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109
© Springer International Publishing AG 2017
J.L. Matson (ed.), Handbook of Treatments for Autism Spectrum Disorder,
Autism and Child Psychopathology Series, DOI 10.1007/978-3-319-61738-1_8
Parent Training for Parents
of Individuals Diagnosed
with Autism Spectrum Disorder
Justin B. Leaf, Joseph H. Cihon, Sara M. Weinkauf,
Misty L. Oppenheim-Leaf, Mitchell Taubman,
and Ronald Leaf
J.B. Leaf, PhD, BCBA-D (*) • J.H. Cihon
M. Taubman • R. Leaf
Autism Partnership Foundation,
200 Marina Drive, Seal Beach, CA 90808, USA
e-mail: Jblautpar@aol.com
S.M. Weinkauf
JBA Institute, Torrance, CA, USA
M.L. Oppenheim-Leaf
Behavior Therapy and Learning Center,
Calgary, Canada
8
Introduction to Parent Training
and ASD
Per the Center for Disease Control and Prevention
(2012), it is now reported that 1 out of every 68
children living in the United States are diagnosed
with autism spectrum disorder (ASD). The high
prevalence has also been reported globally
(Christensen, Baio, & Braun, 2012). For individ-
uals diagnosed with ASD to make meaningful
progress, they require early, intensive, and com-
prehensive intervention (Smith, Groen, & Wynn,
2000), with general consensus that interventions
should be based upon the principles of applied
behavior analysis (Smith & Iadarola, 2015). One
recommended and empirically validated compo-
nent of comprehensive intervention is parent
training (National Autism Center, 2009, 2015).
There are many different varieties of parent
training within the literature (Bearss, Burrell,
Stewart, & Scahill, 2015) with a number of cor-
responding labels. “Parent support” often consists
of several parents gathering together to discuss
ideas, stories, experiences, and information about
ASD and intervention, usually with the facilita-
tion of professionals (Bearss et al., 2015a).
“Parent education” is a form of parent training in
which a professional provides didactic or manual
instruction on concepts related to ASD and/or
intervention (Bearss et al., 2015a). Parent training
can also consist of counseling sessions, during
which a therapist works with parents on issues
related to stress, family functioning, and daily liv-
ing. Another approach to parent training includes
parent-mediated intervention, which consists of
hands-on training during which parents are taught
specific techniques that can be used to develop
and improve their own child’s skills (Kasari,
Gulsrud, Paparella, Hellemann, & Berry, 2015).
The goal of parent-mediated intervention is “…
that parents may become co- facilitators in the
intervention process” (Radley, Jeson, Clark, &
O’Neill, 2014, p. 241). It is common for the afore-
mentioned varieties of parent training to occur in
isolation or as a combination with other formats.
Although the term “parent training” can represent
multiple forms, the primary focus of this chapter
will be parent- mediated interventions, parent sup-
port groups, and parent education.
The purpose of this chapter is to (1) discuss the
importance of parent training, (2) provide a histori-
cal perspective of parent training within the field of
110
applied behavior analysis (ABA) as it relates to
autism intervention, (3) provide a general overview
of the research on parent training, and (4) discuss
future research and clinical implications.
Benefits of Parent Training
There are many reasons why parent training
should be included as part of a comprehensive
intervention model. First, given the high preva-
lence of individuals receiving an ASD diagnosis,
it may often be difficult for families to access the
intensity of intervention required for best out-
comes (Symon, 2005). Research has demon-
strated that training parents to implement some
or all of the intervention can help optimize the
intensity of intervention (Wainer & Ingersoll,
2013a). Second, research has demonstrated that
parent training can improve the quality of parent-
child interactions (Koegel, Bimbela, &
Schreibman, 1996), as well as improve upon
desirable behaviors (e.g., language, imitation,
and social behavior) and ameliorate less desir-
able behaviors (e.g., tantrums, self-injury, and
stereotypy; Charlop & Trasowech, 1991; Moes &
Frea, 2002). Third, when parents are trained to
provide intervention, treatment effects can gener-
alize and maintain over time (e.g., Koegel,
Schreibman, Britten, Burke, O’Neill, 1982).
Parent training may result in better generalization
and maintenance as individuals diagnosed with
ASD can receive more hours of intervention,
through parent-mediated intervention, and in set-
tings which may lead to longer-lasting changes.
Fourth, research has demonstrated that parent
training can reduce the stress and depression
often reported by parents of children with a dis-
ability (e.g., Estes et al., 2009). Finally, research
has shown that parents who are trained to provide
intervention often demonstrate an increased opti-
mism about their child’s future, as well as more
positive feelings about influencing their chil-
dren’s development (e.g., Koegel et al., 1982).
As this chapter will show, and other profes-
sionals and organizations have documented, par-
ent training meets the criteria to be considered an
evidence-based practice (National Autism Center,
2009, 2015). Therefore, given the many benefits
parent training can have for the family and the
individual diagnosed with ASD, training for par-
ents and the family as a whole should be included
as part of a comprehensive intervention program.
Seminal and Early Research
on Parent Training
In one of the first empirical investigations of
behavioral intervention for individuals diagnosed
with ASD, Wolf, Risley, and Mees (1963) imple-
mented operant conditioning procedures (e.g.,
extinction and shaping) to decrease the frequency
of tantrums, improve bedtime behavior, and
increase the duration of wearing glasses for a
3.5-year-old boy named Dickey. The results of this
study demonstrated that operant conditioning pro-
cedures were responsible for improved behavior
and provided the first empirical demonstration of
ABA techniques as a treatment for an individual
diagnosed with ASD. One component of this study
was training for the mother and father on provid-
ing intervention for the target goal areas while at
home. Although the specific details of the parent
training were not described, the inclusion of par-
ents within the study lends credence to the impor-
tance of parent training throughout the course of
intervention for individuals diagnosed with ASD.
