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Vol.: (0123456789)
Educ. Treat. Child.
https://doi.org/10.1007/s43494-023-00092-y
REVIEW
Early Intervention Caregiver Training forChildren
withAutism: aQuality Review
EricN.Shannon · SungwooKang·
AmedeeMarchandMartella·
CharissaD.Richards· RonaldC.Martella
Accepted: 6 April 2023
© Association for Behavior Analysis International 2023, corrected publication 2023
Abstract Caregiver-mediated interventions have
been used to address social communication and chal-
lenging behavior in young children with autism spec-
trum disorder (ASD), and caregiver adherence to pro-
grams has predicted child outcomes (Strauss et al.,
2012). Recent reviews have summarized the literature
on caregiver training interventions based on the prin-
ciples of behavior analysis, but none have assessed
the quality of intervention studies. This review evalu-
ated 35 studies (22 single-case and 13 group design
studies) published between 1991 and 2021 using
descriptive analysis and the Council for Exceptional
Children (CEC) quality indicators. Only seven of the
studies reviewed met all quality indicators, as most
studies did not meet standards regarding the reporting
of internal validity or outcome measures and depend-
ent variables. Nearly all studies within the review
reported positive outcomes for caregivers or children
following intervention, but these results are question-
able given the limitations in meeting and reporting
quality indicators. Future studies should ensure that
the prescribed indicators are met when developing,
conducting, and reporting research to increase confi-
dence in their results.
Keywords Caregiver training· Early intervention·
Social communication· Quality indicators
The rate of autism spectrum disorder (ASD) diagno-
ses continues to rise in the United States; the Centers
for Disease Control and Prevention now estimate that
1 in 36 children born will be diagnosed with ASD
(Maenner etal., 2023). Individuals with ASD experi-
ence deficits in social-emotional reciprocity, nonver-
bal communication, developing and understanding
relationships, and restricted and repetitive patterns
of behavior (First, 2022). Aggression, tantrums, and
self-injurious behaviors are also prevalent among
those children with ASD who require significant sup-
ports (Jang et al., 2011; Richards et al., 2016). The
presence of restrictive and repetitive behavior often
results in negative outcomes for both the individual
and their family, including fewer opportunities for
socialization and heightened anxiety during social
situations for the child, and increased parent stress
(Boyd etal., 2012; Joyce etal., 2017). Although chal-
lenging behaviors can create substantial difficulties
for individuals and their families, they can often be
reduced with evidence-based practices established
E.N.Shannon· S.Kang· C.D.Richards· R.C.Martella
Department ofEducational Studies, Purdue University,
WestLafayette, IN, USA
E.N.Shannon(*)
Department ofEducational Services, Purdue University,
100 N. University Street, WestLafayette, IN47907, USA
e-mail: shannoe@purdue.edu
A.MarchandMartella
Department ofPsychological & Brain Sciences, UC Santa
Barbara, SantaBarbara, CA, USA
Educ. Treat. Child.
Vol:. (1234567890)
on the principles of applied behavior analysis (ABA;
Anderson & Carr, 2021; Matson etal., 2012).
Many children with ASD experience delays in
receptive and expressive language, and up to half of
all children with ASD under the age of 6 years have
minimal or no verbal skills (Paul, 2007; Rose etal.,
2016). Receptive and expressive communication
deficits are observable as early as infancy in chil-
dren who later receive a diagnosis of ASD (Franchini
etal., 2018). A lack of expressive language skills is
directly correlated with a deficit in social communi-
cation skills, such as imitation and play (Pecukonis
et al., 2019). In addition, deficits in expressive and
receptive communication are directly correlated with
higher levels of aggression and self-injurious behav-
ior in individuals of all ages (Matson & Adams, 2014;
Matson et al., 2009). These findings coincide with
the assumption in ABA that challenging behavior is a
form of communication (Boonen etal., 2014; Cooper
etal., 2019). In fact, decades of research have shown
that interventions targeting communication effec-
tively increase language skills and decrease challeng-
ing behaviors in children with ASD, including tod-
dlers and preschoolers (Durand & Moskowitz, 2015).
Therefore, early intervention targeting communica-
tion and challenging behavior is critical for young
children with ASD and can have positive long-term
outcomes on social and play skills (Landa, 2007).
Well-established treatments based on the prin-
ciples of ABA have been used for decades, many
of which have been successfully taught to caregiver
implementers. For instance, communication inter-
ventions such as functional communication training
(FCT) and Enhanced Milieu Teaching (EMT) can be
embedded into the daily routines of young children
and their families (Hancock & Kaiser, 2002; Kaiser
& Roberts, 2013). Another naturalistic behavioral
intervention, JASPER (Joint Attention, Symbolic
Play, Engagement, and Regulation), is a play-based
program that focuses on improving the social skills
of young children with ASD in natural settings (Shire
etal., 2019). Comprehensive treatment packages such
as the Early Start Denver Model (ESDM) have shown
improvement in overall functioning and ASD sympto-
mology (Wang etal., 2021). Many of these interven-
tions have taken place in classroom and clinical set-
tings in which the child receives one-on-one support
from a service provider, although caregiver-mediated
interventions have been successful in natural home
environments as well (Dunlap et al., 2006; Mancil
& Boman, 2010). Due to the increasing prevalence
of ASD, there is a growing need for families to be
equipped to implement interventions for their chil-
dren with ASD. This need is heightened in families
that experience barriers to early intervention service
access, such as travel constraints, the need to work
during available appointment times, and increased
waitlists (Nevill etal., 2018). Because caregivers are
present in a large percentage of their child’s waking
life, teaching the use of evidence-based practices
(EBPs) across home settings is essential in the ethical
treatment of communication deficits and challenging
behavior associated with ASD.
Studies have shown that caregiver training is cost-
effective and can have positive outcomes for both
the individual with ASD and their family (Wainer &
Ingersoll, 2015). Caregiver training has been used as
an effective treatment for increasing communication
and reducing challenging behaviors, in particular self-
injurious behavior (Fodstad et al., 2018; Postorino
etal., 2017). Caregiver training has also been reported
to reduce the severity of autism symptomology
while increasing language comprehension and social
communication (Oono etal., 2013; Siller etal., 2013).
Furthermore, skills learned during caregiver-mediated
interventions have successfully generalized to other
contexts (Crockett et al., 2007; Gerow et al., 2018).
These results indicate that caregivers who receive
coaching may successfully provide their children with
supports and opportunities to respond appropriately
outside of sessions, thus increasing the likelihood of
positive child outcomes across additional contexts.
Caregiver training programs have been shown
to increase overall family well-being and have been
reported as both feasible and acceptable to caregivers,
while also being implemented with fidelity (Dabab-
nah & Parish, 2016; Jackson etal., 2016). When car-
egivers are involved in the implementation of inter-
ventions, they are more likely to be confident in their
parenting skills (Kurzrok et al., 2021). The extant
literature indicates that increasing caregiver responsi-
bilities to include implementation of EBPs does not
result in additional stress or mental health problems
for caregivers and, with the proper supports, may
decrease caregiver stress (Lichtlé etal., 2020). More-
over, an increase in caregiver fidelity has been corre-
lated with positive child performance at postinterven-
tion maintenance (Strauss etal., 2012). These results,
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and the opportunity to capture additional learning
opportunities in all environments, make caregiver-
mediated intervention an ideal fit for families across
many different backgrounds (Crais etal., 2006).
Recent reviews of caregiver training interventions
have indicated positive outcomes for children with
ASD and their families. For example, Suppo and
Floyd (2012) reviewed both single-case and group
studies with children with ASD and found consistent
positive outcomes for families. All 23 of the reviewed
studies showed some positive treatment outcomes for
either caregivers and/or children. Nevill etal. (2018)
measured the effect sizes of randomized control trials
(RCTs) and found positive effects in studies regard-
ing social skills, emotional regulation, and cogni-
tive behavior therapy. In the 19 studies analyzed,
Nevill et al. (2018) reported there was moderate
evidence that caregiver training programs decreased
ASD symptom severity and improved communica-
tion skills and inner behaviors (e.g., problem-solving
and remembering). Interventions showed a signifi-
cant treatment effect on socialization, but the quality
of those studies was very low. Although the review
examined caregiver training interventions in detail,
single-case studies were not included. Furthermore,
the quality of outcomes was assessed using GRADE-
quality ratings, a scale that assesses the overall qual-
ity of design, risk of bias, and overall evidence of
studies (Guyatt etal., 2011), but specific quality indi-
cators were not applied to studies within the review.
Finally, Gerow et al. (2018) reviewed 26 studies of
caregiver-implemented interventions, including group
and single case designs, but targeted only those stud-
ies that utilized functional communication training
(FCT). The review found clinically significant out-
comes for children with ASD, whereas caregivers
found the treatments to be socially valid. However,
the focus of the review was on child outcomes, in par-
ticular as they relate to FCT interventions, and most
studies reported little or no experimental analysis of
caregiver implementation data.
Although these reviews have advanced the litera-
ture on caregiver training interventions, none focused
on caregiver performance during caregiver-imple-
mented interventions for young children with ASD. In
addition, none of the aforementioned reviews applied
established quality indicators or criteria to categorize
the evidence base of the studies reviewed. In addition,
numerous caregiver-mediated intervention studies
have been published since their publication. The pur-
pose of this systematic literature review was to sum-
marize the current research on early intervention (up
to age 8) caregiver training interventions for families
of children with ASD. Therefore, this review sought
to answer the following research questions:
1. How successful are caregivers at implementing
early intervention caregiver training for children
with ASD?
2. What are the outcomes of caregiver training
interventions?
3. To what extent does the current research adhere
to the quality indicator standards outlined by the
Council for Exceptional Children (CEC; Cook
etal., 2015)?
Method
Search Procedures
Studies were identified through an electronic search
of Academic Search Complete, ERIC, and PsycINFO.
Databases were searched with the following Boolean
terms: (1) parent training OR parent-mediated OR
parent education OR parenting education OR car-
egiver training OR caregiver-mediated, (2) early
intervention OR early childhood OR preschool, and
(3) autism OR ASD OR autism spectrum disorder.
Only articles in English from peer-reviewed journals
were considered. The original search, conducted in
October 2020, resulted in 558 unique studies to con-
sider for inclusion. An updated search in May 2021
resulted in an additional 32 unique studies.
Inclusion and Exclusion Criteria
Potential studies were reviewed to identify if they met
three inclusion criteria. First, participants needed to
be caregivers of children with or at risk for autism
who were 8 years old or younger. Caregivers were
defined as parents, legal guardians, or other heads of
household directly responsible for childrearing or par-
enting. Studies including child participants older than
8 years old or diagnosed with disabilities other than
ASD were included if the results were separated for
the target population or if the target population con-
sisted of at least 95% of participants, consistent with
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the inclusion criteria of previous caregiver training
reviews (Oono etal., 2013). Second, the study needed
to include a dependent variable (DV) of caregiver
fidelity or task performance, and an independent vari-
able (IV) of a caregiver training intervention based on
behavior analytic principles. The caregiver interven-
tions needed to target decreasing challenging behav-
ior or severity of autism characteristics or increasing
communication, social, emotional, or adaptive skills
in the child. Because the primary focus of the present
review was to examine the performance and outcomes
of caregivers during caregiver-implemented interven-
tions, reporting of child outcomes was not required
for inclusion. However, nearly all included studies
reported at least one DV related to child outcomes.
Third, the research design of the study needed to be
experimental or quasi-experimental. Both single-case
and group design studies were included. Interventions
needed to consist of ongoing individual or group sup-
port or coaching from professionals or researchers.
Therefore, interventions that only introduced asyn-
chronous training, such as an online program with no
live in-person or telehealth coaching, were excluded.
