developmental = quotient
Range	12=9697	13=96113	12=96127
Mean	48.9	64.7	63.3
SD	22.0	27.4	28.5
DBC ASA
Range	10=9648	2=9645	0=9640
Mean	28.7	26.1	23.8
SD	9.2	9.1	10.4
DBC TBPS
Range	25=96118	14=96137	27=96114
Mean	65.4	64.9	73.8
SD	(24.6)	(25.0)	(17.0)
PEP-R =3D = Psychoeducational=20 Profile-Revised; DBC-ASA =3D Developmental Behaviour = Checklist-Autism=20 Screening Algorithm; DBC TBPS =3D Developmental Behaviour = Checklist Total=20 Behavior Problem Score.

Table=20 3 presents a summary of the principal caregivers=92 dependent = measure means=20 and SDs for the PEBM, PEC, and control groups pre- and posttreatment and = at=20 follow-up.

**TABLE 3** -- GHQ Total and = Subscale=20 Scores, Stress Thermometer, and FAD Score Means and SDs by Group and = Time=20 (N =3D 13)
Measure	PEC, n =3D = 33	PEBM, n =3D = 35	Control, n =3D = 35
Pre	Post	F-U	Pre	Post	F-U	Pre	Post	F-U
GHQ total	22.06 (10.02)	19.12 (11.90)	16.70 (10.51)	28.54 (13.43)	18.03 (13.56)	17.06 (7.59)	19.17 (7.61)	21.69 (10.20)	21.46 = (11.94)
GHQ subscale
Somatic = symptoms	6.18 (2.95)	5.75 (4.54)	4.81 (3.62)	7.86 (3.99)	6.11 (4.61)	5.06 (2.96)	5.29 (3.10)	6.77 (4.10)	5.69 (3.45)
Anxiety and = insomnia	7.00 (3.83)	6.06 (4.24)	4.75 (3.79)	9.26 (4.54)	5.20 (4.36)	4.71 (2.82)	6.43 (3.54)	6.26 (3.31)	6.91 (5.15)
Social = dysfunction	6.94 (2.44)	5.34 (2.72)	5.75 (2.85)	8.20 (2.62)	5.49 (3.80)	5.97 (2.22)	6.49 (2.17)	7.40 (2.34)	6.86 (2.85)
Severe = depression	1.91 (3.85)	1.81 (3.14)	1.47 (2.94)	3.20 (4.56)	1.31 (2.76)	.88 (2.52)	0.97 (1.98)	1.31 (2.53)	1.57 (3.07)
Stress = thermometer	2.27 (0.91)	1.82 (0.91)	1.70 (1.05)	2.51 (0.82)	1.86 (0.94)	1.86 (0.88)	2.06 (0.87)	2.26 (1.09)	2.09 (0.89)
FAD score	1.84 (0.66)	1.81 (0.52)	1.64 (0.58)	1.76 (0.46)	1.78 (0.32)	1.67 (0.46)	1.70 (0.64)	1.94 (0.52)	1.74 (0.73)
Note: SDs in = parentheses. GHQ=20 =3D General Health Questionnaire; PEC =3D parent education and = counseling;=20 PEBM =3D parent education and behavioral management; Pre =3D = pretreatment;=20 Post =3D posttreatment; F-U =3D follow-up; FAD =3D McMaster Family = Assessment=20 Device score.