In 1973, Lovaas et al. were the first to evaluate
a comprehensive behavioral intervention program
for individuals diagnosed with ASD. The study
consisted of 20 participants between 3 and
10 years old. All participants received interven-
tion for 12–14 months in an inpatient setting. The
intervention consisted of the implementation of
behavior analytic principles (e.g., reinforcement,
shaping, and punishment) to improve desired
behaviors (e.g., appropriate speech, play, and
social nonverbal behavior) and to eliminate unde-
sired behaviors (i.e., self-stimulation and echola-
lia). Some of the participants’ parents were trained
(group 2), while others did not receive training
(group 1). The researchers used standardized
measures (i.e., Stanford Binet IQ Test and
Vineland Social Maturity Scores) and various
response measures to evaluate the effectiveness of
J.B. Leaf et al.
111
the intervention. Overall, the results indicated
meaningful improvements for the participants.
With respect to the effects of parent training, the
authors stated “…follow-up measures recorded 1
to 4 years after treatment indicated that large dif-
ferences between groups of children were related
to the post-treatment environment (those groups
whose parents were trained to carry out behavior
therapy continued to improve; while children who
were institutionalized regressed)” (Lovaas,
Koegel, Simmons, & Long, 1973, p. 156). Thus,
the results suggested the importance of including
parent training as part of a comprehensive treat-
ment model to ensure maintenance of skills
acquired throughout the course of treatment.
The Lovaas et al. (1973) study was a catalyst
for other seminal research in the behavioral treat-
ment of ASD (e.g., Lovaas, 1987). Lovaas (1987)
evaluated the effects of intensive, comprehensive
behavioral treatment compared to a non- intensive,
eclectic approach. Thirty-eight children were
quasi-randomly assigned into 2 groups, 19 in the
intensive group and 19 children in the control
group. Within the study, Lovaas (1987) stated,
“The parents worked as part of the treatment team
throughout the intervention; they were extensively
trained in the treatment procedures so that treat-
ment could take place for almost all of the sub-
jects’ waking hours, 365 days a year.” (p. 5). Those
involved in the study have stated that parents
became experts in ABA and ASD and in some
cases were the best behavior analyst(s) on the
child’s team (Leaf, McEachin, & Taubman, 2008).
The results of the study not only showed the need
for intensive and comprehensive intervention but
also illustrated the benefits of including parent
training in an intensive, comprehensive model.
These seminal studies and other early investi-
gations on ABA-based treatment for individuals
diagnosed with ASD, as well as the work of other
professionals/researchers evaluating the effects
of parent training for parents of children with or
without ASD (e.g., Baker, Heifetz, & Murphy,
1980; Forehand, Middlebrook, Rogers, & Steffe,
1983; Harris, Wolchik, & Weitz, 1981; Patterson
& Fleischman, 1979), have served as a spring-
board for a plethora of research studies evaluat-
ing the effects of parent training, using a variety
of methods for a variety of skills for their chil-
dren diagnosed with ASD.
Parent Demographics
The plethora of research on parent training has
resulted in many parent participants with varying
demographics. Researcher typically provides
varying degrees of information on these demo-
graphics when discussing their participants. Age is
one demographic frequently noted. Within the par-
ent training literature, there is a wide age range of
the parent participants, with the youngest parent
noted at 21 years old (Anan, Warner, McGillivary,
Chong, & Hines, 2008) and the oldest at 52 years
old (Poslawsky et al., 2015). Gender is another
commonly noted demographic within the litera-
ture. The majority of studies on parent training
have reported training only mothers (Koegel,
Glahn, & Nieminen, 1978; Park, Alver-Morgran,
Canella-Malone, 2011; Reagon & Higbee, 2009);
however, there have been a few studies in which
both mothers and fathers are included (e.g., Estes
et al., 2014; Rocha, Schreibman, & Stahmer, 2007;
Vismara et al., 2013). Some less commonly
reported, and often not reported, demographics
within the parent training literature are socioeco-
nomic status (SES), education, nationality, and
culture.
Training Methods
Several methods have been utilized for training
parents. Some common methods include, but are
not limited to, (1) demonstration and role-play
(e.g., behavioral skills training or the teaching
interaction procedure; Ingersoll & Wainer, 2013a;
Rocha et al. 2007), (2) video modeling (e.g.,
Harris et al. 1981), (3) didactic instruction (e.g.,
Farmer & Reupert, 2013), and (4) active coaching
(Kasari et al., 2015). What follows is a general
overview of these methods with illustrated exam-
ples of each. However, each of these techniques
has additional benefits and limitations, and clini-
cians should examine the literature on each when
selecting a method for parent training.
8 Parent Training
112
Demonstration and Role-Play
One common method used to train parents occurs
when the trainer demonstrates the targeted behav-
ior and the parent participates in role-plays.
Demonstration and role-play commonly take two
different forms within the literature: (1) behav-
ioral skills training (BST) that involves the trainer
describing and demonstrating the skill, providing
opportunities for the learner to practice the skill,
and the trainer providing feedback (e.g.,
Seiverling, Williams, Sturmey, & Hart, 2012) and
(2) the teaching interaction procedure (TIP) in
which the teacher describes the skill, discusses
rationales for why the skill is important, demon-
strates the skill, role-plays the skill, and provides
feedback (e.g., Rocha et al., 2007).
There are numerous benefits for the use of
demonstration and role-playing during the course
of training. For one, demonstrations provide an
opportunity for the trainer to model examples and
non-examples of the targeted skill. As such, mod-
eling sets the occasion for observational learning
of the targeted skill(s). Second, role-plays can lead
to increased opportunities to provide positive rein-
forcement for approximations in a non- threatening,
structured environment, therefore potentially
decreasing stress and increasing the parent’s confi-
dence to display the skill in the criterion context.
This method also allows the trainer to train loosely
and program common stimuli and for training to
align closely with the natural contingencies, all of
which are important in promoting generalization
across environments (Stokes & Baer, 1977).
Finally, the inclusion of rationales (a component
of TIPs) may lead to better understanding of the
importance of the skill and may result in longer
maintenance of the skill in the absence of the
trainer and in the natural environment. That is,
rationales can put the skill into context for the
trainee (e.g., it is important to have the environ-
ment appropriately arranged before working on a
skill, such as requesting, to allow for many pre-
pared learning opportunities to be captured effi-
ciently) which may lead to more generalized skills
that maintain for longer periods of time.
Ingersoll and Wainer (2013b) provide an
example of the use of BST during parent training.