The first and fourth authors reviewed the titles and
abstracts of the 590 studies identified from the elec-
tronic searches to determine the sample of studies
that met the inclusion criteria. The web application
Rayyan (Ouzzani etal., 2016) was used to code stud-
ies for inclusion and exclusion, and excluded studies
were labeled with an exclusion reason (see Fig.1). Of
the 590 studies, 185 were excluded during this step
because they did not involve the target participants
(inclusion criterion 1), 199 were excluded due to the
target DV or IV (inclusion criterion 2), and 29 were
excluded because they did not utilize an acceptable
experimental design (inclusion criteria 3). In total,
Fig. 1 PRISMA Flow Dia-
gram. Note. This diagram
indicates the number of
articles identified through
electronic searches of the
literature and ancestral
search, screened for inclu-
sion criteria
Studies identified through
database searching
(n = 795)
ScreeningIncluded weiveRlartsecnA Identification
Studies screened viatitle and
abstractreview
(n =590)
Studies screened via full text
review (n = 172)
Records excluded (n =418)
-Not target participants (n =185)
-Not target DV or IV (n = 199)
-Non-experimental design (n =29)
-Not in English (n =5)
Included articles (n = 30)
Duplicates removed
(n =205)
Records excluded (n =142)
-Not target participants (n =21)
-Not target DV or IV (n = 90)
-Non-experimental design (n =31)
Unique articles via ancestral search of
included articles (n = 613)
Articles excluded viatitle and
abstract (n = 542)
-Not target participants (n =151)
-Not target DV or IV (n = 388)
-Non-experimental design (n =3)
-Not in English (n =5)
Articles excluded viafull article
review (n =66)
-Not target participants (n =25)
-Not target DV or IV (n = 32)
-Non-experimental design (n =9)
Additional articles included
(n = 5)
Included articles in the review
(n = 35)
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413 studies were excluded at this step. Five additional
studies were excluded because the full text was not in
English. Both authors read the full text of the remain-
ing 172 studies. After text review, 21 studies were
excluded for participant reasons (e.g., participants
identified as having developmental disabilities but not
specifically ASD; participants were older than 8 years
old), 90 were excluded because they did not meet the
defined DV or IV requirements (e.g., caregiver out-
comes were not reported; intervention was not based
on the principles of ABA), and 31 were excluded
because they did not meet the design requirements
(e.g., utilized pretest–posttest design with a single
group or AB design with one participant). In total,
142 studies were excluded after the full screening.
The remaining 30 studies met the inclusion criteria
for this review, including three studies that were iden-
tified via the second electronic search of the literature.
In addition, an ancestral search of the refer-
ence section of all included studies was conducted.
This search yielded an additional 613 unique peer-
reviewed studies that were assessed using the same
screening procedures. Of those studies, 542 were
excluded during a review of the titles and abstracts,
151 were excluded because they did not meet the
prespecified participant requirements, 388 were
excluded because the DV or IV requirements, and 3
were excluded because they did not meet the experi-
mental design requirements. A full review was con-
ducted on the remaining 71 studies, during which
25 were excluded based on participant requirements,
32 were excluded based on DV or IV requirements,
and 9 were excluded based on experimental design
requirements. In total, 66 studies were excluded dur-
ing this step, and 5 studies met the criteria for inclu-
sion in this review. In summary, across two electronic
searches and the ancestral search of the literature,
35 out of 1,203 unique studies were included in this
review.
To confirm studies were accurately included
or excluded, interrater agreement was calculated
between the two authors who examined all studies
at both the title and abstract review and full review
stages. The agreement level was 79.8%. Disagree-
ments were discussed by the two authors until a
consensus was reached. If consensus could not be
reached, disagreements were settled by consult-
ing a third author. During the screening of titles and
abstracts, disagreements typically centered around the
strictness of studies for exclusion/inclusion (i.e., one
reviewer excluded only studies that explicitly stated
exclusion criteria and more liberally included stud-
ies for full review, whereas the other was looking for
specific statements of inclusion and excluding more
studies due to inference). When reaching a consensus,
the authors agreed to more liberally include studies at
this stage to prevent unnecessary exclusion, although
only one of the studies that was disagreed upon at this
step was later included after full review. During full-
text review, disagreements often concerned whether
caregiver measures were directly related to imple-
mentation fidelity.
Coding Procedures
Studies in the review were evaluated using the qual-
ity indicator (QI) standards as outlined by the Coun-
cil for Exceptional Children (CEC, 2014) and Cook
etal. (2015) (Note: For a complete description of the
QI standards, visit: https://exceptionalchildren.org/
sites/default/files/2021-04/EBP_FINAL.pdf.) The
CEC standards for evidence-based practices consist
of 28 subindicators across eight QI domains: Con-
text and setting (one subindicator), participants (two
subindicators), intervention agents (two subindi-
cators), description of practice (two subindicators),
implementation fidelity (three subindicators), inter-
nal validity (nine subindicators), outcome measures/
dependent variables (six subindicators), and data
analysis (three subindicators). Six of the subindica-
tors were applied to only group design studies, and
four were applied to only single-case design studies.
Therefore, group designs were evaluated using 24
quality subindicators and single-case designs were
evaluated using 22. Each subindicator was evaluated
as either met or not met. If all applicable subindica-
tors were met within a domain, the QI was considered
met. Coding procedures of the CEC standards are
below. Unless otherwise noted, subindicators were
used to evaluate both single-case and group designs.
Quality Indicator 1 (Q1): Context andSetting
To meet this indicator, studies needed to describe
the critical aspects of the context and setting
(CEC, 2014). For this review, studies met this QI
if they described the location (e.g., home, clinic)
and routine (e.g., play, mealtime) in which the
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caregiver-implemented intervention took place (QI
1.1).
Quality Indicator 2 (Q2): Participants
To meet this indicator, studies needed to describe the
relevant participant characteristics and the disability
or risk status of participants (CEC, 2014). For this
review, studies met QI 2.1 if they reported the rela-
tionship of the caregiver to the child and the age of
the child. QI 2.2 was met if studies indicated how an
ASD diagnosis was determined for child participants.
Quality Indicator 3 (Q3): Intervention Agent
To meet this indicator, studies needed to describe
the role and training of the intervention agent who
directly implemented the program for the child (CEC,
2014). Studies only needed to state that caregivers
were the direct intervention agent to meet QI 3.1. If
caregivers merely observed researchers modeling
strategies with their child, or if caregiver performance
was not assessed, this subindicator was not met. For
QI 3.2, studies needed to specify the necessary train-
ing required for intervention agents to implement the
program. The interventions within this review were
two-tiered in nature, because researchers trained car-
egivers and then caregivers implemented the inter-
vention with child participants. Therefore, inter-
vention agent training occurred as the independent
variable for all studies within this review and needed
to be described in such a way that training could be
reasonably replicated. Studies met QI 3.2 if they
described the researcher-to-caregiver training pro-
cess with sufficient detail, including but not limited
to the amount and duration of lessons, coaching steps
taken by researchers, training materials provided to
adult participants, and caregiver progress monitoring
and demonstration of competence. Studies that used
well-established caregiver training programs, such
as the Early Start Denver Model or Project ImPACT,
met this subindicator if they provided citations to the
original source material.
Quality Indicator 4 (Q4): Description ofPractices
To meet this indicator, studies needed to describe
the intervention practice and materials required with
enough detail that it could be reasonably replicated
(CEC, 2014). For the purpose of this review, this
indicator was applied to the practice that caregivers
implemented directly with child participants. Studies
met QI 4.1 if they described the active role caregiv-
ers played when interacting with their child as part
of the intervention in sufficient detail that it could be
reasonably replicated. Studies met this subindicator
by reporting the expected behaviors of the caregiver
in detail or by describing the fidelity steps used for
data collection QI 4.2 was met if studies described the
specific toys or materials required to implement the
intervention, if necessary.
Quality Indicator 5 (Q5): Implementation Fidelity
To meet this indicator, studies needed to verify how
the practice was implemented (CEC, 2014). QI 5.1
required studies to report implementation fidelity
using direct and reliable measures. In this review,
studies often met this by providing the fidelity check-
list used to assess caregiver performance. For QI 5.2,
studies needed to report the dosage in which imple-
mentation fidelity was assessed. Single-case studies
often met QI 5.2 by displaying graphs and reporting
on the duration of sessions. Group design studies also
needed to report the program dosage. Merely stat-
ing that caregivers were assessed prior to and after
intervention did not satisfy QI 5.2. For QI 5.3, studies
needed to report when, where, and for whom fidelity
was assessed across each intervention component.
Quality Indicator 6 (Q6): Internal Validity
To meet this indicator, studies needed to demonstrate
that the independent variable was controlled by the
researchers and any potential confounding variables
were controlled (CEC, 2014). For QI 6.1, studies
needed to demonstrate that researchers systematically
manipulated the independent variable. Studies met
QI 6.2 if they described the essential aspects of the
control group or baseline conditions with sufficient
detail. This subindicator was not met if the study
merely stated that the control condition was “busi-
ness as usual.” QI 6.3 was met if studies described
that there was no access to treatment in the base-
line phase or the control group. QI 6.4 only applied
to group designs and was met if studies randomly
assigned participants, matched participants between
the groups, or appropriately justified why participants
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could or should not be randomly assigned. QIs 6.5
through 6.7 were only applied to single-case designs.
QI 6.5 was met if there were at least three demonstra-
tions of effect at three different times. QI 6.6 was met
if there were at least five data points in all baseline
phases (with some exceptions, such as the presence
of dangerous behavior). QI 6.7 was met if appropri-
ately designed single-case studies (e.g., withdrawal,
multiple-baseline) were implemented that control for
threats to internal validity . QIs 6.8 and 6.9 were only
applied to group designs. Studies met QI 6.8 when
overall attrition was below 30%; QI 6.9 was met when
the differential attrition between groups was less than
10%.
Quality Indicator 7 (Q7): Outcome Measures/
Dependent Variables
To meet this indicator, studies needed to describe the
dependent variables and outcomes to determine the
reliability of the effects of the treatment (CEC, 2014).
QI 7.1 was met if studies reported social validity, or
the treatment appeared to have meaningful effects on
participants’ quality of life, defined for this review as
those related to core diagnostic deficits of ASD. Stud-
ies met QI 7.2 if they clearly described the measure-
ment of all relevant dependent variables, including
outcomes related to caregiver implementation fidelity.
QI 7.3 was met if studies reported the effects of all
relevant measures, with graphs for single-case studies
and p levels and effect sizes for group designs. Stud-
ies met QI 7.4 if the timing of measures was appro-
priate, such as at least three data points in each phase
for single-case studies and suitable timing of pretest
and posttest measures for group designs. QI 7.5 was
met if studies reported high levels of agreement/inter-
nal reliability, either with interobserver agreement (≥
80%), kappa (≥ .60), or score reliability coefficient
(≥ .80). QI 7.6, which only applied to group designs,
was met if studies reported sufficient evidence that
their measures were valid, such as via content validity
or citing previous research.
Quality Indicator 8 (Q8): Data Analysis
To meet this indicator, studies needed to describe how
the data analysis was conducted (CEC, 2014). QI 8.1,
which only applies to group designs, was met if the
data analysis for comparing two groups is commonly
accepted within the field (e.g., statistical tests such
as a t-test, ANOVA, ANCOVA) and appropriate for
testing the hypothesis/hypotheses (i.e., appropriate
comparisons were made). Studies met QI 8.2, which
only applies to single-case studies, by providing a
clear graph in which visual analysis was possible
to determine treatment effects. Studies met QI 8.3,
which only applies to group designs, if an effect
size statistic was reported for all relevant outcomes,
including outcomes that were not statistically
significant.
Descriptive Coding
Each included study was coded for descriptive char-
acteristics by the first and second authors (Table1).
Extracted information included: child participant
demographics, caregiver participant demographics,
setting, child dependent variables and measures, car-
egiver dependent variables and measures, and results.
Coded information was aggregated, and discrepancies
were discussed until a consensus was met.
Interrater Agreement
Each included study was coded using the CEC QI
standards by the first and second authors. Reviewers
were two special education doctoral students who
had previously reviewed QI standards in a doctoral
course. The reviewers examined Cook et al. (2015)
and met to discuss coding procedures relevant to this
review prior to collecting data. Interrater agreement
was determined via point-by-point agreement on each
subindicator. Agreement percentage was calculated
by dividing the number of agreements by the number
of agreements plus disagreements and multiplying
by 100. One single-case study and one group design
study were chosen from the review for training
purposes, and independent coding occurred after
the reviewers reached at least 80% agreement. After
training, interrater agreement for subindicator coding
averaged 84% (range: 58%–100%). Discrepancies
between coding were discussed until a consensus was
reached. On occasion, disagreements were settled
after consulting with the fifth author, a professor of
special education and behavior analysis with more
than 30 years of experience conducting research.