GHQ Total=20 Score.=20

Pretreatment, 29.1% of the total sample received a GHQ total score = equal to=20 or above the clinical cutoff score of 25, indicative of a clinical level = of=20 mental health problems (=20 Goldberg and Williams, 1988 ). Posttreatment, covarying for pretest = value,=20 the main effect of treatment group was not statistically significant, = nor was=20 any interaction between pretest value and group observed. No significant = differences were found in comparing PEBM to PEC. However, at follow-up, = the=20 overall (three-group) interaction between pretest score used as a = covariate and=20 group was highly significant for GHQ total score (F =3D 2, 97, = p =3D=20 .007). Subsequent pairwise analyses found that although the main effect = was not=20 significant for the PEBM/control group comparison, the interaction = between=20 pretest score and group was statistically significant (F =3D 1, = 66,=20 p =3D .001). The same pattern was found for the comparison of PEC = to the=20 control group (F =3D 1, 64, p =3D .051). No statistically = significant=20 differences were found in comparing PEC to PEBM (=20 Table 4 ). The heterogeneity of slopes relating follow-up score to = pretest=20 score implies that the effect of treatment is dependent on the level of=20 symptomatology at pretest. The J-N technique showed that the PEBM was=20 significantly better than no treatment above a pretest GHQ total score = of 18.49.=20 The J-N technique also established that the advantage of PEC over the = control=20 group was significant for pretest values on this measure above 18.29. In = the=20 total sample, these values corresponded to the 47th and 46th = percentiles,=20 respectively. There was no evidence that the mental health of the = parents who=20 were in the healthier half of the sample deteriorated from pre-to = posttreatment=20 (t₄₇ =3D −1.34, p=3D .19) = or from=20 posttreatment to follow-up (t₄₇ =3D = −.08,=20 p =3D .94). Inspection of GHQ subscale scores suggested that the=20 interventions may have differential effects on different facets of=20 psychopathology.

**TABLE 4** -- Main Effects = and=20 Covariate Interactions for Principal Caregiver Measures
	Occasion	Effect	Overall = F(dfr,dfd)	Control vs. PEBM=20 F(dfn,dfd)	Control vs. PEC=20 F(dfn,dfd)
GHQ total = score	Post	Group	ns	ns	ns
	Cov Int	ns	ns	ns
F-U	Group	ns	ns	ns
	Cov Int	5.17^*=20	11.39^*=20	0.72, p =3D = .051
GHQ somatic = symptoms	Post	Group	ns	ns	ns
	Cov Int	4.26^*=20	8.39^*=20	ns
F-U	Group	ns	ns	ns
	Cov Int	4.63^*=20	10.26^*=20	ns
GHQ anxiety = and=20 insomnia	Post	Group	ns	ns	ns
	Cov Int	ns	ns	ns
F-U	Group	ns	ns	ns
	Cov Int	7.32^*=20	12.93^*=20	9.00^*=20
GHQ severe = depression	Post	Group	ns	ns	ns
	Cov Int	5.72^*=20	12.34^*=20	6.26^*=20
F-U	Group	ns	ns	ns
	Cov Int	4.67^*=20	9.95^*=20	5.40^*=20
Stress = thermometer	Post	Group	ns	ns	ns
	Cov Int	ns	ns	ns
F-U	Group	6.91^*=20	7.40^*=20	ns
	Cov Int	5.24^*=20	7.49^*=20	ns
FAD = score	Post	Group	ns	ns	ns
	Cov Int	ns	ns	ns
F-U	Group	ns	5.40^*=20	ns
	Cov Int	4.77^*=20	7.85^*=20	5.85^*=20
Note: None of the = comparisons=20 between the PEBM and PEC groups were significant. dfn,dfd = =3D degrees=20 of freedom numerator, degrees of freedom denominator; PEBM =3D = parent=20 education and behavioral management; PEC =3D parent education and=20 counseling; GHQ =3D General Health Questionnaire; Pre =3D = pre-treatment; Post=20 =3D post-treatment; F-U =3D 6-month follow-up; ns =3D not = significant; Cov Int =3D=20 covariate interaction.

**p <.01;
***p <.005.
*p < .05

GHQ Somatic Symptoms. Posttest, the overall (three-group) = comparison=20 was significant for the somatic symptoms subscale, with significant=20 heterogeneity in the relationship with pretest scores (F =3D 2, = 96,=20 p =3D .016). Subsequent analyses revealed a significant = interaction between=20 pretest score and group for the comparison of PEBM to the control groups = (F =3D 1, 66, p =3D .005; Table=20 4 ). The heterogeneity of slopes relating the posttest score to the = pretest=20 score implies that the effect of treatment is dependent on the level of = somatic=20 symptomatology pretest. Using the J-N technique and an α level of = .05, it was=20 established that PEBM was statistically better than no treatment = posttest above=20 a pretest GHQ somatic symptom score of 7.04. This value corresponds to = the 79th=20 percentile and indicates that approximately 21 % of participants with = the more=20 severe somatic symptoms would be expected to benefit immediately from = PEBM=20 treatment rather than no treatment.