Within this study, the researchers demonstrated
the effectiveness of BST in a group and a one-to-
one instructional format to teach parents how to
implement components of Project Impact. Project
Impact is a teaching procedure that uses a combi-
nation of naturalistic behavioral intervention
with a developmental approach to teach students
various social behaviors and to improve language
development. In this study, parents attended six
group training sessions and six individual train-
ing sessions. The researchers evaluated improve-
ment via formal standardized assessments for the
children (e.g., Social Responsiveness Scale) as
well as treatment fidelity evaluations. The results
showed that parents improved their delivery of
the intervention components and that the children
showed improvements on the targeted skills.
TIPs have also been demonstrated as a suc-
cessful method to train parents in the implementa-
tion of various behavior analytic techniques. For
example, Rocha et al. (2007) implemented a TIP
to teach three parents how to implement Pivotal
Response Training (PRT) and Discrete Trial
Teaching (DTT) to increase joint attention for his
or her child. Parents were taught various proce-
dures associated with DTT (e.g., providing an
appropriate instruction, providing feedback, and
completing the trial) and PRT (e.g., using choice,
motivation, and following his/her child’s lead).
Training consisted of the researcher providing
information about the procedures and rationales,
(e.g., why joint attention is important) followed
by a teacher modeling the behavior, the parent
implementing the procedure, and receiving feed-
back on their implementation. Results of the study
showed that parents increased the amount of joint
attention bids provided, and children demon-
strated improvement in joint attention.
Video Modeling
Another common training method explored within
the parent training literature is video modeling
(e.g., Berquist & Charlop, 2014). Video modeling
has many benefits as a training tool. For one, simi-
lar to role-playing, video modeling provides
examples and non-examples of the targeted skill.
J.B. Leaf et al.
113
Also, when video models contain multiple exem-
plars, they increase the likelihood of generaliza-
tion of the skill (Stokes & Baer, 1977). Unlike
role-plays, video modeling provides parents with a
permanent product that they can reference in the
absence of the trainer. Video modeling is com-
monly included as a component of other training
methods.
Harris et al. (1981) taught 11 parents how to
implement a variety of behavior analytic tech-
niques (e.g., shaping, data collection, chaining,
and prompting) focusing on the language devel-
opment of their children. The intervention was
conducted within a group instructional format
and consisted of BST with the addition of video
models. Although the authors of the study stated
that videos were included, no description was
provided as to what was specifically shown on
the videos. At the conclusion of the study,
improvements were observed in the children’s
language skills.
More recently, Berquist and Charlop (2014)
taught six parents how to evaluate an intervention
that consisted of multiple components, including
video modeling. Training consisted of a combi-
nation of a manual and training sessions using
BST. A video was used in conjunction with the
manual and contained a variety of information
for evaluating interventions (e.g., operationally
defining targeted behavior, how data collection
can be determined to be effective, and identifying
the claim of the intervention). Parents were
taught how to evaluate a treatment across 14 dif-
ferent dimensions (e.g., graphed results, identify-
ing question of interest, and identifying target
behavior). The results of a multiple baseline
design showed an increase in the parents display-
ing the dimensions of evaluative behaviors.
Didactic Instruction
Didactic instruction, as applied to parent training,
provides parents with information on how to
implement various procedures and increase their
general understanding of those procedures.
Although didactic instruction can be imple-
mented in isolation, it is commonly implemented
with other procedures within the parent training
literature (e.g., Farmer & Reupert, 2013).
Didactic instruction offers several benefits for
parents and trainers. It can provide parents foun-
dational information which may lead to a better
understanding of the importance of the various
procedures that they are taught. When didactic
instruction is provided in a group instructional
format, it provides parents the opportunity to
learn from each other, develop support networks,
and solve problem with other parents. With
respect to the trainer, didactic instruction allows
for training large numbers of parents, which may
result in more efficient training.
Farmer and Reupert (2013) provide an exam-
ple of a study that used didactic instruction as part
of a parent training intervention. The researchers
conducted a 6-week parent education program for
86 parents living in rural Australia. The program
was implemented in a group instructional format
with each group lasting 6 h. Each week’s session
covered a new topic (e.g., what is autism, social
understanding, and sensory processing). At the
conclusion of the 6 weeks, parents self-reported
(i.e., parents filled out a Likert scale across 15 dif-
ferent questions) an increase in knowledge of the
various topics.
Active Coaching
Another form of parent training is known as
active coaching. Active coaching consists of the
trainer providing in vivo feedback, while the
trainee attempts to demonstrate the targeted skill.
Typically, active coaching is implemented simul-
taneously with other procedures, such as didactic
instruction (e.g., Kasari et al., 2015) and/or mod-
eling (e.g., Radley et al., 2014).
Active coaching has many benefits as a
method to train parents. For instance, active
coaching sets the occasion for trainers to provide
immediate feedback. Immediate feedback may
be more desired than delayed feedback when tar-
geting new skills (Cooper, Heron, & Heward,
2007) to prevent incorrect implementation of the
intervention for an extended period of time. Also,
active coaching is conducive to training in the
8 Parent Training
114
environment in which the skill is to occur as
opposed to an analogue setting. Targeting a skill
in the environment in which it is to be used
increases the likelihood of the behavior coming
under control of the naturally occuring stimulus
conditions (Stokes & Baer, 1977).
In an example of active coaching, Kasari,
Gulsrud, Paparella, Hellemann, and Berry (2015)
compared the JASPER parent-mediated model to
a psychoeducational intervention (PEI) for 86 par-
ents. The parents were randomly assigned to the
PEI or JASPER condition. The JASPER model
consisted of 10 h of active coaching targeting joint
engagement through a combination of develop-
mental and behavioral procedures. Parents were
taught to recognize their child’s developmental
level of play, how to jointly engage in an activity,
and how to keep their child engaged. The PEI
model consisted of 10 h of didactic instruction
during which parents were taught about autism,
improving social behavior, and managing parental
stress. The primary measure was joint engagement
between the parent and child. Additional measures
included child play skills, standardized assess-
ments of the child’s skill level (e.g., Reynell recep-
tive language test), and measures of parental stress
(e.g., Parental Stress Index). The results of the
study indicated that parents assigned to the
JASPER model showed higher levels of joint
engagement, but there were mixed results on the
other child- specific measures. Although in regard
to stress measures, the parents in the PEI condition
showed lower levels post-intervention when com-
pared to parents in the JASPER condition.