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Table 1 Descriptive Coding of Included Articles
Study Participants (Caregiver,
Child)
Program/ IV and Set-
ting
DVs (Caregiver, Child) Dosage Results (Caregiver,
Child)
Generalization/ Mainte-
nance
Bradshaw etal. (2017) 3 parents; 1 Eastern
European, 2 white
Children: 3 white
males; 21, 15, 17 MO
Pivotal Response
Treatment in home
and clinic
Frequency of PRT
strategy use
Joint attention, recep-
tive and expressive
language
1-hr sessions for up to
12 weeks
Immediate positive
gains with variable
data in all caregivers
Immediate positive
gains, with some
variability
Nearly all measures
decreased but remained
higher than baseline at
1-month follow-up
Brian etal. (2017) Intervention group
(30): 2 fathers, 2
grandmothers, 26
mothers
Children: 4 females,
26 males; 3 Asian, 3
multiracial, 24 white;
avg. 25.33 MO
Control group (32): not
provided
Children: 11 females,
21 males; 4 Asian, 2
Black, 2 Mixed, 24
white; avg. 25.19 MO
Social ABCs in home
and community
Interval recording
of 10 PRT-related
techniques
Rate of receptive and
expressive commu-
nication, and interval
recording of social
orienting; diagnostic
assessments
11 1.5-hr sessions and
two booster sessions
over 12 weeks
Fidelity of implemen-
tation significantly
greater in treatment
group (R2 = .71, P
<.001), with a large
effect size (ƒ2 = 2.45)
Receptive and expres-
sive communication
and social orienting
significantly greater
in treatment group,
but no significant dif-
ferences in diagnostic
measures
Parent fidelity and
child communication
significantly greater at
12-week follow up in
treatment group
Brown & Woods
(2015)
3 mothers
Children: 3 males; 1
Black, 1 Latinx, 1
white; 28, 23, 26 MO
KidTalk-TaCTICS
Project in home and
clinic
Frequency of commu-
nication intervention
strategies
Frequency of expres-
sive communication
acts
24 weekly sessions for
60–75 min long
Clear positive increase
in two strategies and
minimal change in
two strategies
Some increases in child
communication with
high variability and
overlap
Parent and child
data maintained or
increased at 1 and 3
months
Carter etal. (2011) 62 total dyads: caregiv-
ers not provided
Children: 11 females,
51 males; 6% Ameri-
can Indian/Mixed,
5% Asian, 4% Black;
39% Latinx 47%
white; avg. 21.30 MO
Hanan’s ‘More Than
Words’ in home
Interval recording of
non-verbal and verbal
responsivity to child
during play routines
Weighted frequency of
expressive communi-
cation and diagnostic
assessments
8 group sessions and 3
in-home sessions
Nonsignificant differ-
ences in caregiver
responsivity and child
outcomes between
treatment and control
groups
No main effects 5
months after treatment
Educ. Treat. Child.
Vol.: (0123456789)
Table 1 (continued)
Erturk etal. (2021) 2 mothers; 1 Asian, 1
white
Children: 2 males; 50
and 52 MO; 1 Asian,
1 multiracial
Targeted training of
early communication
skills in home
Fidelity of targeted
social communication
facilitation strategies;
percent of steps cor-
rectly implemented
Mands, imitation,
and joint attention;
percent of opportuni-
ties with appropriate
response
17–26 sessions of
10–45 min long
Mastery criteria
reached after 3 ses-
sions for all behaviors
with no overlap
Increase in total and
independent response
rate with minimal
overlap
Results were similar to
intervention dur-
ing generalization
toy probes. Results
decreased slightly
during maintenance
sessions conducted
after mastery criteria
was reached
Gevarter etal (2021) 2 fathers, 1 mother; all
Latinx; avg. 25 YO
Children: 3 Latinx
males; 35, 13, 23 MO
Naturalistic develop-
mental behavioral
intervention targeting
communication in
home
Frequency of commu-
nication intervention
strategies
Frequency of target
communication
responses
1–1.5-hr initial train-
ing with subsequent
coaching sessions
Immediacy effect in
caregiver and child
outcomes with
minimal overlap,
increased variability,
and some decreasing
trends
Generalization probes
without the coach or
researcher present were
similar to treatment
outcomes
Grahame etal. (2015) Intervention group
(25): caregivers not
provided
Children: 1 female, 24
males; 3 other, 22
white; avg. 60.44 MO
Control group (20):
caregivers not pro-
vided
Children: 5 females,
15 males; 4 other, 16
white; avg. 62.75 MO
Managing Repetitive
Behaviors Pro-
gramme in home and
clinic
Frequency of target
and inappropriate
responses to child
restrictive and repeti-
tive behavior
ASD symptomology
(CGI-I); restricted
and repetitive behav-
iors (RRB; frequency/
duration of behavior
and parent report)
8 weekly 2-hr group
sessions with indi-
vidual support
Significant interaction
effects for interven-
tion group in 1 of 4
strategies
Significant difference
in CGI-I scores
across groups. Some
decrease in RRB
Minimal treatment
effects at maintenance,
8–14 weeks after inter-
vention
Guðmundsdóttir etal.
(2017)
Mother,
Child: 1 male; Mixed,
avg. 58 MO
Teaching DANCE in
home
Frequency of teaching
episodes presented
with target behavior
Frequency of social
attending during child
requests
53 hr over 10.5 months
(1-hr long sessions)
Increase in level of
strategy use, with
variable data and
overlap with baseline
Immediate increase
in level and trend of
prosocial behaviors
Treatment effects mostly
maintained during
follow-up sessions one
month after training
Educ. Treat. Child.
Vol:. (1234567890)
Table 1 (continued)
Gulsrud etal. (2016) Intervention group
(43): avg. 36.9 YO
Children: 8 females,
35 males; 4 Asian,
3 Latinx, 9 other, 27
white; avg 30.7 MO
Control group (43):
avg. 34.9 YO
Children: 8 females,
35 males; 6 Asian,
2 Black, 4 Latinx, 5
other, 26 White; avg
32.3 MO
JASPER in home Fidelity of JASPER
intervention; percent
of strategy use across
2-min intervals
Diagnostic assessments
Two 30-min sessions
per week for 10
weeks
Caregiver strategy
use significantly
increased across all
four intervention
domains
Effect sizes of child
outcomes not pro-
vided
N/A
Hampton etal. (2020) Caregivers (68 total): 8
fathers, 3 grandmoth-
ers, 57 mothers
Children: Interven-
tion group (34): 76%
male; 64% white; avg.
43 MO
Control group (34):
79% male, 52%
white; avg. 43 MO
JASP + EMT + SGD
in home and clinic
Fidelity of JASP +
EMT + SGD inter-
vention; frequency
and percent of
opportunities during
sessions
ESCS, PLS-5, and fre-
quency of utterances
during interactions
Two 40-60 min clinic
sessions and one
75–90 min home
session/week for 12
weeks
Significant increase in
4 of 5 caregiver strat-
egy use outcomes
Significant increase in
joint attention
Treatment effects
remained significant in
3 of 5 parent strategy
outcomes at 4-month
follow-up
Ingersoll & Berger
(2015)
Treatment group (14):
all mothers
Children: 3 females,
11 males; avg. 41.57
MO; 5 other, 9 white
Control group (13): 1
father, 12 mothers
Children: 5 females,
8 males; avg. 46.08
MO; 1 other, 12 white
Project ImPACT online
in home
Researcher rating of
caregiver implemen-
tation fidelity
N/A
16 hr of online lessons
(both groups) and
two 30-min sessions/
wk for 12 weeks
(treatment)
Pretreatment per-
formance, group
assignment, and
program comple-
tion significantly
predicted caregiver
fidelity; aggregated
fidelity data of groups
not provided
N/A
Ingersoll & Gergans
(2007)
3 mothers
Children: 1 female, 2
males; 31, 37, 42 MO
Reciprocal Imitation
Training in clinic
Rate and 30-s partial
interval recording of
RIT strategies
Rate of spontaneous
object and gesture
imitation
Two 30–40 min
sessions/wk for 10
weeks
Caregiver strategy
use increased with
varying results across
participants
Child imitation
increased but
remained highly
variable
Parent behavior mostly
maintained and child
behavior mostly
decreased at 1-month
follow-up session
Educ. Treat. Child.
Vol.: (0123456789)
Table 1 (continued)
Ingersoll & Wainer
(2013)
8 mothers
Children: 1 female,
7 males; 1 Black, 1
Latinx, 1 Mixed, 5
white; avg. 53.38 MO
Project ImPACT in
home and clinic
Researcher rating of
caregiver implemen-
tation fidelity
Rate of spontaneous
expressive communi-
cation
One or two 1-hr
sessions/wk for 12
weeks
Both caregiver fidel-
ity rating and child
communication use
increased over time,
with high levels of
overlap with baseline
Parent and child
behaviors maintained
at 4-week follow-up
session
Parent and child behav-
iors generalized during
home sessions
Kaiser etal. (2000) 6 mothers
Children: 6 males; avg.
41.83 MO
EMT in home and
clinic
Frequency and percent
of opportunities of
intervention strategy
use
Frequency of spontane-
ous and prompted
social- communica-
tion skills
Two 45-min sessions/
wk for 12 weeks
Minimal immediacy
effect with increasing
trends for caregivers
and children
Child and parent
behaviors maintained
at 6 monthly follow-up
sessions
Killmeyeret al. (2019) 1 aunt, 2 mothers, avg.
31 YO
Children: 3 males; 1
Asian, 2 Indian; 34,
32, 27 MO
Modified Project
ImPACT focusing on
contingent imitation
in home
Frequency of correctly
performed contingent
imitation and ques-
tions/directives
Frequency of spontane-
ous visual eye gaze
Three sessions/wk for
3 weeks
Immediate treatment
effects for both car-
egiver behaviors
Highly variable child
data with overlap,
with increasing levels
and trends
Treatment effects gener-
ally maintained for
children and parents
during play samples
2–3 weeks after treat-
ment
Lane etal. (2016) 2 mothers in their early
30s
Children: 2 males; 31
and 35 MO
Three naturalistic
teaching strategies in
clinic
Frequency of narration,
imitation, and envi-
ronmental arrange-
ment and responding
to child requests
Frequency of vocal
communication
responses and verbal
or nonverbal initia-
tions
One 1-hr session/wk
for 3 weeks
Increase in caregiver
behaviors, with
decreasing trends
upon introduction of
additional tiers
Increase in child
communication,
with variability and
decreasing trends
Two parent behaviors
maintained at mastery
criteria for one partici-
pant at 3-week follow-
up session
Law etal. (2018) 3 mothers
Children: 3 males; 1
Chinese, 1 Indian,
1 Malay; 52, 44, 30
MO
Map4speech in home
and community
Percent occurrence of
10 fidelity variables
during 2-min routines
Frequency of prompted
and unprompted
utterances and gesture
use
Avg of 24 feedback
sessions about 15
min long
Steady, increasing trend
of caregiver and child
behaviors
Parent strategy use gen-
eralized during novel
setting phase. Strategy
use maintained at three
1-month follow-up
sessions
Educ. Treat. Child.
Vol:. (1234567890)
Table 1 (continued)
Matthews etal. (2018) Treatment group (18):
3 fathers, 15 moth-
ers; avg 34.61 YO;
2 Asian, 1 Black, 1
Latinx, 14 white
Children: 18 males,
avg. 40.83 MO
Control group (18): 2
fathers, 16 mothers;
avg. 36.77 YO; 2
Asian, 4 Latinx, 12
white
Children: 1 female, 17
males; avg. 40.72 MO
JumpStart, based on
PRT in home and
clinic
Percent occurrence of
PRT fidelity strate-
gies during 10-min
routines
Percentage of verbal
responses to caregiver
communication
Two 2.5-hr sessions/wk
for 4 weeks
Caregiver and child
outcomes increased
significantly more in
treatment group
Parent outcomes
decreased but remained
higher than baseline,
while child outcomes
continued to increase
at 12-week follow-up
McDuffie etal. (2013) 8 mothers, avg. 34.25
YO
Children: 4 females, 4
males; avg. 43.75 MO
Naturalistic language
intervention targeting
verbal responsiveness
in home and clinic
Frequency of indirect
prompting and verbal
responses in 10-min
session; partial
interval recording of
follow-in comment-
ing
Frequency of verbal
and non-verbal com-
munication acts
Four 90-min in-person
sessions and 12
telehealth coaching
sessions
Caregiver behavior
increased marginally
Communication
increased for all chil-
dren (phase averages;
no graphs provided)
N/A
Meadan etal. (2016) 3 mothers; 1 Middle
Eastern, 2 white
Children: 1 female, 2
males; 4, 3, 2 YO
Naturalistic communi-
cation intervention in
home (telehealth)
Researcher-rated fidel-
ity score of interven-
tion techniques
Frequency of com-
munication ini-
tiations and percent
of responding to
caregiver communi-
cation
Two 30-min sessions/
wk for 3.5 months
Caregiver and child
behaviors increased,
with high variability
and overlap from
baseline
Parent strategy use
decreased but remained
above baseline levels at
maintenance
Moran & Whitman
(1991)
8 mothers; 25-42 YO
Children: 1 female, 7
males; avg. 5.3 YO
Targeted training of
social interaction
skills in home
Interval recording of
social communication
and behavior manage-
ment skills
Interval recording of
challenging behavior
and social communi-
cation skills
18 sessions 90 min
long
Caregiver outcomes
generally improved,
with little overlap
with baseline
Child outcomes gener-
ally improved, with
some overlap with
baseline
Results remained rela-
tively stable in three
to nine maintenance
probes
Educ. Treat. Child.