At follow-up, the overall pattern of results, with significant = interactions=20 between pretest score and group, was maintained for the PEBM versus = control=20 group analysis. The J-N procedure showed that participants with pretest = somatic=20 symptom scores above 6.58 stood to benefit significantly compared with = the=20 comparison group (69th percentile). This indicates that in the = long-term, a=20 greater portion of the sample (31%) with somatic symptoms was likely to = have=20 significant improvement in their somatic symptoms resulting from PEBM = treatment=20 compared to no treatment.

GHQ Anxiety and=20 Insomnia.=20

Posttreatment, neither the main effect nor the interaction between = pretest=20 score and group was statistically significant for PEBM or PEC compared = to the=20 control group. Similarly, no significant differences were found in = comparing=20 PEBM to PEC posttreatment. At follow-up, the overall (three-group) = interaction=20 between pretest score and group was highly significant for GHQ anxiety = and=20 insomnia scores (F =3D 2, 95, p =3D .001). Subsequent = analyses found=20 significant interactions between pretest score and group for PEBM versus = control=20 (F =3D 1, 65, p =3D .001) and for PEC versus control = (F =3D 1,=20 63, p =3D .004; Table=20 4 ). For PEBM, the J-N technique showed that participants with = pretest=20 anxiety and insomnia scores above 5.35 (39th percentile) stood to = benefit=20 significantly compared to no treatment. For PEC, benefit occurred above = 6.00=20 (50th percentile). Thus, approximately 61% of the sample that presented = with the=20 highest levels of anxiety and insomnia would be predicted to benefit = from PEBM=20 compared with those with no treatment. PEC is likely to be effective in=20 significantly reducing symptoms of anxiety and insomnia in 50% of = parents.

GHQ Social Dysfunction.=20

This analyses produced one nearly significant main effect between the = PEBM=20 and control groups, indicating an almost significant effect of treatment = posttest, regardless of pretest status (F =3D 1, 66, p =3D = .064; Table=20 4 ). However, neither the main effect nor the interaction between = pretest=20 score and group was statistically significant for the PEC to control = comparison=20 and for the PEC to PEBM comparison posttest. The overall pattern of = results,=20 with nearly statistically significant main effects for the PEBM versus = control=20 group comparison was maintained at follow-up (F =3D 1, 65, p =3D = .081).

GHQ Depression.=20

The main effect was not significant for the overall (three-group) = comparison,=20 but the interaction between the pretest score used as a covariate and = group was=20 significant for GHQ Depression posttreatment scores (F=3D 2, = 96,p =3D=20 .007). Subsequent pairwise analyses revealed that the main effect was = not=20 significant for the PEBM versus control group comparison, although the=20 interaction between pretest score by group was statistically significant = (F=20 =3D 1, 66, p =3D .001). The same pattern was found for the = comparison of=20 PEC to the control group (F =3D 1, 63, p =3D .015; Table=20 4 ). No statistically significant differences were found comparing = PEC to=20 PEBM.

The heterogeneity of slopes relating the posttest score to the = pretest score=20 implies that the effect of treatment is dependent on level of depressive = symptomatology at pretest. J-N procedures, using an α =3D .05 = level, established=20 that PEBM was significantly superior to no treatment posttest above a = pretest=20 GHQ depression score of 1.53. PEC was superior only for pretest GHQ = depression=20 scores above 4.10. In the total sample, these scores corresponded to the = 73rd=20 and 84th percentiles, respectively. Approximately one fourth of the = sample who=20 were the most depressed benefited from PEBM compared with 16% who = benefited from=20 PEC.