Although there are many benefits to active
coaching, there are some disadvantages found
within the literature. First of all, in many studies,
the procedures associated with active coaching
are not thoroughly described which may make it
difficult to replicate. Second, active coaching
may be labor intensive as it requires one-on-one
intervention with the parent and child and, there-
fore, less efficient than other methods of parent
training. Third, since it is usually combined with
other training procedures, it is often difficult to
determine if active coaching itself or another
component of the training package is responsible
for the behavior change.
Instructional Formats
The aforementioned training methods are com-
monly implemented in three different instruc-
tional formats. The first, and most common,
instructional format within the literature is a one-
to- one instructional format. One-to-one instruc-
tional formats provide the opportunity for the
trainer to work directly with the parents on an
individual basis. Researchers have demonstrated
the effectiveness of a one-to-one format for train-
ing parents using a variety of training methods,
including video modeling (e.g., Berquist &
Charlop, 2014) and demonstration and role-play
(e.g., Rocha et al., 2007).
A second instructional format in which vari-
ous training techniques can be implemented is
group instruction. Group instruction consists of
two or more parents participating in the interven-
tion simultaneously. Group instruction sets the
occasion for observational learning which may
result in more efficient training targeted (e.g.,
Leaf et al., 2013) as parents can acquire skills not
directly. Group instruction has been used within
the literature with video modeling (e.g., Harris
et al., 1981), demonstration and role-play (e.g.,
Laugeson, Frankel, Mogil, & Dillon, 2009), and
didactic instruction (e.g., Farmer & Reupert,
2013). The PEERS model of social skills groups
(for a detailed description of the PEERS Model
see, Laugeson et al., 2009; Yoo et al., 2014) is a
prime example of parent training that occurs in a
group instructional format. For example,
Laugeson et al. (2009) utilized BST within a
group instructional format to teach 33 parents to
improve their child’s friendships with peers.
After 12 sessions of intervention, parents more
effectively facilitated relationships using the pro-
cedures taught.
Group instruction and one-to-one instruction
can also occur in combination (e.g., Anan et al.,
2008). For example, Harris, Wolchik, and Milch
(1983) conducted and evaluated the effects of
training 11 parents of children diagnosed with
ASD. The authors targeted a variety of skills
(e.g., data collection, shaping, promoting gener-
alization) using BST. The researchers conducted
training in a group instructional format and
J.B. Leaf et al.
115
conducted home visits to provide one-to-one
training. The researchers measured the parents’
speech-oriented language toward their respective
child and found an improvement following
intervention.
An increasingly common instructional format
for parent training is telehealth (e.g., Suess et al.,
2014; Vismara et al., 2013), which involves the
use of telecommunication technologies (e.g.,
video conferencing) to provide training to par-
ents remotely. This format is often used due to
large geographical distances between the family
and the trainer (Vismara et al., 2013). Telehealth
has advantages over more traditional instruc-
tional formats (i.e., in person). For instance, tele-
health can be used to provide training for parents
who otherwise would not be able to access train-
ing due to distance or limited services.
Additionally, depending on the nature of the
training, telehealth can be accessed at the par-
ents’ leisure, minimizing scheduling conflicts.
Telehealth is also amenable to training occurring
in multiple environments, which can be individu-
alized and selected based on parent responding.
For example, a more structured environment can
be selected when necessary and systematically
transferred to the natural environment.
In an example of the use of parent training via
telehealth, Vismara et al. (2013) trained eight
parents in the principles of the Early Start Denver
Model (ESDM; for detailed description of
ESDM, see Estes et al., 2014; Vismara et al.,
2009; Vismara, McCormick, Young, Nadhan, &
Monlux, 2013). The intervention occurred across
12 sessions, each lasting 1.5 h, within a one-to-
one instructional format. The sessions consisted
of the parent discussing the child behaviors that
had occurred in the last week, followed by a
10 min observation of the child and parent inter-
acting, and then discussing the skill topics from
previous sessions, new skill topics, and how to
implement these in generalized environments.
The main dependent variables for the parents
were parent-child interaction, parent satisfaction,
and fidelity of treatment. After treatment had
concluded, the parents implemented the proce-
dures with higher levels of treatment fidelity and
higher levels of engagement and reported that
they had a better understanding and appreciation
of how to help their child.
Although there are advantages to telehealth,
there are some disadvantages as well. For one,
the trainer can only observe what is occurring on
the screen, which makes it difficult to assess what
other events may be influencing the parent’s
behavior. Second, telehealth does not allow the
trainer to model the correct behavior/procedure
directly with the individual diagnosed with
ASD. Finally, telehealth has to be implemented
with extreme caution to protect the client’s rights
and to avoid HIPPA violations.
Parent Targets
Within the literature on parent training, parents
have been trained to implement a variety of teach-
ing procedures. Some of these procedures have
included, but are not limited to, DTT (e.g., Neef,
1995), PRT (e.g., Buckley, Ente, & Ruef, 2014),
ESDM (e.g., Vismara, Colombi, & Rogers, 2009),
the Picture Exchange Communication System
(PECS; e.g., Park, Alber-Morgan, & Cannella-
Malone, 2011), and Functional Communication
Training (FCT; e.g., Suess et al., 2014).
Discrete Trial Teaching DTT is a commonly
implemented procedure during the course of
treatment for many individuals diagnosed with
ASD. DTT consists of three primary compo-
nents: the teacher delivering an instruction, a
response made from the learner, and a teacher-
delivered consequence (Lovaas, 1987). Lovaas
et al. (1973) and Lovaas (1987) included parent
training on the implementation of DTT. Since
these publications, there have been numerous
studies which have also involved the training of
parents on the implementation of DTT (e.g.,
Crockett, Fleming, Doepke, & Stevens, 2007;
Koegel et al., 1978; Lafaskis & Sturmey, 2007;
Rocha et al., 2007; Schreibman, Kaneko, &
Koegel, 1991).
For example, Neef (1995) investigated the use
of a pyramidal training approach (i.e., trainees
becoming trainers) compared to professional-led
training with 26 parents (20 mothers, 6 fathers).