Vol.: (0123456789)
Table 1 (continued)
Raulston etal. (2020) 1 father, 2 mothers;
avg. 33 YO; 1 Black,
2 white
Children: 1 female,
2 males; avg. 63.33
MO; 1 Black, 2
White
Social skills interven-
tion during playdates
in home
Percentage of fidelity
techniques used
Frequency of verbal
or AAC mands and
responses to mands
5–6 sessions, 30–45
min long
Immediacy effect with
no overlap in car-
egiver outcomes
Child language
increased for all
participants
Two triads received
maintenance, with
parent performance at
near intervention levels
Rocha etal. (2007) 1 father, 2 mothers; 33,
38, 37 YO
Children: 1 female, 2
males; 42, 27, 26 MO
DTT and PRT to
teach joint attention
intervention in clinic
and home
Partial interval record-
ing of joint attention
bids
Partial interval record-
ing of responses to
joint attention bids
At least 51 20-min ses-
sions over 6 weeks
Caregiver and child
outcomes improved,
with some overlap
with baseline
Inconsistent outcomes
across participants
during generalization
probes at home
Rogers etal. (2012) Treatment group (49):
all mothers
Children: 12 females,
37 males; avg. 21
MO; 34 white
Control group (49): all
mothers
Children: 10 females,
39 males; avg. 21
MO; 37 White
P-ESDM in clinic Researcher rated Likert
fidelity score
Imitation and joint
attention probes
One 1-hr session/wk
for 12 weeks
Caregivers in treatment
improved nonsig-
nificantly more than
control group
Nonsignificant
improvement in imi-
tation with no effect
in joint attention
N/A
Rogers etal. (2019) P-ESDM group (24):
all mothers
Children: 8 females, 16
males; avg. 2.1 YO;
1 Asian, 3 Multicul-
tural, 8 no data, 12
white
P-ESDM with enhance-
ments group (21): all
mothers
Children: 6 females, 15
males; avg. 2.1 YO;
1 Asian, 3 Black, 4
multiracial, 7 no data,
8 white
P-ESDM and
P-ESDM++ in home
and clinic
Researcher rated Likert
fidelity scale
Diagnostic assessments
1.5-hr sessions for
12 weeks (1/wk for
P-ESDM, 2/wk for
P-ESDM++)
Caregivers in ESDM
group decreased strat-
egy use. ESDM++
group increased
strategy use, but
difference was not
significant
No significant effects in
child assessment
N/A
Educ. Treat. Child.
Vol:. (1234567890)
Table 1 (continued)
Stadnick etal. (2015) Treatment group (16):
all mothers; avg.
34.80 YO
Children: 81% males;
avg. 46.75 MO; 13%
Asian, 6% Black, 6%
Latinx, 44% multira-
cial, 31% white
Control group (14): all
mothers; avg. 36.50
YO
Children: 79% males;
avg. 64.07 MO; 14%
Latinx, 50% multira-
cial, 7% other, 29%
white
Project ImPACT in
clinic
Researcher rated Likert
fidelity score
Functioning on
Vineland-II
One 1-hr session/wk
for 12 weeks
Nonsignificant increase
of caregiver fidelity
in treatment group
compared to control
group
Child communication
scores significantly
higher in treatment
group
N/A
Stahmer etal. (2020) Treatment group (12):
all mothers; 3 Asian,
6 Latinx, 1 multira-
cial, 4 other, 4 white
Children: 1 female, 11
males; avg. 23.08 MO
Control group (13): all
mothers; 1 Filipino, 6
Latinx, 1 multiracial,
6 other, 7 White
Children: 7 females, 6
males; avg. 22.46 MO
Project ImPACT for
Toddlers in home and
clinic
Researcher rated Likert
fidelity score
Communication on
Vineland-II and
CSBS-ITC
One 2-hr session/wk
for 12 weeks
Significant increase of
some caregiver fidel-
ity domains in treat-
ment group compared
to control group
Nonsignificant increase
in child outcomes
Moderate to large effect
size of parent fidelity
for treatment group
at 3-month follow-up
compared to small
effect sizes for control
group
Vismara etal. (2009) 8 parents
Children: 8 children;
avg. 27.50 MO; 2
Latinx, 6 white
Early Start Denver
Model in clinic
Researcher rated Likert
fidelity score
Frequency of social
communication
behaviors and
researcher rated
engagement score
One 1-hr session/wk
for 12 weeks
Immediacy effects and
increasing trend in
caregiver fidelity,
with little overlap
Child behavior
increased in level and
trend, with variabil-
ity and overlap with
baseline
Child behavior remained
higher and more
variable than baseline
and parent behavior
maintained at 4 follow-
up sessions
Educ. Treat. Child.
Vol.: (0123456789)
Table 1 (continued)
Vismara etal. (2013) 1 father, 7 mothers
Children: 8 children;
avg 27.50 MO; 2
Latinx, 6 white
Early Start Denver
Model parent model
in home (telehealth)
Researcher rated Likert
fidelity score
Frequency of utter-
ances and nonverbal
joint attention; global
communication out-
comes via MacArthur
CDI
One 1.5-hr session/wk
for 12 weeks
Increase in level of
caregiver behavior,
with some overlap
and positive trends
in baseline for some
participants
Minimal effect in child
behavior
Scores remained high
and stabilized at three
3-month follow-up
sessions
Vismara etal. (2012) 2 fathers, 7 mothers; 1
Latinx, 8 white
Children: 1 female, 8
males; avg. 28.89 MO
Early Start Denver
Model in home (tel-
ehealth)
Researcher rated Likert
fidelity score
Frequency of utter-
ances and imitative
play actions; engage-
ment via CBRS
One 1-hr session/wk
for 12 weeks
Caregiver fidelity
increased, with
increasing trends
occurred during
baseline in 5 of 9
participants
Child imitation and
utterances increased
in level and trend
Child outcomes
decreased but remained
above baseline levels
and parent outcomes
remained above
mastery criteria during
3 follow-up sessions
every 2 weeks after
intervention
Waddington etal.
(2019)
All mothers
Children: 5 boys;
avg. 40.60 MO; 1
Cambodian, 1 Indian,
1 Maori, 2 New Zea-
land European
Early Start Denver
Model in home
Researcher rated Likert
fidelity score
Partial interval record-
ing of play and com-
munication outcomes
One 1-hr session/wk
for 12 weeks
Minimal effects with
consistent overlap for
4 of 5 caregivers; 1
caregiver with clear
increasing level and
trend
Limited and inconsist-
ent effects in child
behavior
Inconsistent child
outcomes and parent
fidelity increased over
baseline in 4 of 5
participants at 4-week
follow-up probe
Wainer & Ingersoll
(2015)
5 mothers
Children: 5 children;
avg. 42.20 MO; 2
Asian, 1 Latinx, 1
multiracial, 1 white
Reciprocal Imitation
Training in home
(telehealth)
Researcher rated Likert
fidelity score
Rate of spontaneous
imitation during
probes
Three 30-min sessions Immediate improve-
ment with little
overlap in caregiver
behavior
Minimal effects in child
behavior
Parent fidelity returned
to near-baseline levels
at 1 and 3 months
Educ. Treat. Child.
Vol:. (1234567890)
Table 1 (continued)
Wainer etal. (2021) Treatment group (10):
all female
Children: 2 females, 8
males; avg. 40 MO;
1 Asian, 4 Black, 4
Latinx, 1 multiracial
Control group (10): all
female
Children: 4 females, 6
males; avg. 35 MO; 4
Latinx, 1 multiracial,
5 white
Reciprocal Imitation
Training in home
Researcher rated Likert
fidelity score
Social communication
via Social Communi-
cation Checklist and
developmental level
via MSEL
Once/wk for 5 weeks Caregiver RIT fidelity
significantly higher in
treatment group
Child SCC score
significantly higher in
treatment group
N/A
Williams etal. (2020) Treatment group (29):
4 males, 25 females;
avg. 36.24 YO
Children: 8 females, 21
males; avg. 68.03 MO
Control group (29): 2
males, 27 females;
avg. 36.72 YO
Children: 9 females, 20
males; avg. 67.93 MO
Incredible Years
Autism Spectrum and
Language Delays in
home and clinic
Frequency of 7 parent-
ing practices during
10-min observations
Communication via
Social Communica-
tion Questionnaire
and CBCL
Two 1-hr session/wk
for 12 weeks
Caregiver outcomes
improved more than
control group in most
practices, but none
significantly
No significant effects
on child behaviors
N/A
Zaghlawan &Ostrosky
(2016)
1 father, 1 mother
Children: two boys; 37
and 60 MO
Modified Reciprocal
Imitation Training in
home
Partial interval record-
ing of contingent
imitation strategies
and percent of correct
episodes of object
and gestural imitation
strategy use
Partial interval record-
ing of object and
gestural imitation
skills
15–21 sessions Immediate positive
effect for caregiver
gestural imitation,
with limited and
inconsistent effects
on other outcomes
Minimal effects on
child behaviors
N/A
ASD autism spectrum disorder, CBCL Child Behavior Checklist, CBRS Child Behavior Rating Scale, CGI-I Clinical Global Impressions: Improvement scale, CSBS-ITC Com-
munication and Symbolic Behavior Scales-Infant Toddler Checklist, DTT discrete trial training, EMT enhanced milieu teaching, ESCS Early Social Communication Scales, ESDM
Early Start Denver Model, JASPER joint attention, symbolic play, engagement, and regulation; MacArthur CDI MacArthur Communicative Development Inventory, MO months
old, MSEL Mullen Scales of Early Learning, PLS-5 Preschool Language Scales, Fifth Edition, PRT Pivotal Response Treatment, SGD speech generating device, YO years old
Educ. Treat. Child.
Vol.: (0123456789)
Results
In line with the research questions, descriptive study
characteristics and an assessment of the quality indi-
cators of each study were analyzed. Table1 indicates
descriptive information about participants (child, car-
egiver), program/IV and setting, child DVs, caregiver
DVs, dosage, and results (child, caregiver). Of the 35
studies, the majority (n = 22) employed a single-case
study design, including multiple baseline (n = 15),
multiple probe (n = 1), nonconcurrent multiple base-
line (n = 3), nonconcurrent multiple probe (n = 2),
and quasi-experimental with a series of A–B replica-
tions (n = 1). The remaining were group design stud-
ies (n = 13), including randomized controlled trials
(n = 8), and pre–post quasi-experimental designs (n
= 5).
Descriptive Analysis
Participants andSetting
Across 35 studies, there were 761 child participants
diagnosed with or at-risk for ASD. The mean age of
the participants was 38.77 months (range = 15–108
months), and 76.6% were male (n = 583). Race/
ethnicity was reported for 89.5% of children (n =
681) and in 23 out of 35 studies, including Cauca-
sian/white (59.8% of reported; n = 407), Hispanic/
Latinx (10.3%, n = 70), Asian (6.5%, n = 44), mul-
ticultural/mixed (5.6%, n = 38), African American/
Black (2.6%, n = 18), and Other (15.3%, n = 104).
Most ethnicities were not specified, but a few stud-
ies stated Cambodian, Chinese, European, Filipino,
Indian, Malaysian, Maori, Middle Eastern, and Native
American participants. Most caregiver participants
were mothers (93.5% of reported, n = 477), but 13
studies included fathers (5.9%, n = 30), and three
studies recruited other family members (grandmother
or aunt) as participants (0.6%, n = 3). Caregiver age
was reported in only 15 studies, with an average age
of 34.89 years old (range = 24–45).
Home was the primary setting across 16 single-
case and four group studies. Some studies provided
a combination of both home and clinic settings,
such as training Discrete Trial Training (DTT) in
the clinic while implementing JASPER (Joint Atten-
tion, Symbolic Play, Engagement, and Regulation)
+ Enhanced Milieu Teaching (EMT) + Speech
Generating Devices (SGD) in home settings. One
study used video teleconferencing training at home
and monthly face-to-face training in the clinic. Fif-
teen single-case and 10 group design studies reported
in-person caregiver training, whereas four single-
case and two group design studies solely utilized tel-
ehealth caregiver training. Three single-case studies
implemented both in-person training and telehealth
training.
Independent andDependent Variables
Intervention packages were primarily used to train
caregivers to implement strategies regarding child
communication or behavior. Packages included: (1)
Pivotal Response Treatment (PRT; Koegel et al.,
1999); (2) Hanan’s More Than Words (HMTW;
Weitzman, 2013); (3) JASPER and/or EMT (Kai-
ser & Roberts, 2013; Shire et al., 2019); (4) Recip-
rocal Imitation Training (RIT; Ingersoll, 2010); (5)
Project ImPACT (Ingersoll & Dvortcsak, 2019); (6)
Early Start Denver Model (Wang et al., 2021); (7)
researcher-developed interventions for social com-
munication facilitation such as joint attention and
imitation; and (8) appropriate responses to child chal-
lenging behavior. Five studies reported that total car-
egiver training duration was less than 12 hrs, 18 stud-
ies reported training duration between 12 and 24 hrs,
five studies reported training duration of more than
24 hrs, and seven studies did not specify the number
of training hours.