The overall pattern of results, with significant interactions between = the=20 pretest score and group was maintained at follow-up for PEBM versus = control and=20 for PEC versus control analyses (=20 Table 4 ). For PEBM, the J-N technique showed that participants with = pretest=20 depression scores above 1.26 (72nd percentile) stood to benefit = significantly=20 compared with no treatment. PEC benefit occurred above 3.01 (80th = percentile).=20 Care must be exercised in interpreting these values because the groups = had=20 differing levels of depression at pretest. In particular, few = participants in=20 the comparison group had scores in the range in which PEC was estimated = to be=20 superior to no treatment.

Stress Thermometer = and=20 FAD.=20

Posttreatment, the main effect and interaction between the pretest = score used=20 as a covariate and group were not statistically significant for PEBM or = PEC=20 compared with the control for both measures. Similarly, no significant=20 differences were found in comparing PEBM to PEC posttreatment. At = follow-up, the=20 overall (three-group) comparison and interaction between pretest score = and group=20 were both significant for stress thermometer ratings (F =3D = 1,97,=20 p=3D. 01 and F =3D 2, 97,p=3D.007) and (F 2, 97 = =3D 4.77,=20 p =3D.01 and F_1,66 =3D 5.40, = p=3D. 23),=20 respectively. Subsequent analyses revealed a significant main effect for = the=20 PEBM/control group comparison for the stress thermometer=20 (F_1,66 =3D 7.4,p =3D .008) and = for the FAD=20 (F_1,66 =3D 7.85, p =3D.007). The = interaction=20 between pretest score and group was similarly statistically significant = for the=20 comparison of PEBM to the control group (p =3D .008) for the = stress=20 thermometer (F_1,66 =3D 7.4, p = =3D .008) and=20 the FAD (F_1,64 =3D 5.85, p = =3D.018; Table=20 4 ). The heterogeneity of slopes relating the follow-up test score = to the=20 pretest score implies that the effect of treatment is dependent on the = levels of=20 stress and family functioning pretest. Using α =3D .05, it was = established that=20 any effects are caused by PEBM, which is superior to control as a = function of=20 increasing pretest status for both variables. The J-N procedure showed = that the=20 advantage of PEBM over no-treatment control was significant for pretest = values=20 on stress scores above 2.45 (96th percentile) and FAD scores above 1.89 = (67th=20 percentile) and an even lower score of 1.75 for PEC (57th = percentile).

DISCUSSION

This study provides evidence that both a parent education and skills = training=20 program and a parent education and counseling program for parents of = young=20 children with autism was of benefit to their mental health and = well-being. Not=20 surprisingly, this applied particularly if parents had preexisting = mental health=20 problems.

Given that parents were not recruited into the study based on = psychiatric=20 symptomatology or psychological distress, there was a wide range of = scores on=20 outcome measures pretest and the effect of the interventions was = contingent on=20 pretest status. Those parents already showing low levels of distress = atthe=20 beginning of the study could not be expected to show improvements on = these=20 measures. This was reflected in significant interactions between pretest = scores=20 and intervention group in the analyses of covariance. Nevertheless, more = than=20 half of the sample had serious problems with their mental health. These=20 participants were shown to benefit from either the PEBM or PEC = intervention=20 compared to the no treatment condition. The benefit of these = interventions=20 commenced for the parents well below the GHQ cutoff score for a caseness = of 25.=20 The interventions are also clearly of benefit in the relief of anxiety = and=20 insomnia and for more severe somatic symptoms and depression. The = benefit of=20 either intervention in reducing both overall psychiatric symptomatology = and=20 somatic and anxiety and depression symptoms in the parent emerges over = the long,=20 rather than short, term following intervention. This may suggest that = the=20 benefits are cumulative and promote future mental health. This concept = of=20 resilience building is also described as a longer-term outcome of=20 cognitive-behavioral therapy for depression (=20 Wallis, 2002 ). Family functioning also significantly improved over = time in=20 the 33%=9643% of treatment families who had the highest level of = dysfunction.