8 Parent Training
116
Training involved how to select and arrange
stimuli, provide instructions and prompts, deliver
contingent consequences, record data, and struc-
ture the teaching session (all of which are compo-
nents of DTT). The pyramidal approach involved
training five parents, referred to as Tier 1 parents,
until mastery. Those parents then conducted the
training for additional parents, referred to as Tier
2 parents, and were matched based on demo-
graphics and child skill level. The Tier 2 parents
then provided the training for the next group of
parents, and this pattern was continued until all
of the parents were trained, thus the term “pyra-
midal training.” All parents in the professional-
led training group were trained exclusively by
professionals rather than previously trained par-
ents. The percentage of steps demonstrated cor-
rectly across both groups improved from baseline
to intervention; however, parents who received
the pyramidal training performed better on gen-
eralization probes.
Pivotal Response Training PRT is a naturalis-
tic treatment intervention that focuses on teach-
ing pivotal behaviors for children diagnosed
with autism spectrum disorder. These behaviors
are considered to be pivotal as they lead to
widespread behavioral gains. PRT focuses on
increasing motivation, responsivity to multiple
cues, self-management, and social initiations.
Several studies have explored training parents
in the PRT model. For example, Buckley, Ente,
and Ruef (2014) provided training to a parent of
a child with an ASD at the family’s home, which
consisted of providing instructional materials
on PRT, video models, reviewing videos of the
parent implementing the intervention, and role-
playing. Targeted skills included, but were not
limited to, letting the child select the activities/
materials, interspersing mastered and acquisi-
tion tasks, and providing choices (Buckley
et al., 2014). Data was collected on the child’s
rate of compliance and the parent’s target skills,
and both showed an increase in the rate of cor-
rect responding following training. Measures of
improved quality of life (i.e., interviews follow-
ing the intervention) also indicated that the par-
ent enjoyed the training and felt the quality of
life improved for herself and her child.
Early Start Denver Model ESDM is a compre-
hensive treatment approach for children under
4 years of age (Estes et al., 2014; Vismara et al.,
2009, 2013). ESDM incorporates a developmen-
tal and naturalistic behavioral approach and
includes parent involvement as a core concept
within the treatment process.
In an example of training parents in the
ESDM, Vismara et al. (2009) evaluated the
effects of parent training with eight parents who
received 12 weeks of training with each training
session lasting 1 h. Vismara and colleagues uti-
lized BST and provided parents with a manual on
ESDM principles to teach parents to implement
14 different components of ESDM. Additionally,
the researchers evaluated child progress across
numerous behaviors (e.g., verbal utterances, imi-
tative behaviors, and attentiveness). The training
resulted in improved implementation of ESDM
components by the parent participants, which
also corresponded with improvement across the
child measures.
Picture Exchange Communication System It
has been reported that approximately 25% of
children diagnosed with ASD will not develop
functional vocal language (Tager-Flusberg, Paul,
& Lord, 2005). To help children communicate,
the use of augmentative and alternative commu-
nication systems, such as the PECS (Bondy &
Frost, 1994), is sometimes required. PECS is a
systematic teaching approach that uses pictures
to help children communicate. Researchers have
demonstrated the effectiveness of PECS to
improve communication skills (e.g., Park, Alber-
Morgran, & Cannella-Malone, 2011) and increase
spontaneous speech (e.g., Anderson, Moore, &
Bournce, 2007) with individuals diagnosed with
ASD. However, there have been relatively few
studies that have evaluated parents’ roles in
PECS implementation (Ben Chaabane Alber-
Morgan, & DeBar, 2009; Park et al., 2011).
Park et al. (2011) provided an example of one of
the few studies that included parents within the
PECS implementation. Park and colleagues trained
three mothers of 2-year-old children with an ASD
to implement Phase 1, Phase 2, Phase 3A, and
Phase 3B of PECS (for detailed description of the
Phases of PECS see; Bondy & Frost, 1994).
J.B. Leaf et al.
117
Training was conducted utilizing BST. The results
showed an increase in the percentage of indepen-
dent picture exchanges and a high level of treat-
ment integrity across each of the three mothers.
Functional Communication Training When
attempting to ameliorate aberrant behavior, it is
important to find a socially appropriate, functional
alternative behavior. One procedure which has
demonstrated effectiveness in teaching such behav-
iors is FCT (Carr & Durand, 1985). FCT has been
used to teach responses that produce the same con-
sequence that the less desirable behavior would
have produced (e.g., requesting a break to escape a
task as opposed to engaging in physical aggres-
sion). FCT is a commonly implemented technique
to address aberrant behavior (Tiger, Hanley, &
Bruzek, 2008), and researchers have demonstrated
that parents can be trained in its implementation
(Wacker et al., 2005, 2013).
Suess et al. (2014) provided an example of
training parents to implement FCT via telehealth.
The training involved didactic instruction and
coaching for three parents to conduct FCT with
their respective child following a functional
behavior assessment (FBA). The FBA was con-
ducted to determine the likely function of the
aberrant behavior so an appropriate replacement
behavior could be selected. The researchers mea-
sured the percentage of steps completed correctly
by the parents from a dyad-specific task analysis.
Suess and colleagues’ results indicated an increase
in the percentage of correct steps completed by
the parents and a corresponding decrease in the
children’s aberrant behavior.
Multiple Component Quality behavioral inter-
vention requires a therapist to not only implement
one procedure but a variety of procedures and to
implement these procedures accurately (Leaf
et al., 2016). Thus, a therapist should be fluent in
the implementation of procedures such as DTT,
shaping, behavior reduction programs, social
skills interventions, etc. (Leaf et al., 2016). Given
the amount of time parents spend with their chil-
dren, some of which may involve providing inter-
vention, it is equally important for parents to be
fluent in a number of behavior change techniques.
As such, there have been several studies that have
explored training parents on a variety of proce-
dures (e.g., Cordisco, Strain, & Depew, 1988;
Harris et al., 1983; Heitzman- Powell, Buzhardt,
Rusinko, Miller, 2014; Koegel et al., 1978;
Sallows & Graupner, 2005).