The majority of studies (n = 29) targeted depend-
ent measures related to social communication skills.
Eleven studies focused on increasing early communi-
cation in social contexts, such as joint attention, man-
ding, and imitation. Nine studies targeted prompted
and spontaneous verbal responses during social inter-
actions, and one study measured the DV using the
Social Communication Questionnaire (SCQ; Beru-
ment et al., 1999). Eight studies targeted expressive
communication skills, and five studies measured the
DV using standardized language assessments such as
the Mullen Scales of Early Learning (MSEL; Mullen,
1995). Three studies applied operational definitions
of expressive communication that were individual-
ized for each participant. One study focused on the
child’s social communication behavior regarding
on-task behavior, and another targeted restricted and
repetitive behaviors.
Educ. Treat. Child.
Vol:. (1234567890)
Study Results
Study results indicated generally positive outcomes.
In single-case studies, caregiver training had a posi-
tive functional relation on caregiver outcomes in 8
studies (36.4%), a general positive effect but with-
out a clear functional relation in 13 studies (59.1%),
and no clear effect in 1 study (4.5%). For child out-
comes, there was a positive functional relation in 4
studies (18.2%), a general positive effect in 14 stud-
ies (63.6%), and no clear effect in 4 studies (18.2%).
In group studies, caregiver training had a statistically
significant positive effect on caregiver outcomes in
seven studies (53.8%) and a nonsignificant positive
effect in six (46.2%). For child outcomes, there was
a statistically significant positive effect in six studies
(54.5% of reported studies), a nonsignificant positive
effect in three studies (27.3%), no clear effect in two
studies (18.2%), and no child outcomes were reported
in two studies.
Data on maintenance or generalization were
reported in the majority of studies (74.3%, n = 26).
In single-case studies with maintenance sessions 2
weeks to 6 months after the completion of interven-
tion (81.8%, n = 18), caregiver outcomes maintained
at target levels in 12 studies (66.7% of reported stud-
ies), decreased but remained above baseline levels in
five studies (27.8%), and returned to baseline levels
in one study (5.6%). Two studies included generaliza-
tion probes, one with inconsistent results when probes
took place at home instead of the clinic, and the other
with similar results to intervention when generalized
toys were used to facilitate communication. Two sin-
gle-case studies did not assess maintenance or gener-
alization. In group studies, caregiver outcomes during
the maintenance phase had a significant positive treat-
ment effect in two studies, a nonsignificant positive
treatment effect in two studies, and no clear effect in
two studies. Seven group studies did not assess main-
tenance or generalization.
Quality Indicator Evaluation
The results of the CEC quality indicator evaluation
are summarized for single-case and group studies
in Table2. For a study to be classified as methodo-
logically sound, all eight QIs must have been met.
To meet a QI, studies needed to meet each of the
corresponding subindicators. The total number of
subindicators varies by design, with single-case stud-
ies evaluated on 22 subindicators and group studies
evaluated on 24 subindicators. Four of the 22 (18.2%)
single-case studies (i.e., Erturk etal., 2021; Ingersoll
& Gergans, 2007; Law etal., 2018; and Rocha etal.,
2007) and 3 of the 13 (23.1%) group studies (i.e.,
Brian etal., 2017; Stadnick etal., 2015; and Stahmer
etal., 2020) met all eight QIs. Thus, 7 of the 35 stud-
ies (20.0%) met all eight QIs.
QI 1: Context andSetting
All 22 of the single-case studies provided sufficient
detail to meet the lone subindicator for QI 1. Twelve
of the 13 (92.3%) group studies met QI 1. Gulsrud
etal. (2016) did not indicate where training sessions
took place. Overall, 34 of the 35 (97.1%) studies met
QI 1 by adequately describing the context and setting.
QI 2: Participants
Twenty of the 22 (90.9%) single-case studies met QI
2. Bradshaw etal. (2017) did not meet QI 2.1 because
it was unclear who the caretakers were that performed
the intervention; Moran and Whitman (1991) did
not meet QI 2.2 due to a lack of information about
how the children were diagnosed. Twelve of the 13
(92.3%) group studies met QI 2. Carter etal. (2011)
did not meet QI 2.1 because child information was
aggregated instead of separated by group. Therefore,
of the 35 total studies, 32 (91.4%) provided sufficient
detail of the child participants and their caretakers to
meet QI 2.
QI 3: Intervention Agent
All 22 single-case studies met QI 3. Twelve of the
13 (92.3%) group studies met QI 3. Grahame et al.
(2015) did not meet QI 3.2 because individualized
training of caregivers involved “good practices,”
but it was unclear what practices were necessary to
implement the intervention. For the 35 total studies,
34 (97.1%) met QI 3 by describing the intervention
agent in sufficient detail.
QI 4: Description ofPractice
Twenty of the 22 (90.9%) single-case studies and
10 of 13 (76.9%) group studies met QI 4. Two
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Table 2 Quality Indicators of Single-Case and Group Design Parent Training Studies
Single-Case Designs
QI 1 QI 2 QI 3 QI 4 QI 5 QI 6 QI 7 QI 8
.1 .1 .2 .1 .2 .1 .2 .1 .2 .3 .1 .2 .3 .4 .5 .6 .7 .8 .9 .1 .2 .3 .4 .5 .6 .1 .2 .3
Bradshaw etal. (2017) Y N Y Y Y Y Y Y Y Y Y Y Y — Y N N — — Y Y Y N Y — — Y —
Brown & Woods (2015) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y N — — Y Y Y N Y — — Y —
*Erturk etal. (2020) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y Y — — Y Y Y Y Y — — Y —
Gevarter etal. (2021) Y Y Y Y Y N Y Y Y Y Y Y N — Y N N — — Y Y N N Y — — N —
Guðmundsdóttir etal. (2017) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y Y — — Y Y Y N Y — — Y —
*Ingersoll & Gergans (2007) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y Y — — Y Y Y Y Y — — Y —
Ingersoll & Wainer (2013) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y N Y — — Y Y Y N Y — — Y —
Kaiser etal. (2000) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y N — — Y Y Y N Y — — Y —
Killmeyer etal. (2019) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y N — — Y Y Y N Y — — Y —
Lane etal. (2016) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y N Y — — Y Y Y Y Y — — Y —
*Law etal. (2018) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y Y — — Y Y Y Y Y — — Y —
McDuffie etal. (2013) Y Y Y Y Y Y Y Y N Y Y Y N — Y N Y — — Y Y N Y Y — — N —
Meadan etal. (2016) Y Y Y Y Y Y Y N Y Y Y N N — Y N Y — — Y N Y Y Y — — Y —
Moran & Whitman (1991) Y Y N Y Y N Y Y Y Y Y Y Y — Y N Y — — Y Y N Y Y — — N —
Raulston etal. (2020) Y Y Y Y Y Y Y Y Y Y Y Y N — Y N N — — Y Y Y N Y — — Y —
*Rocha etal. (2007) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y Y — — Y Y Y Y Y — — Y —
Vismara etal. (2009) Y Y Y Y Y Y Y N Y Y Y Y Y — Y N N — — Y N Y Y Y — — N —
Vismara etal. (2013) Y Y Y Y Y Y Y Y Y Y Y Y Y — N Y N — — Y Y Y Y Y — — Y —
Vismara etal. (2012) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y N — — Y Y Y N Y — — N —
Waddington etal. (2019) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y N — — Y Y Y N N — — Y —
Wainer & Ingersoll (2015) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y N N — — Y Y Y N Y — — Y —
Zaghlawan &Ostrosky (2016) Y Y Y Y Y Y Y Y Y Y Y Y Y — Y Y Y — — Y Y Y Y N — — Y —
% of studies that met QI 100 90.9 100 90.9 86.4 27.3 27.3 77.3
Group Designs
QI 1 QI 2 QI 3 QI 4 QI 5 QI 6 QI 7 QI 8
.1 .1 .2 .1 .2 .1 .2 .1 .2 .3 .1 .2 .3 .4 .5 .6 .7 .8 .9 .1 .2 .3 .4 .5 .6 .1 .2 .3
*Brian etal. (2017) Y Y Y Y Y Y Y Y Y Y Y Y Y Y — — — Y Y Y Y Y Y Y Y Y — Y
Carter etal. (2011) Y N Y Y Y N N Y Y Y Y N Y Y — — — Y Y Y Y Y Y Y N Y — Y
Grahame etal. (2015) Y Y Y Y N N Y Y Y Y Y Y Y Y — — — Y Y Y Y N Y Y N Y — N
Gulsrud etal. (2016) N Y Y Y Y Y Y Y Y Y Y Y Y Y — — — Y Y Y Y N Y Y Y Y — N
Hampton etal. (2020) Y Y Y Y Y Y Y Y Y Y Y Y Y Y — — — Y Y Y Y N Y Y Y Y — N
Ingersoll & Berger (2015) Y Y Y Y Y Y Y Y Y Y Y Y N Y — — — Y Y Y Y N Y N N Y — N
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single-case studies (i.e., Gevarter etal., 2021; Moran
& Williams, 1991) and three group studies (Carter
et al., 2011; Grahame et al., 2015; Wainer et al.,
2021) did not meet QI 4.1 because essential details to
replicate the coaching process were missing. In addi-
tion, one group study (i.e., Carter etal., 2011) did not
meet QI 4.2 because information was not provided on
materials that were essential to the implementation of
the intervention and measurement of the dependent
variable. Overall, 30 of the 35 (85.7%) studies ade-
quately explained the description of practices to meet
QI 4.
QI 5: Implementation Fidelity
Nineteen of the 22 (86.4%) single-case studies met
QI 5. Two studies (i.e., Meadan etal., 2016; Vismara
et al., 2009) did not meet QI 5.1 because the crite-
ria of scoring on a researcher-assessed Likert-style
rating system was unclear. McDuffie et al. (2013)
did not meet QI 5.2 because the length of telehealth
coaching sessions was not reported. Twelve of the 13
(92.3%) group studies met QI 5. One study (i.e., Rog-
ers et al., 2012) did not meet QI 5.1 because it uti-
lized an unpublished, researcher-assessed Likert-style
rating scale with unclear scoring protocols. Thus, 31
of the 35 (88.6%) studies provided sufficient detail on
the measurement of caregiver implementation fidelity
to meet QI 5.
QI 6: Internal Validity
Six of the 22 single-case studies (27.3%) met QI 6.
All single-case studies in the review met QI 6.1 and
21 studies met QI 6.2. Meadan etal. (2016) did not
meet QI 6.2 because baseline conditions were not
adequately described. Eighteen single-case (81.8%)
studies met QI 6.3. Of the four studies that did not
meet QI 6.3, two (i.e., Gevarter etal., 2021; McDuffie
et al., 2013) introduced an aspect of the caregiver
training intervention during baseline sessions. In
addition, insufficient baseline information made it
difficult to determine if participants had access to
treatment in Meadan etal. (2016), and Raulston etal.
(2020) appeared to prompt the use of intervention
strategies when providing instructions to participants
during baseline.