There was no statistical evidence to support the overall superiority = of PEBM=20 over PEC. The PEBM intervention was effective in alleviating the = symptoms of=20 somatic complaints, anxiety, insomnia, stress, and family dysfunction in = a=20 greater percentage of parents in the longer term. The less structured = PEC=20 intervention led to a relief of depressive symptoms in a slightly larger = percentage of parents. The costs of PEBM and PEC are equivalent in terms = of=20 therapist time, educational materials, and number of sessions, although = PEBM=20 does require the parents to do homework tasks. The evidence of greater = treatment=20 effects 6 months after the interventions may point to a cumulative = benefit as=20 parents apply skills learned. This =93sleeper effect=94 has been = described following=20 cognitive-behavioral therapy for the treatment of anxiety and depression = (=20 Rossell=D2 and Burnal, 1999 ). All of the parents participating in = the=20 treatment groups indicated that they would attend another such program = should it=20 be offered in the future and rated the program highly.

Limitations

It is possible that potential differences in regional services and=20 populations may have confounded differences in outcome. However, there = were no=20 significant differences between control and intervention regions for = parental=20 socioeconomic status and age and child developmental level, gender, and = amount=20 of early intervention received. Pretreatment scores were used as = covariates in=20 the data analysis to further account for any pretreatment differences = between=20 subjects. Education and treatment services for children with autism and = their=20 families vary widely between countries and within countries such as the = United=20 States (=20 Volkmar, 2005 ). The quality and quantity of available services may=20 contribute to the mental health and adjustment of parents, thus = influencing the=20 extent to which parent education and skills training is of benefit to = parental=20 mental health.

The same therapists administered both treatments but were rotated = between=20 therapies, and review of videotapes of randomly selected sessions = ensured=20 treatment condition compliance. It should be noted that results have = been=20 reported with no adjustment for multiple testing. Given the substantial = degree=20 of relationship between many of the outcome measures, it is difficult to = determine a suitable adjustment factor that does not inappropriately = reduce=20 power. However, care should be exercised in interpreting the outcomes of = isolated measures with marginally significant p values. Effects = for the=20 primary outcome measure (GHQ) can withstand substantial adjustment for = multiple=20 testing and remain statistically significant.

All outcome measures of parental adjustment were self-reports. The = GHQ is a=20 well-established and reliable measure. Criterion validity of the GHQ as = a=20 measure of psychiatric disturbance has been established with reference = to=20 standardized psychiatric assessments, the Present State Examination, or = the=20 Clinical Interview Schedule in 12 studies providing a variance-weighted = mean=20 validity sensitivity coefficient of 84% and specificity coefficient of = 82% (=20 Goldberg and Williams, 1988 ). However, the GHQ scales are only = indicative=20 measures of complex psychiatric constructs, and in this study, an = independent,=20 standardized clinical assessment was not conducted to validate the GHQ = findings.=20 It is possible that the interventions may have been beneficial to the = secondary=20 caregiving parent. About half of the fathers attended, but this number = was=20 insufficient to provide empirical evidence of the benefit of these = interventions=20 for fathers.

Clinical Implications

This randomized, controlled trial produced evidence that either a=20 manual-based PEBM or PEC intervention for parents of young children with = autism=20 is likely to improve parental mental health and adjustment in parents,=20 particularly those with preexisting mental health problems. At least = half of the=20 parents had mental health problems; therefore, in situations of scarce=20 resources, perhaps they should be selected to receive a PEC program. = However,=20 parents who did not have mental health problems may have gained some = unmeasured=20 benefit, and they all gave positive feedback about the experience. Their = presence may also be an element that contributed to recovery in the = parents who=20 did have problems. A further aim of the study was to investigate the = benefit of=20 the interventions on parenting skills reflected in their child=92s = behavior and=20 development. This outcome will be the subject of a companion = paper.

Disclosure: Drs. Tonge and Brereton are the sole = authors of=20 the parent training manual used in this study. The manuals were = published=20 recently by Jessica Kingsley Publishers, and the authors receive = royalties=20 (5%) from sales. The other authors have no financial = relationships to=20 disclose.