Lerman, Swiezy, Perkins-Parks, and Roane
(2000) provide an example of training three par-
ents on a variety of behavior change techniques
based upon the principles of ABA. The behavior
change techniques included the use of differen-
tial reinforcement, instructional and communi-
cation prompts, as well as how to respond to
inappropriate behavior, increase compliance,
and provide instructions. Training consisted of
written instructions outlining various concepts
and techniques, as well as in situ feedback. The
results of a multiple baseline design showed that
the parents implemented the techniques with
greater accuracy following intervention and
child measures indicated the techniques were
effective.
Child Targets
Many of the studies evaluating parent training
involve measures of child behavior as the primary
dependent variable. These measures provide an
opportunity to determine if the technique(s) on
which the parents are trained were effective for
their children. Many of the child skills targeted
within the parent training literature fall within the
core deficit areas of the ASD diagnosis, but there
are additional skills outside of the core deficits
that are frequently targeted as well.
Language One of the diagnostic criteria for
individuals diagnosed with ASD is an impair-
ment in language, which can range from mild
(e.g., difficulties with complex social language)
to severe (e.g., having no appropriate vocal lan-
guage; American Psychiatric Association, 2013).
Behavioral interventions frequently address lan-
guage skills for individuals diagnosed with
ASD. Therefore, it is not surprising that many
parent training programs have focused on train-
ing parents to implement techniques to improve
language. As such, child measures within the par-
ent training research have shown that, following
8 Parent Training
118
training, parents were effective in increasing sound
production (e.g., Harris et al., 1983), word produc-
tion (e.g., Harris et al., 1983), requesting (e.g.,
Suess et al., 2014), spontaneous language (e.g.,
Charlop & Trasowech 1991; Ingersoll & Wainer,
2013a), social exchanges (e.g., Park et al., 2011),
and social communication (e.g., Ingersoll &
Wainer, 2013b; Reagon & Higbee, 2009; Vismara
et al., 2009). For instance, Charlop and Trasowech
(1991) evaluated parent training focused on lan-
guage development for three parents of children
diagnosed with ASD using BST. Parents were
taught to implement a progressive time delay
prompt (i.e., gradually increasing the amount of
time before a prompt is provided) to help increase
spontaneous speech from their respective child.
Using a multiple baseline design, the results
showed that there was an increase in the children’s
spontaneous speech and generalization to other
people and locations following parent training.
Social Skills Another core deficit for individuals
diagnosed with ASD is a qualitative impairment in
social behavior (American Psychiatric Association,
2013). As such, comprehensive, quality interven-
tion should address deficits in social behavior
(Leaf et al., 2016). Much of the research involving
parents has focused on training techniques to
increase specific social behaviors and/or to facili-
tate pro-social relationships (Crockett et al., 2007;
Kashinath, Woods, & Goldstein, 2006; Laugeson
et al., 2009; Radley, Jenson, Clark, & O’Neill,
2014; Yoo et al., 2014). One example of parent
training targeting social behavior was a study con-
ducted by Kashinath et al. (2006) in which the
researchers used BST to teach five parents how to
implement a variety of behavioral procedures
(e.g., cuing, time delay, and modeling). One of the
targeted skills was improving the child’s indoor
play, and the results showed that parent training
led to improvements with this skill. Laugeson
et al. (2009) provide another example in which
parents were trained how to help facilitate and fos-
ter relationships (e.g., friendships) within the
PEERS model. After training occurred, partici-
pants who were included in the PEERS model
demonstrated an improvement in their social
behavior and interactions with peers.
Reduction of Aberrant Behavior Individuals
diagnosed with ASD can display a variety of aber-
rant behaviors (e.g., stereotypic behavior, self-
injury, aggression, sleeping challenges, etc.), all of
which can interfere with learning and decrease
their overall quality of life (Bearss et al., 2015). As
such, there are many techniques that can decrease
the frequency, intensity, and duration of aberrant
behavior. Decreasing the likelihood of aberrant
behavior can also decrease stress and anxiety for
parents and the rest of the family (Durand,
Hieneman, Clarke, Wang, & Rinaldi, 2013).
Therefore, research on parent training has explored
training parents in techniques to ameliorate these
challenges. Within the parent training literature,
child measures have helped show that parents who
successfully implemented techniques on which
they were trained resulted in a decrease in aggres-
sion displayed by their child (e.g., Lerman et al.,
2000; Powers, Singer, Stevens, 1992), as well as
decreases in whining (Powers et al., 1992), non-
compliance (Lerman et al., 2000; Powers et al.,
1992), stereotypy (e.g., Bearss et al., 2015), irrita-
bility (e.g., Bearss et al., 2015), self-injury (e.g.,
Learman et al., 2000), sleeping issues (e.g., Malow
et al., 2014), and mealtime challenges (e.g.,
Najdowski et al., 2010; Seiverling et al., 2012;
Sharp, Bureel, & Jaquess, 2014).
In an example of parent training to decrease
aberrant behavior, Bearss and colleagues (2015)
conducted a comparison investigation consisting
of randomly placing 91 parents in a parent train-
ing program and 89 parents in a parent education
program across six different centers in the United
States. The parent training program consisted of
BST, while the parent education program con-
sisted of providing parents with didactic informa-
tion. Using the Aberrant Behavior Checklist as
their main measure, both treatments led to a
decrease in aberrant behavior, but the results
showed that parent training was superior to par-
ent education for reducing aberrant behavior
according to the parents across both groups.
Other Skills Parent training research has also
examined child behaviors that do not fall within
the core deficit categories of ASD. Additional
parent training interventions have resulted in
J.B. Leaf et al.
119
improvements of child skills within the areas of
self-help skills (e.g., Cordisico et al., 1988), joint
attention (e.g., Kasari et al., 2015, Rocha et al.,
2007), receptive instructions (e.g., Lafasakis &
Sturmey, 2007), discrimination (e.g., Koegel et al.,
1978), and cognitive development (e.g., Anan
et al., 2008). Researchers have also used parent
training to help parents improve their stress levels
(e.g., Al-Khalaf, Dempsey, & Dally, 2014; Ali
Samadi & Mahmoodizadeh, 2014), increase their
self-efficacy (e.g., Poslawsky et al., 2015), increase
general knowledge of autism (e.g., Farmer &
Reupert, 2013), and increase their ability to record
behavior (e.g., Herbert & Baer, 1972).