QI 6.5, 6.6, and 6.7 only apply to single-case
studies. Of these subindicators, 21 of the 22
Table 2 (continued)
Matthews etal. (2018) Y Y Y Y Y Y Y Y Y Y Y Y Y Y — — — Y Y Y Y Y Y Y N Y — Y
Rogers etal. (2012) Y Y Y Y Y Y Y N Y Y Y N N Y — — — N N N Y Y Y N Y Y — Y
Rogers etal. (2019) Y Y Y Y Y Y Y Y Y Y Y Y N Y — — — Y N Y Y Y Y N Y Y — Y
*Stadnick etal. (2015) Y Y Y Y Y Y Y Y Y Y Y Y Y Y — — — Y Y Y Y Y Y Y Y Y — Y
*Stahmer etal. (2020) Y Y Y Y Y Y Y Y Y Y Y Y Y Y — — — Y Y Y Y Y Y Y Y Y — Y
Wainer etal. (2021) Y Y Y Y Y N Y Y Y Y Y Y Y Y — — — Y Y Y Y N Y N Y Y — Y
Williams etal. (2020) Y Y Y Y Y Y Y Y Y Y Y Y Y Y — — — Y Y Y Y Y N Y N Y — Y
% of studies that met QI 92.3 92.3 92.3 76.9 92.3 69.2 23.1 69.2
Total % of studies that met QI 97.1 91.4 97.1 85.7 88.6 42.9 25.7 74.3
Studies marked with an asterisk met all Council for Exceptional Children (CEC) quality indicators; Y = yes; N = no
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single-case studies met QI 6.5; the graph of one
nonconcurrent multiple-baseline study (i.e., Vis-
mara et al., 2013) made it difficult to determine
the timing of intervention introduction. QI 6.6 and
QI 6.7 were the weakest areas for the single-case
designs. Twelve single-case studies met QI 6.6. The
10 studies (i.e., Bradshaw et al., 2017; Gevarter
etal., 2021; Ingersoll & Wainer, 2013; Lane etal.,
2016; McDuffie et al., 2013; Meadan et al., 2016;
Moran & Whitman, 1991; Raulston et al., 2020;
Vismara et al., 2009; Wainer & Ingersoll, 2015)
that did not meet the requirements for QI 6.6 did
not have enough baseline sessions. Only 11 single-
case studies met QI 6.7. Of the 11 studies that did
not meet QI 6.7, were6 multiple-baseline studies
(i.e., Brown & Woods, 2015; Kaiser et al., 2000;
Killmeyer etal., 2019; Vismara et al., 2012; Wad-
dington et al., 2019; Wainer & Ingersoll, 2015)
where the intervention was not staggered suffi-
ciently, 1 (i.e., Vismara etal., 2013) had a noncon-
current multiple-baseline design, and 4 (i.e., Brad-
shaw et al., 2017; Gevarter et al., 2021; Raulston
etal., 2020; Vismara etal., 2009) did not stagger the
intervention appropriately and were nonconcurrent
For the group studies, 9 of the 13 (69.2%) met QI
6. As with the single-case studies, all group studies
met QI 6.1. Eleven studies met QI 6.2. Two stud-
ies (i.e., Carter etal., 2011; Rogers etal., 2012) did
not meet QI 6.2 because they only described the
control condition as “business as usual.” Ten group
studies (76.9%) met QI 6.3. Of the three studies that
did not meet QI 6.3, Ingersoll and Berger (2015)
and Rogers et al. (2019) introduced two versions
of interventions without a control group, and Rog-
ers etal. (2012) provided the control group twice as
many external therapy hours as the treatment group,
which may have affected treatment outcomes.
QI 6.4, 6.8, and 6.9 only apply to group studies.
Of these subindicators, all group studies met QI 6.4.
Twelve studies (92.3%) met QI 6.8, and 11 studies
(84.6%) met QI 6.9. One study (i.e., Rogers etal.,
2012) did not meet QIs 6.8 and 6.9 because attri-
tion data were not provided. Another study that did
not meet QI 6.9 (Rogers etal., 2019) experienced
a large differential attrition between groups. Of the
35 total studies, 15 (42.9%) met QI 6 by providing
adequate detail to determine that the independent
variable was under the control of the experimenter.
QI 7: Outcome Measures andDependent Variables
Six of the 22 single-case studies (27.3%) and 3 of the
13 group studies (23.1%) met all subindicators for QI
7. All single-case and 12 group studies met QI 7.1.
One group study (Rogers etal., 2012) did not demon-
strate positive outcomes nor report on an assessment
of social validity. Twenty of the single-case and all
group studies met QI 7.2. There was a lack of clear
descriptions of fidelity measures in two single-case
studies (Meadan et al., 2016; Vismara et al., 2009).
Nineteen single-case studies met QI 7.3. Three sin-
gle-case studies (Gevarter et al., 2021; McDuffie
etal., 2013; Moran & Whitman, 1991) did not graph
relevant dependent variables related to caregiver per-
formance. QI 7.3 was problematic for group designs
with only 8 of 13 studies meeting the expectation. Of
the five group studies that did not meet 7.3, one study
(Gulsrud etal., 2016) reported no effect sizes of car-
egiver outcomes, two studies (Grahame etal., 2015;
Hampton et al., 2020) reported effect sizes of only
some measures, and two studies (Ingersoll & Berger,
2015; Wainer et al., 2021) did not report all effect
sizes and some caregiver outcomes.
QI 7.4 was the most problematic subindicator for
single-case design studies. Eleven of the 22 single-
case studies met QI 7.4. Of the 11 single-case stud-
ies that did not meet QI 7.4, 1 study (Guðmundsdóttir
etal., 2017) had frequent and unjustified gaps during
the intervention phase, 1 study (Waddington et al.,
2019) was a nonconcurrent multiple-baseline design
in which the timing of the intervention was not jus-
tified, and 9 studies (Bradshaw etal., 2017; Brown
& Woods, 2015; Gevarter et al., 2021; Ingersoll &
Wainer, 2013; Kaiser et al., 2000; Killmeyer et al.,
2019; Raulston et al., 2020; Vismara et al., 2012;
Wainer & Ingersoll, 2015) did not properly stag-
ger intervention tiers. Twelve group studies met the
expectations for QI 7.4. One group study (Williams
etal., 2020) did not meet QI 7.4 because the posttest
assessment took place 2 months after the intervention
was completed.
Twenty single-case studies met the requirements
for QI 7.5. Two single-case studies (Waddington
etal., 2019; Zaghlawan etal., 2016) failed to achieve
at least an 80% interobserver agreement level or an
acceptable reliability coefficient. QI 7.5 was a weak-
ness for group studies. Nine of the 13 group studies
met the expectations for QI 7.5. Of the four group
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studies that did not meet 7.5, two (Ingersoll & Berger,
2015; Rogers etal., 2012) did not report interobserver
agreement measures, one (Rogers etal., 2019) only
assessed agreement in 10% of sessions and scored
fair interclass correlation agreement, and one (Wainer
et al., 2021) only assessed agreement of caregiver
fidelity in 10% of sessions.
QI 7.6 is only applied to group studies and was
also a weakness of the studies reviewed. Eight of the
13 group studies met this subindicator. For the five
studies that did not meet QI 7.6 (Carter etal., 2011;
Grahame et al., 2015; Ingersoll & Berger, 2015;
Matthews etal., 2018; Williams et al., 2020), it was
unclear if the research team developed the measure,
and no validity of the measure was reported. Overall,
9 of the 35 total studies (25.7%) adequately described
the outcome measures and dependent variables.
QI 8: Data Analysis
Seventeen of the 22 single-case studies (77.3%) met
QI 8 (Note: QI 8.2 is the only subindicator applied
exclusively to single-case studies). Of the five studies
that did not meet QI 8.2, three (Gervarter etal., 2021;
McDuffie etal., 2013; Vismara et al., 2012) did not
graph relevant caregiver outcomes, the graph of one
(Moran & Whitman, 1991) was too small to prop-
erly analyze, and one (Vismara et al., 2013) placed
all eight participants on the same axis, making it too
difficult to analyze data appropriately. Nine of the 13
(69.2%) group studies met QI 8 (Note: subindicators
QI 8.1 and QI 8.3 only apply to group studies). QI
8.1 was met by all studies. Of the four studies that did
not meet QI 8.3, two (Grahame etal., 2015; Gulsrud
et al., 2016) only reported the effect sizes of some
measures, one (Hampton et al., 2020) only reported
the effect sizes of statistically significant outcomes,
and one (Ingersoll & Berger, 2015) reported no effect
sizes. In all, 26 of the 35 studies (74.3%) conducted
data analysis appropriately and met QI 8.
Discussion
The present review sought to answer: (1) How suc-
cessful are caregivers at implementing early inter-
vention caregiver training for children with ASD?;
(2) What are the outcomes of caregiver training
interventions?; and (3) Does the current research
adhere to the quality indicator standards outlined by
the CEC and Cook etal. (2015)?. We identified 35
experimental studies that implemented caregiver-
mediated interventions for young children with
ASD. We summarized relevant study characteris-
tics and evaluated the quality of 22 single-case and
13 group studies using the CEC quality indicator
standards. Characteristics varied widely across stud-
ies, although most adult participants were mothers,
most child participants were male, and the majority
of reported descriptions of race and ethnicity were
white, consistent with previous reviews (e.g., Gerow
etal., 2018; Nevill etal., 2018). Treatment packages
primarily targeted caregiver behavior to encourage
appropriate social communication or reduce chal-
lenging behavior. Six studies used ESDM, four used
Project ImPACT, four used RIT, three used JASPER
and/or EMT, three used PRT, and one used HMTW.
In addition, 14 studies utilized researcher-developed
interventions that targeted social communication
caregiver behavior.
Regarding the first two research questions, results
indicated that caregiver-mediated interventions can
improve outcomes for both caregivers and their chil-
dren. Of the 22 single-case studies, caregiver out-
comes improved in 21 studies (95%), and child out-
comes improved in 18 studies (82%). Similar positive
outcomes were seen in the 13 group studies, with car-
egiver measures improving in all 13 studies (6 signifi-
cantly) and child measures improving in 9 studies (6
significantly).
Caregiver-mediated interventions based upon the
principles of behavior analysis have a long history of
use for families with a young child with ASD. Prior
reviews, such as Nevill etal. (2018), Suppo & Floyd
(2012), and Gerow etal. (2018), have reported that
these interventions can have positive outcomes on
both the child and the caregiver. However, previ-
ous reviews did not explore the general effects of
caregiver-mediated interventions across both single-
case and group design studies. The present review
indicates that caregivers may be ideal intervention
agents across a variety of programs or intervention
domains, and therefore caregivers should be trained
as intervention agents by both clinicians and research-
ers. Reflected in the results of the reviewed studies
were changes in caregiver behavior during interven-
tions that targeted specific skills such as communica-
tion, play, and managing challenging behavior. Many
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of these studies also reported positive outcomes in
maintenance and generalization phases.
However, regarding the third research question
examining the extent to which the reviewed stud-
ies met CEC quality indicators, few studies met all
the QIs. Therefore the results need to be interpreted
with caution. Only 7 of the 35 studies in this review
met all CEC quality indicators. Four of the 22 single-
case studies (Erturk et al., 2021; Ingersoll & Ger-
gens, 2007; Law etal., 2018; Rocha etal., 2007) and
3 of the 13 group studies (Brian et al., 2017; Stad-
nick etal., 2015; Stahmer et al., 2020) met all QIs.
It should be noted that over 90% of studies in this
review provided sufficient information regarding the
setting, child participants, and the caregiver interven-
tion agents (QIs 1–3). In addition, 85.7% of studies
provided sufficient information regarding the descrip-
tion of practice (QI 4), which is vital for studies to be
properly interpreted and replicated. Fidelity measures
(QI 5) were also appropriately described in 88.6%
of studies, although this is unsurprising given that
implementation fidelity is often a primary measure
when evaluating caregiver implementation. On the
other hand, there was a myriad of reasons studies did
not meet all QIs, some indicators were consistently
missed and, therefore, should become a greater focus
for researchers that conduct these interventions.
The remaining QIs were far more troublesome
for the studies in this review. Only 42.9% of stud-
ies appropriately addressed internal validity (QI
6), including just 27.3% of single-case and 69.2%
of group studies. Twelve of the 22 single-case stud-
ies (54.5%) had enough baseline sessions (QI 6.6),
whereas only 11 (50%) had designs that were strong
enough to reasonably rule out common threats to
internal validity (QI 6.7). It is essential that single-
case studies utilize proper research methods that
result in clear, stable baseline data so that functional
relations can be inferred (Ledford & Gast, 2018).
Although it may be appropriate for some studies to
have shorter baseline periods due to intense chal-
lenging behavior or other contextual conditions, sev-
eral studies in this review did not explain why so few
baseline sessions occurred or why interventions were
implemented after improving trends during baseline.
Some of these issues may be attributed to studies
being published prior to the release of the CEC QIs,
particularly those with insufficient baselines, numer-
ous multiple baseline studies failed to meet QI 6.7
due to concerns with implementation staggering. In
particular, intervention tiers were often introduced
before intervention effects were evident in previous
tiers, such as after a single intervention session with
a prior participant. In some situations, such as when
working with participants at-risk for dangerous chal-
lenging behaviors or those that are likely to withdraw
from the study during extended baseline phases, it
may be a socially valid decision in applied settings
to sacrifice internal validity due to “the constraints
placed on researchers” (Martella etal., 2013, p. 40).
However, this needs to be justified by researchers, and
failing to do so makes it appear that rigorous stand-
ards were not followed, when in fact, it could have
been a logical and reasonable research decision.