REFERENCES

1. = American=20 Psychiatric Association (1994), Diagnostic and Statistical Manual = of=20 Mental Disorders, 4th Edition (DSM-IV). Washington, DC: American = Psychiatric=20 Association Press

2.=20 Australian Bureau of Statistics (1997), Australian Standard=20 Classification of Occupations, 2nd ed. Canberra: Commonwealth = of=20 Australia

3. = Bolton P, Pickles A, Murphy M, Rutter M (1998), Autism, = affective and=20 other psychiatric disorders: patterns of familial aggregation. = Psychol=20 Med 28:385=96395

4.=20 Brereton A, Tonge B (2005), Preschoolers With Autism: A = Parent=20 Education and Skills Training Programme. London: Jessica Kingsley=20 Publishers

5.=20 Brereton A, Tonge B, MacKinnon A, Einfeld S (2002), Screening = young=20 people for autism using the Developmental Behavior Checklist. J Am = Acad Child=20 Adolesc Psychiatry 41:1369=96375 =

6. Bristol M, Gallagher J, Holt K (1993), = Maternal=20 depressive symptoms in autism: response to psychoeducational = intervention.=20 Rehabil Psychol 38:3=9610

7. Byles J, Byrne C, Boyle MH, Offord DR = (1988),=20 Ontario Child Health Study: reliability and validity of the general = functioning=20 subscale of the McMaster Family Assessment Device. Fam Process=20 27:97=96104

8.=20 Drew A, Baird G, Baron-Cohen S, (2002), A pilot randomised = control trial=20 of a parent training intervention for pre-school children with autism. = Eur=20 Child Adolesc Psychiatry 11:266=96272 =

9. Dunn M, Burbine T, Bowers C, = Tantleff-Dunn S=20 (2001), Moderators of stress in parents of children with autism. = Community=20 Ment Health J 37:39=9652

10. Einfeld S (1992), Clinical assessment of = psychiatric symptoms in MR individuals. Aust N Z J Psychiatry=20 26:48=9663

11.=20 Einfeld S, Tonge B (2002), Manual for the Developmental = Behaviour=20 Checklist: Primary Carer Version and Teacher Version, 2nd ed. = Victoria:=20 University of New South Wales and Monash University =20

12. Epstein N, = Baldwin L,=20 Bishop D (1983), The McMaster Family Assessment Device. J Marital Fam = Ther 9:171=96180

13.=20 Fisman S, Wolf L, Ellison D, Freeman T (2000), A longitudinal = study of=20 siblings of children with chronic disabilities. Can J Psychiatry=20 45:369=96375

14.=20 Frison L, Pocock S (1992), Repeated measures in clinical trials: = analysis using mean summary statistics and its implications for design. = Stat=20 Med 12:1685=961704

15. Goldberg D, Williams P (1988), A = User=92s=20 Guide to the GHQ. Berkshire, UK: NFER Nelson =20

16. Harris S = (1994),=20 Treatment of family problems, In: Behavioral Issues in Autism, = Schopler=20 E, Mesibov G, eds. New York: Plenum Press, pp 161=96175 =20

17. Harrold M, = Lutzker J,=20 Campbell R (1992), Improving parent-child interactions. J Behav Ther = Exp=20 Psychiatry 23:89=96100

18. Howlin P, Goode S, Hutton J, Rutter M = (2004),=20 Adult outcome for children with autism. J Child Psychol = Psychiatry=20 45:212=96229

19.=20 Huitema B (1980), The Analysis of Covariance and = Alternatives.=20 New York: Wiley

20.=20 Koegel R, Bimbela A, Schreibman L (1996), Collateral effects of = parent=20 training on family interactions. J Autism Dev Disord = 26:347=96359=20

21. Lord C, = Rutter M,=20 Le Couter A (1994), Autism diagnostic interview-revised. J Autism Dev = Disord 24:659=96685

22. Moes D, Frea W (2002), Contextualized = behavioral=20 support in early intervention for children with autism and their = families. J=20 Autism Dev Disord 35:519=96533 =