Types of Measurement
Researchers have used a variety of measures to
evaluate the effects of parent training. Numerous
studies have used direct measures (i.e., objective
data) of the behavior of the parents (e.g., imple-
menting FCT, implementing shaping, implement-
ing DTT) who participated (e.g., Berquist &
Charlop, 2014; Corsidico et al., 1988; Crockett,
Fleming, Doepke, Stevens, 2007; Harris et al.,
1981, 1983; Herbet & Baer, 1972; Lafasakis &
Sturmey, 2007). Other studies have used subjec-
tive, rather than objective, measures to demonstrate
improvements in parent behavior (e.g., Cordisco
et al. 1988; Farmer & Reupert, 2013; Heitzman-
Powell et al., 2014). There have also been several
studies that have used formal and/or standardized
assessments to measure progress (Anan et al.,
2008; Bearss et al., 2015b; Estes et al., 2014).
While parent behavior is generally the pri-
mary focus of parent training, the desired out-
come of training parents is to produce positive
behavior change with their children. Therefore,
measures of the child’s behavior change are com-
monly taken and, in some cases, are the primary
dependent variables (e.g., Charlop & Trasowech,
1991; Cordisco et al., 1988; Harris et al., 1983;
Herbert & Baer, 1972; Ingersoll & Wainer, 2013).
There also have been several studies that have
combined various measures (e.g., Cordisco et al.,
1988; Harris et al., 1983; Herbert & Baer, 1972;
Ingersoll & Wainer, 2013a).
Future Directions
The research on parent training is robust.
Researchers have shown that parent training can
be effective in changing the behavior of parents of
individuals diagnosed with an ASD using multiple
methods (e.g., behavioral skills training, coaching,
video modeling, etc.). Researchers have also dem-
onstrated that parents who receive training can
implement a variety of procedures (e.g., shaping,
discrete trial teaching, ESDM, etc.) that result in
meaningful changes for them and their children.
Despite the extensive parent training literature
base, there are several areas in which future
research and clinical practice could focus.
Parent Demographics
One potential area future researchers should
address involves expanding the descriptions of
parent participants. Researchers should make a
concerted effort to provide a complete descrip-
tion of the demographics of the parents who are
participating in the training. There are demo-
graphics that could potentially affect the effec-
tiveness of an intervention, including, but not
limited to, the parents’ age and gender, education
level, socioeconomic status (SES), and cultural
characteristics. It is common for researchers to
provide information regarding age and gender;
however, there are examples in which little to no
demographic information is reported, and demo-
graphics, such as culture and SES, are typically
never reported. Without providing demographic
information, it would be difficult, if not impossi-
ble, to identify any relationship between parent
variables and response to training.
Reporting demographic information to help
identify the conditions under which certain train-
ing methods can lead to better skill acquisition is
crucial. For example, researchers have shown that
parent training may be less effective for parents of
lower SES (e.g., Clark & Baker, 1983; Knapp &
Deluty, 1989). Some associated challenges with
this demographic, such as working multiple jobs,
may result in less effective training for reasons
such as time limitations or scheduling challenges.
8 Parent Training
120
As such, future researchers should strive to pro-
vide a complete description of the parents partici-
pating in training to allow researchers to analyze
their results with respect to these demographics.
As a result, researchers and clinicians could
attempt to identify which demographics result in
better skill acquisition with respect to certain train-
ing procedures. This would also allow for future
research to investigate the best training procedures
to use for different demographics to allow for all
parents to better access effective parent training.
Gender is another important demographic that
may influence the effectiveness of parent training.
It has been reported that mothers and fathers of
individuals diagnosed with ASD have different
roles within the family context (Pleck &
Masciadrelli, 2004), have varying levels of stress
(Flippin & Crais, 2011), and interact with their
children in different manners (Flippin & Crais,
2011). If gender is part of the conditions under
which a certain method of parent training is effec-
tive, reporting information on parents’ gender
within the research is critical. Furthermore,
researchers should make an effort to evaluate par-
ent training for fathers of individuals diagnosed
with an ASD because, while there have been some
studies which have included fathers, it is far more
common for mothers to participate thus leaving
father participation vastly underrepresented
(Flippin & Crais, 2011). A father’s involvement,
interaction styles, and stress may be different than
a mother’s and may influence the selection of the
training procedure, format, and targets.
The culture of the parent who participates in the
training is another demographic that is not com-
monly reported. Culture plays a large role in how a
family may interact with each other and other
families, handle having a child with a diagnosis,
prioritize training targets, and view their role in
intervention. It is difficult to examine research find-
ings with respect to cultural aspects when informa-
tion on culture is not reported. More importantly, if
culture is not reported, it is a possibility that cul-
tural characteristics were not taken into account
when designing the parent training features that are
under examination. Ignoring cultural characteris-
tics, even if unintentional, could lead to failures to
replicate, ineffective training, cultural insensitivity,
and reduced consumer acceptability.
Measurement
The parent training literature includes a variety
of ways in which researchers measure the effects
of parent training. These measures include
direct objective measurement of parent behav-
ior (e.g., Neef, 1995), direct objective measure-
ment of child behavior (e.g., Rocha et al.,
2007), subjective data (e.g., Farmer & Reupert,
2013), standardized assessments (e.g., Ingersoll
& Wainer, 2013b), and/or a combination (e.g.,
Rocha et al. 2007). One of the hallmarks of
behavior analysis (and science in general) is the
reliance on objective data (Cooper et al., 2007).
Therefore, subjective measurement can provide
valuable information regarding the parent train-
ing program (e.g., social validity) but should
not be relied upon as the main measure of
effectiveness.
Social Validity
An additional measurement that should be
found in clinical practice is social validity
(Wolf, 1978). Although social validity was not
originally identified as one of the seven dimen-
sions of ABA (Baer, Wolf, & Risley, 1968,
1987), Wolf (1978) stated that measures of
social validity is how ABA would find its
“heart,” so that our consumers would find an
opportunity to provide us with feedback. Parents
should be involved from the onset of training in
selection of goals and procedures to be imple-
mented. Additionally, researchers should mea-
sure satisfaction with the results of the training
with the parents and, when possible, the indi-
viduals diagnosed with ASD. Although social
validity has been included in some parent train-
ing research, there are many studies in which it
has not. Future researchers should make an
effort to include social validity in every future
study that evaluates parent training. Clinicians
should also measure social validity as part of a
comprehensive evaluation of their training pro-
gram to ensure satisfaction by those involved in
the training and to inform clinicians of any
modifications to the training that may make it
more socially valid for future use.