Neither single-case (27.3%) nor group studies
(23.1%) consistently reported sufficient information
on the outcome measures or dependent variables (QI
7). Eleven of the single-case studies (50%) ensured
that the frequency and timing of outcome measures
were appropriate (QI 7.4), an issue that primarily
derived from moving into the intervention phase too
quickly. For group studies, there were three primary
issues with QI 7. First, the levels and effect sizes were
provided for all caregiver outcomes (QI 7.3) in just
61.5% of studies. Although many intervention studies
focus primarily on child outcomes, it is also necessary
for researchers to provide effect size measures for all
caregiver outcomes. This analysis will allow the field
to determine the size of the training effects on the
intervention agents’ level of engagement with child
participants. Second, nine studies (69.2%) reported
adequate internal validity (QI 7.5), usually via inter-
observer agreement (IOA). It is well-established that
observer agreement should be reported in the field of
behavior analysis (Baer etal., 1968). Low rates or the
absence of IOA data in four studies brings into ques-
tion the accuracy of intervention results. Finally, evi-
dence of the validity of outcome measures (QI 7.6),
often reported as content, construct, or social valid-
ity of child outcomes, was provided in only 61.5% of
group studies. Several studies in this review failed to
meet this subindicator because the discrete behavior
being measured was not appropriately described or
necessary materials were not included in an appen-
dix. Although there may be an unwillingness by
researchers to give away their “trade secrets,” doing
so benefits the field two-fold. First, studies need to
adequately provide this information so the field can
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properly examine if the measures are appropriate,
replicate the procedures in future studies, and assess
their generalizability in applied settings. Second, and
more important, if the intervention is successful in
improving caregiver and child outcomes, the inter-
vention will have a greater impact on the field if that
information is spread freely.
There were limitations to the present review. First,
potential studies that could have contributed to the
study may have been omitted if they did not report
information on caregiver participants. In particular,
some studies implied that caregiver training occurred,
but because the focus was on child outcomes and not
the caregivers as intervention agents, we could not
definitively include the studies in this review. Like-
wise, studies that do not show a positive outcome are
less likely to be published, and there were no attempts
to identify such studies. Second, of the 35 studies in
this review, 11 were published prior to the release
of the CEC quality indicators in 2014, and another
5 were published within a year of their release.
Depending upon the timing of their submission, as
many as 16 studies may have been completed prior to
the release of the QIs. It is possible that these stud-
ies were more rigorously designed than indicated, but
this information was not reported. Third, the present
review used visual analysis to assess the effectiveness
of single-case studies, but a statistical analysis would
provide additional evidence. Future studies could
conduct a meta-analysis to determine the effect size of
caregiver training on both adult and child outcomes.
Fourth, interrater agreement for inclusion and exclu-
sion criteria was slightly below the acceptable range
of 80% agreement, because one author more liberally
included studies during the initial screening of titles
and abstracts. However, conducting interrater agree-
ment on 100% of studies during this step allowed
the research team to discuss all disagreements at an
early stage and ensured that the team accurately des-
ignated studies to be included and excluded. In addi-
tion, although the overall interrater agreement of QI
coding was above the acceptable level of 80%, agree-
ment for individual studies was as low as 58%. Cod-
ers met and came to a consensus on all disagreements
and recalibrated future coding based on those discus-
sions. However, future studies could improve reliabil-
ity by retraining on codes that consistently resulted in
disagreements.
Conclusions
The results of the present literature review are prom-
ising. Caregiver-mediated early intervention sup-
ports can result in positive outcomes for adults and
children. Providing families with additional treat-
ment options is critical to maximizing outcomes for
young children with ASD. However, our application
of the CEC quality indicators reveals that studies are
not successfully implementing and reporting research
procedures to the highest standards. Because of this,
it is difficult to have confidence in their results. Future
studies should continue to explore the effects of car-
egiver training interventions while adhering to the
quality standards accepted within the field. In par-
ticular, researchers should more consistently include
an appropriate number of baseline sessions for all
participants, report on both child and adult outcomes,
report IOA across all participants and phases, include
social validity measures, and provide full descriptions
of the measures used.
Compliance with Ethical Standards
Conflicts of Interest There are no potential conflicts of inter-
est or competing interests with any of the authors.
References
*Indicates articles included in the present review
Anderson, A., & Carr, M. (2021). Applied behaviour analysis
for autism: Evidence, issues, and implementation barriers.
Current Developmental Disorders Reports, 8(4), 191–200.
https:// doi. org/ 10. 1007/ s40474- 021- 00237-x
Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some cur-
rent dimensions of applied behavior analysis. Journal of
Applied Behavior Analysis, 1(1), 91–97. https:// doi. org/
10. 1901/ jaba. 1968.1- 91
Boonen, H., Maljaars, J., Lambrechts, G., Zink, I., Van Leeu-
wen, K., & Noens, I. (2014). Behavior problems among
school-aged children with autism spectrum disorder:
Associations with children’s communication difficulties
and parenting behaviors. Research in Autism Spectrum
Disorders, 8(6), 716–725. https:// doi. org/ 10. 1016/j. rasd.
2014. 03. 008
Boyd, B. A., McDonough, S. G., & Bodfish, J. W. (2012).
Evidence-based behavioral interventions for repetitive
behaviors in autism. Journal of Autism & Developmen-
tal Disorders, 42(6), 1236–1248. https:// doi. org/ 10. 1007/
s10803- 011- 1284-z
Educ. Treat. Child.
Vol.: (0123456789)
*Bradshaw, J., Koegel, L. K., & Koegel, R. L. (2017). Improv-
ing functional language and social motivation with a
parent-mediated intervention for toddlers with autism
spectrum disorder. Journal of Autism & Developmental
Disorders, 47(8), 2443–2458. https:// doi. org/ 10. 1007/
s10803- 017- 3155-8.
*Brian, J. A., Smith, I. M., Zwaigenbaum, L., & Bryson, S.
E. (2017). Cross-site randomized control trial of the
social ABCs caregiver-mediated intervention for toddlers
with autism spectrum disorder. Autism Research, 10(10),
1700–1711. https:// doi. org/ 10. 1002/ aur. 1818.
*Brown, J. A., & Woods, J. J. (2015). Effects of a triadic par-
ent-implemented home-based communication interven-
tion for toddlers. Journal of Early Intervention, 37(1),
44–68. https:// doi. org/ 10. 1177/ 10538 15115 589350.
*Carter, A. S., Messinger, D. S., Stone, W. L., Celimli, S., Nah-
mias, A. S., & Yoder, P. (2011). A randomized controlled
trial of Hanen’s “more than words” in toddlers with early
autism symptoms. Journal of Child Psychology & Psychi-
atry and Allied Disciplines, 52(7), 741–752. https:// doi.
org/ 10. 1111/j. 1469- 7610. 2011. 02395.x.
Cook, B. G., Buysse, V., Klingner, J., Landrum, T. J., McWil-
liam, R. A., Tankersley, M., & Test, D. W. (2015). CEC’s
standards for classifying the evidence base of practices in
special education. Remedial & Special Education, 36(4),
220–234. https:// doi. org/ 10. 1177/ 07419 32514 557271
Cooper, J. O., Heron, T. E., & Heward, W. L. (2019). Applied
behavior analysis (3rd ed.). Pearson Education.
Crais, E. R., Roy, V. P., & Free, K. (2006). Parents’ and profes-
sionals’ perceptions of the implementation of family-cen-
tered practices in child assessments. American Journal of
Speech-Language Pathology, 15(4), 365–377. https:// doi.
org/ 10. 1044/ 1058- 0360(2006/ 034)
Crockett, J. L., Fleming, R. K., Doepke, K. J., & Stevens, J. S.
(2007). Parent training: Acquisition and generalization of
discrete trials teaching skills with parents of children with
autism. Research in Developmental Disabilities, 28(1),
23–36. https:// doi. org/ 10. 1016/j. ridd. 2005. 10. 003
Council for Exceptional Children. (2014). Council for Excep-
tional Children: Standards for evidence-based practices in
special education. Teaching Exceptional Children, 80(4),
504–511. https:// doi. org/ 10. 1177/ 00144 02914 531388
Dababnah, S., & Parish, S. L. (2016). Feasibility of an empiri-
cally based program for parents of preschoolers with
autism spectrum disorder. Autism, 20(1), 85–95. https://
doi. org/ 10. 1177/ 13623 61314 568900
Dunlap, G., Ester, T., Langhans, S., & Fox, L. (2006). Func-
tional communication training with toddlers in home envi-
ronments. Journal of Early Intervention, 28, 81–96.
Durand, V. M., & Moskowitz, L. (2015). Functional communi-
cation training. Topics in Early Childhood Special Educa-
tion, 35(2), 116–126. https:// doi. org/ 10. 1177/ 02711 21415
569509
*Erturk, B., Hansen, S. G., Machalicek, W., & Kunze, M.
(2021). Parent-implemented early social communication
intervention for young children with autism spectrum dis-
order. Journal of Behavioral Education, 30(4), 641–663.
https:// doi. org/ 10. 1007/ s10864- 020- 09387-1.
First, M. B. (2022). Diagnostic and statistical manual of men-
tal disorders:DSM-5-TR (M. B. 1st ed.; 5th ed., text rev.).
American Psychiatric Association.
Fodstad, J. C., Kirsch, A., Faidley, M., & Bauer, N. (2018).
Demonstration of parent training to address early self-
injury in young children with intellectual and devel-
opmental delays. Journal of Autism & Developmental
Disorders, 48(11), 3846–3857. https:// doi. org/ 10. 1007/
s10803- 018- 3651-5
Franchini, M., Duku, E., Armstrong, V., Brian, J., Bryson, S.
E., Garon, N., Roberts, W., Roncadin, C., Zwaigenbaum,
L., & Smith, I. M. (2018). Variability in verbal and non-
verbal communication in infants at risk for autism spec-
trum disorder: Predictors and outcomes. Journal of
Autism & Developmental Disorders, 48(10), 3417–3431.
https:// doi. org/ 10. 1007/ s10803- 018- 3607-9
Gerow, S., Hagan-Burke, S., Rispoli, M., Gregori, E., Mason,
R., & Ninci, J. (2018). A systematic review of parent-
implemented functional communication training for chil-
dren with ASD. Behavior Modification, 42(3), 335–363.
https:// doi. org/ 10. 1177/ 01454 45517 740872
*Gevarter, C., Najar, A. M., Flake, J., Tapia-Alvidrez, F., &
Lucero, A. (2021). Naturalistic communication train-
ing for early intervention providers and Latinx parents of
children with signs of autism. Journal of Developmental
& Physical Disabilities, 34, 147–169. https:// doi. org/ 10.
1007/ s10882- 021- 09794-w.
*Grahame, V., Brett, D., Dixon, L., McConachie, H., Lowry,
J., Rodgers, J., Steen, N., & Le Couteur, A. (2015). Man-
aging repetitive behaviours in young children with autism
spectrum disorder (ASD): Pilot randomised controlled
trial of a new parent group intervention. Journal of Autism
& Developmental Disorders, 45(10), 3168–3182. https://
doi. org/ 10. 1007/ s10803- 015- 2474-x.
*Guðmundsdóttir, K., Sigurðardóttir, Z. G., & Ala’i-Rosales,
S. (2017). Evaluation of caregiver training via telecommu-
nication for rural Icelandic children with autism. Behavio-
ral Development Bulletin, 22(1), 215–229. https:// doi. org/
10. 1037/ bdb00 00040.
*Gulsrud, A. C., Hellemann, G., Shire, S., & Kasari, C. (2016).
Isolating active ingredients in a parent-mediated social
communication intervention for toddlers with autism
spectrum disorder. Journal of Child Psychology & Psy-
chiatry and Allied Disciplines, 57(5), 606–613. https://
doi. org/ 10. 1111/ jcpp. 12481.
Guyatt, G., Oxman, A. D., Akl, E. A., Kunz, R., Vist, G.,
Brozek, J., Norris, S., Falck-Ytter, Y., Glasziou, P.,
deBeer, H., Jaeschke, R., Rind, D., Meerpohl, J., Dahm,
P., & Schünemann, H. J. (2011). GRADE guidelines: 1.
Introduction—GRADE evidence profiles and summary of
findings tables. Journal of Clinical Epidemiology, 64(4),
383–394. https:// doi. org/ 10. 1016/j. jclin epi. 2010. 04. 026
*Hampton, L. H., Kaiser, A. P., & Fuller, E. A. (2020). Multi-
component communication intervention for children with
autism: A randomized controlled trial. Autism, 24(8),
2104–2116. https:// doi. org/ 10. 1177/ 13623 61320 934558.
Hancock, T. B., & Kaiser, A. P. (2002). The effects of trainer-
implemented enhanced milieu teaching on the social com-
munication of children with autism. Topics in Early Child-
hood Special Education, 22(1), 39–54. https:// doi. org/ 10.
1177/ 02711 21402 02200 104
Ingersoll, B. (2010). Brief report: Pilot randomized controlled
trial of reciprocal imitation training for teaching elic-
ited and spontaneous imitation to children with autism.