23. Olsson M, Hwang C (2001), Depression in = mothers=20 and fathers of children with intellectual disability. J Int Dis = Res=20 45:535=96543

24.=20 Rossell=D2 J, Burnal G (1999), The efficacy of = cognitive-behavioral and=20 interpersonal treatments for depression in Puerto Rican adolescents. = J=20 Consult Clin Psychol 67:734=96745 =

25. Salt J, Shemilt J, Sellars V, Boyd S, = Coulson T,=20 McCool S (2002), The Scottish Centre for Autism preschool treatment = programme:=20 II. The results of a controlled treatment outcome study. Autism=20 6:33=9646

26.=20 Schopler E, Reichler R, DeVellis R, Daly K (1 990), = Psychoeducational=20 Profile Revised (PEP-R). Austin, TX: Pro-Ed =20

27. Schreibman L = (2000),=20 Intensive behavioral/psychoeducational treatments for autism: research = needs and=20 future directions. J Autism Dev Disord 30:373=96378 = =20

28. Schreibman L, = Anderson A=20 (2001), Focus on integration: the future of the behavioral treatment of = autism.=20 Behav Ther 32:619=96632

29. Shields J (2001), The NAS EarlyBird = Programme:=20 partnership with parents in early intervention. National Autistic = Society.=20 Autism 5:49=9656

30. Tunali B, Power T (2002), Coping by = redefinition:=20 cognitive appraisals in mothers of children with autism and children = without=20 autism. J Autism Dev Disord 32:25=9634 =20

31. Volkmar F = (2005),=20 International perspectives. In: Handbook of Pervasive Developmental=20 Disorders, 3rded., Volkmar F, Paul R, Klin A, Cohen D, eds. New = York: Wiley,=20 pp 1193=961254

32.=20 Wallis D (2002), Depression, anxiety and self-esteem: a clinical = field=20 study. Behav Change 19:112=96120 =

33. Yim SY, Moon HW, Rah UW, Lee IY (1996),=20 Psychological characteristics of mothers of children with disabilities.=20 Yonsei Med J 37:380=96400

34. Yirmiya N, Shaked M (2005), Psychiatric = disorders=20 in parents of children with autism: a meta analysis. J Child Psychol=20 Psychiatry 46:69=9683

0890-8567/06/4505-0561
DOI: = 10.1097/01.chi.0000205701.48324.26

Email to = Colleague Print Version =

=20

= Abstract=20
Ful= l=20 Text

Frontmatter=20
- METHOD=20
  - Research=20 Design
  - Subjects=20
  - Measures=20
    
    Parent=20 Measures.
    Child=20 Measures.
  - Procedure=20
    
    Screening=20 and Pretreatment Assessment.
    PEBM=20 Skills Training.
    PEC.=20
    Nonintervention = Control Group.
    Posttreatment=20 and Follow-up Assessments.
  - Data=20 Analysis
    
    Principal=20 Caregiver Measures.
- RESULTS=20
  - Intervention=20 Effects: Principal Caregiver Measures
    
    GHQ=20 Total Score.
    GHQ=20 Anxiety and Insomnia.
    GHQ=20 Social Dysfunction.
    GHQ=20 Depression.
    Stress=20 Thermometer and FAD.
- DISCUSSION=20
  - Limitations =
  - Clinical=20 Implications
- CREDITS=20
- REFERENCES=20

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Effects on Parental Mental Health of an Education and Skills = Training=20 Program for Parents of Young Children With Autism: A Randomized = Controlled=20 Trial

Articles

Effects on Parental Mental Health of an Education and Skills = Training=20 Program for Parents of Young Children With Autism: A Randomized = Controlled=20 Trial

ABSTRACT

Keywords:

METHOD

Research Design

Subjects

Measures

Procedure

Data Analysis

RESULTS

Intervention Effects: Principal Caregiver Measures

DISCUSSION

Limitations

Clinical Implications

REFERENCES