J.B. Leaf et al.
121
Training the Trainers
Both in future research and in clinical practice,
behavior analysts must discover the most effec-
tive and efficient ways to train professionals who
will be providing parent training. As mentioned
earlier, the most appropriate method may differ
from trainee to trainee so this is also an important
area to consider to ensure that training is as effec-
tive and efficient as possible.
An important area to consider when teaching
professionals to train parents is how to do so with
clinical sensitivity, that is, to do so with an under-
standing of the struggles that parents of individu-
als diagnosed with ASD go through on a daily
basis. It is important to teach the trainers to train
parents with compassion and empathy, as well as
maintaining balance between the child’s individ-
ual needs and the needs of the entire family unit.
These skills are critical if professionals are going
to work effectively with parents. If behavior ana-
lysts are to focus on training in the absence of
these skills, parents may be less likely to feel
comfortable participating in training. In other
words, ignoring the contingencies under which
parents are operating and paying sole attention to
the contingencies affecting the child’s behavior
may lead to ineffective or short-term changes in
parent behavior. For example, identifying that a
child’s challenging behavior is maintained by
social positive reinforcement (e.g., parent atten-
tion) and training the parent to ignore the behav-
ior without understanding the contingencies
operating for the parents may result in teaching
the parent a “skill” that he/she cannot use in the
natural environment. So when in a grocery store,
if the child engages in challenging behavior,
ignoring the child’s behavior may not be the most
ideal approach for the parent if providing atten-
tion to the child serves a negatively reinforcing
effect for the parent.
Although these “soft skills” may be hard to
conceptualize and may not be as simple to define
as a more concrete procedure, such as prompting,
they are critical skills that need to be taught to
future parent trainers. A first step would be for
future researchers to identify and operationally
define all of the soft skills that are needed for
trainers to effectively work with parents of chil-
dren with ASD. Additionally, future researchers
should evaluate ways to train soft skills to the
individuals who will be providing the parent
training. Finally, future researchers should evalu-
ate if the parent trainers who were taught soft
skills provided training that resulted in quicker
rates of learning for the parent trainees, higher
levels of parent satisfaction, and greater parental
utilization of skills taught.
Training future behavior analysts how to work
with parents is critical to providing a higher qual-
ity of intervention leading to better outcomes for
individuals diagnosed with autism. Therefore,
how to provide effective parent training should
be included as a component of a behavior ana-
lysts training (e.g., undergraduate programs,
graduate programs, and service providers).
Pertinent parent training skills should also be
required as part of certification/licensure. Thus,
training the trainers is not only an important com-
ponent of future research but also an important
component of clinical practice.
A Progressive Model
The majority of research on parent training has
focused on a professional-led training program
for parents to implement a single procedure (e.g.,
Suess et al., 2014), a few procedures (e.g., Barton
& Lissman, 2015), or how to implement a com-
prehensive intervention (e.g., Buckley et al.,
2014). Although parent training has been used to
teach parents to implement a variety of proce-
dures, the majority of these studies presumably
have taught parents to implement the procedures
in a way that requires strict adherence to specific
protocols. Furthermore, the underlying concep-
tual basis for the technique is often not trained
which may lead to training parents to implement
the techniques inflexibly. Training parents to fol-
low a protocol may be easier to train, measure,
and is often the current model of the field (Leaf
et al. 2016); however, this type of training could
be considered a prescriptive model (i.e., parents
are taught to implement specific procedures
under specific contextual variables) rather than a
8 Parent Training
122
flexible model in which the parents can make in-
the- moment changes based on the child’s behav-
ior (i.e., a progressive model; Leaf et al., 2016).
Training in a progressive model consists of
training the parents on the principles underlying
the procedures and rationales for their use as well
as on the procedures themselves. This may allow
for greater overarching impact, longer mainte-
nance, and generalization of skills (e.g., Leaf et al.,
2016). Additionally, this could be considered more
of a psychoeducational model in which parents
develop a broader understanding of behavioral
principles. Training in this model contrasts with
training that is solely focused on following a spe-
cific, strict protocol (e.g., a prescriptive model).
While several studies have evaluated compo-
nents of a progressive model (Leaf et al., 2016),
none have specifically evaluated the model with
respect to parent training. However, components of
the progressive model were utilized as part of
Lovaas et al. (1973) and Lovaas (1987). Within a
progressive model, as applied to parent training,
the parent would be trained to use clinical judg-
ment, in-the-moment assessment and decision-
making, and flexible teaching while implementing
a variety of behaviorally based techniques. When
parents are trained in this model, instead of adher-
ing to a strict protocol, they would be trained to
understand the principles of ABA, as well as when
and how to adjust teaching and make in-the-
moment assessments. Future researchers should
investigate the use of this model for parent training
and focus on measures of parents’ clinical judg-
ments, in-the-moment assessments and decision-
making, flexibility in teaching and prompt fading,
and implementation of multiple procedures simul-
taneously. Additional measures could include com-
prehension of guiding principles as opposed to
learning specific, isolated procedures. Training in
this way may result in long-term success for both
the parent and the individual diagnosed with ASD.
Conclusion
For over 50 years, the principles of ABA have
been utilized to implement interventions for indi-
viduals diagnosed with ASD (Smith, 2012).
From the beginning of the applied research and
clinical implementation of ABA-based proce-
dures for individuals diagnosed with ASD, pro-
fessionals have demonstrated the advantages and
importance of parent training. Today, parent
training has support as an evidence-based
procedure (Smith & Iadarola, 2015) which can be
used to instruct parents how to implement a vari-
ety of procedures (e.g., BST, DTT) to teach a
wide assortment of skills (e.g., language, social,
self- help). Although there are several areas that
should be evaluated by future researchers and
explored by clinicians, there is a breadth of evi-
dence supporting parent training as part of a com-
prehensive treatment program. Providing parent
training can result in better outcomes for indi-
viduals diagnosed with ASD and an improved
quality of life for parents, children, and all mem-
bers of the family unit.
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