Educ. Treat. Child.
Vol:. (1234567890)
Journal of Autism & Developmental Disorders, 40(9),
1154–1160. https:// doi. org/ 10. 1007/ s10803- 010- 0966-2
*Ingersoll, B., & Berger, N. I. (2015). Parent engagement with
a telehealth-based parent-mediated intervention program
for children with autism spectrum disorders: Predictors
of program use and parent outcomes. Journal of Medical
Internet Research, 17(10), E227. https:// doi. org/ 10. 2196/
jmir. 4913.
*Ingersoll, B., & Gergans, S. (2007). The effect of a parent-
implemented imitation intervention on spontaneous imi-
tation skills in young children with autism. Research in
Developmental Disabilities, 28(2), 163–175. https:// doi.
org/ 10. 1016/j. ridd. 2006. 02. 004.
*Ingersoll, B., & Wainer, A. (2013). Initial efficacy of project
ImPACT: A parent-mediated social communication inter-
vention for young children with ASD. Journal of Autism
& Developmental Disorders, 43(12), 2943–2952. https://
doi. org/ 10. 1007/ s10803- 013- 1840-9.
Ingersoll, B., & Dvortcsak, A. (2019). Teaching social commu-
nication to children with autism and other developmental
delays (2-book set): The project ImPACT guide to coach-
ing parents and the project ImPACT manual for parents.
Guilford.
Jackson, A. C., Liang, R. P.-T., Frydenberg, E., Higgins, R. O.,
& Murphy, B. M. (2016). Parent education programmes
for special health care needs children: A systematic
review. Journal of Clinical Nursing, 25(11–12), 1528–
1547. https:// doi. org/ 10. 1111/ jocn. 13178
Jang, J., Dixon, D. R., Tarbox, J., & Granpeesheh, D. (2011).
Symptom severity and challenging behavior in children
with ASD. Research in Autism Spectrum Disorders, 5(3),
1028–1032. https:// doi. org/ 10. 1016/j. rasd. 2010. 11. 008
Joyce, C., Honey, E., Leekam, S. R., Barrett, S. L., & Rodg-
ers, J. (2017). Anxiety, intolerance of uncertainty and
restricted and repetitive behaviour: Insights directly from
young people with ASD. Journal of Autism & Develop-
mental Disorders, 47(12), 3789–3802. https:// doi. org/ 10.
1007/ s10803- 017- 3027-2
*Kaiser, A. P., Hancock, T. B., & Nietfeld, J. P. (2000). The
effects of parent-implemented enhanced milieu teaching
on the social communication of children who have autism.
Early Education & Development, 11(4), 423–446. https://
doi. org/ 10. 1207/ s1556 6935e ed1104_4.
Kaiser, A. P., & Roberts, M. Y. (2013). Parent-implemented
enhanced milieu teaching with preschool children who
have intellectual disabilities. Journal of Speech, Lan-
guage, & Hearing Research, 56(1), 295–309. https:// doi.
org/ 10. 1044/ 1092- 4388(2012/ 11- 0231)
*Killmeyer, S., Kaczmarek, L., Kostewicz, D., & Yelich, A.
(2019). Contingent imitation and young children at-risk
for autism spectrum disorder. Journal of Early Interven-
tion, 41(2), 141–158. https:// doi. org/ 10. 1177/ 10538 15118
819230.
Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C.
M. (1999). Pivotal response intervention I: Overview of
approach. Journal of the Association for Persons with
Severe Handicaps, 24(3), 174–185. https:// doi. org/ 10.
2511/ rpsd. 24.3. 174
Kurzrok, J., McBride, E., & Grossman, R. B. (2021).
Autism-specific parenting self-efficacy: An examination
of the role of parent-reported intervention involvement,
satisfaction with intervention-related training, and car-
egiver burden. Autism: The International Journal of
Research & Practice, 25(5), 1395–1408. https:// doi. org/
10. 1177/ 13623 61321 990931
Landa, R. (2007). Early communication development and
intervention for children with autism. Mental Retarda-
tion & Developmental Disabilities Research Reviews,
13(1), 16–25. https:// doi. org/ 10. 1002/ mrdd. 20134
*Lane, J. D., Ledford, J. R., Shepley, C., Mataras, T. K.,
Ayres, K. M., & Davis, A. B. (2016). A brief coach-
ing intervention for teaching naturalistic strategies to
parents. Journal of Early Intervention, 38(3), 135–150.
https:// doi. org/ 10. 1177/ 10538 15116 663178.
*Law, G. C., Neihart, M., & Dutt, A. (2018). The use of
behavior modeling training in a mobile app parent train-
ing program to improve functional communication of
young children with autism spectrum disorder. Autism:
The International Journal of Research & Practice,
22(4), 424–439. https:// doi. org/ 10. 1177/ 13623 61316
683887.
Ledford, J. R., & Gast, D. L. (Eds.). (2018). Single case
research methodology: Applications in special education
and behavioral sciences (3rd ed). Routledge. https:// doi.
org/ 10. 4324/ 97813 15150 666
Lichtlé, J., Downes, N., Engelberg, A., & Cappe, E. (2020).
The effects of parent training programs on the quality
of life and stress levels of parents raising a child with
autism spectrum disorder: A systematic review of the
literature. Review Journal of Autism & Developmen-
tal Disorders, 7(3), 242–262. https:// doi. org/ 10. 1007/
s40489- 019- 00190-x
Maenner, M. J., Warren, Z., Williams, A. R., Amoakohene, E.,
Bakian, A. V., Bilder, D. A., Durkin, M. S., Fitzgerald, R.
T., Furnier, S. M., Hughes, M. M., Ladd-Acosta, C. M.,
McArthur, D., Pas, E. T., Salinas, A., Vehorn, A., Wil-
liams, S., Esler, A., Grzybowski, A., Hall-Lande, J., Shaw,
K. A. (2023). Prevalence and characteristics of autism
spectrum disorder among children aged 8 years - Autism
and Developmental Disabilities Monitoring Network, 11
Sites, United States, 2020. MMWR. Surveillance Summa-
ries, 72(2), 1–14. https:// doi. org/ 10. 15585/ mmwr. ss720
2a1
Mancil, G. R., & Boman, M. (2010). Functional communica-
tion training in the classroom: A guide for success. Pre-
venting School Failure, 54(4), 238–246. https:// doi. org/ 10.
1080/ 10459 88100 37451 95
Martella, R. C., Nelson, J. R., Morgan, R. L., & Marchand-
Martella, N. E. (2013). Understanding the interpreting
educational research. .
Matson, J. L., & Adams, H. L. (2014). Characteristics of
aggression among persons with autism spectrum dis-
orders. Research in Autism Spectrum Disorders, 8(11),
1578–1584. https:// doi. org/ 10. 1016/j. rasd. 2014. 08. 004
Matson, J. L., Boisjoli, J., & Mahan, S. (2009). The relation
of communication and challenging behaviors in infants
and toddlers with autism spectrum disorders. Journal of
Developmental & Physical Disabilities, 21(4), 253–261.
https:// doi. org/ 10. 1007/ s10882- 009- 9140-1
Matson, J. L., Turygin, N. C., Beighley, J., Rieske, R., Tureck,
K., & Matson, M. L. (2012). Applied behavior analy-
sis in autism spectrum disorders: Recent developments,
Educ. Treat. Child.
Vol.: (0123456789)
strengths, and pitfalls. Research in Autism Spectrum Dis-
orders, 6(1), 144–150. https:// doi. org/ 10. 1016/j. rasd. 2011.
03. 014
*Matthews, N. L., Orr, B. C., Harris, B., McIntosh, R.,
Openden, D., & Smith, C. J. (2018). Parent and child
outcomes of JumpStartTM, an education and training pro-
gram for parents of children with autism spectrum disor-
der. Research in Autism Spectrum Disorders, 56(August),
21–35. https:// doi. org/ 10. 1016/j. rasd. 2018. 08. 009.
*McDuffie, A., Machalicek, W., Oakes, A., Haebig, E., Weis-
mer, S. E., & Abbeduto, L. (2013). Distance video-tel-
econferencing in early intervention: Pilot study of a natu-
ralistic parent-implemented language intervention. Topics
in Early Childhood Special Education, 33(3), 172–185.
https:// doi. org/ 10. 1177/ 02711 21413 476348.
*Meadan, H., Snodgrass, M. R., Meyer, L. E., Fisher, K. W.,
Chung, M. Y., & Halle, J. W. (2016). Internet-based
parent-implemented intervention for young children with
autism: A pilot study. Journal of Early Intervention,
38(1), 3–23. https:// doi. org/ 10. 1177/ 10538 15116 630327.
*Moran, D. R., & Whitman, T. L. (1991). Developing general-
ized teaching skills in mothers of autistic children. Child
& Family Behavior Therapy, 13(1), 13–37. https:// doi. org/
10. 1300/ J019v 13n01_ 02.
Nevill, R., Lecavalier, L., & Stratis, E. (2018). Meta-analysis
of parent-mediated interventions for young children with
autism spectrum disorder. Autism, 22(2), 84–98. https://
doi. org/ 10. 1177/ 13623 61316 677838
Oono, I., Honey, E., & McConachie, H. (2013). Parent-medi-
ated early intervention for young children with autism
spectrum disorders (ASD). The. Cochrane Database of
Systematic Reviews, 4(4), CD009774. https:// doi. org/ 10.
1002/ 14651 858. CD009 774. pub2
Ouzzani, M., Hammady, H., Fedorowicz, Z., & Elmagarmid,
A. (2016). Rayyan—A web and mobile app for systematic
reviews. Systematic Reviews, 5(210), 1–10. https:// doi. org/
10. 1186/ s13643- 016- 0384-4
Paul, R. (2007). Communication and its development in autism
spectrum disorders. In F. Volkmar (Ed.), Autism. Cam-
bridge University Press.
Pecukonis, M., Plesa Skwerer, D., Eggleston, B., Meyer, S., &
Tager-Flusberg, H. (2019). Concurrent social communica-
tion predictors of expressive language in minimally verbal
children and adolescents with autism spectrum disorder.
Journal of Autism & Developmental Disorders, 49(9),
3767–3785. https:// doi. org/ 10. 1007/ s10803- 019- 04089-8
Postorino, V., Sharp, W., McCracken, C., Bearss, K., Burrell,
T., Evans, A., & Scahill, L. (2017). A systematic review
and meta-analysis of parent training for disruptive behav-
ior in children with autism spectrum disorder. Clinical
Child & Family Psychology Review, 20(4), 391–402.
https:// doi. org/ 10. 1007/ s10567- 017- 0237-2
*Raulston, T. J., Hansen, S. G., Frantz, R., Machalicek, W., &
Bhana, N. (2020). A parent-implemented playdate inter-
vention for young children with autism and their peers.
Journal of Early Intervention, 42(4), 303–320. https:// doi.
org/ 10. 1177/ 10538 15119 880943.
Richards, C., Moss, J., Nelson, L., & Oliver, C. (2016). Per-
sistence of self-injurious behaviour in autism spectrum
disorder over 3 years: A prospective cohort study of risk
markers. Journal of Neurodevelopmental Disorders,
8(20), 21. https:// doi. org/ 10. 1186/ s11689- 016- 9153-x
*Rocha, M. L., Schreibman, L., & Stahmer, A. C. (2007).
Effectiveness of training parents to teach joint attention
in children with autism. Journal of Early Intervention,
29(2), 154–172. https:// doi. org/ 10. 1177/ 10538 15107
02900 207.
*Rogers, S. J., Estes, A., Lord, C., Vismara, L., Winter, J.,
Fitzpatrick, A., Guo, M., & Dawson, G. (2012). Effects
of a brief early start Denver model (ESDM)–based parent
intervention on toddlers at risk for autism spectrum disor-
ders: A randomized controlled trial. Journal of the Ameri-
can Academy of Child & Adolescent Psychiatry, 51(10),
1052–1065. https:// doi. org/ 10. 1016/j. jaac. 2012. 08. 003.
*Rogers, S. J., Estes, A., Vismara, L., Munson, J., Zierhut, C.,
Greenson, J., Dawson, G., Rocha, M., Sugar, C., Senturk,
D., Whelan, F., & Talbott, M. (2019). Enhancing low-
intensity coaching in parent implemented early start Den-
ver model intervention for early autism: A randomized
comparison treatment trial. Journal of Autism & Devel-
opmental Disorders, 49(2), 632–646. https:// doi. org/ 10.
1007/ s10803- 018- 3740-5.
Rose, V., Trembath, D., Keen, D., & Paynter, J. (2016). The
proportion of minimally verbal children with autism spec-
trum disorder in a community-based early intervention
programme. Journal of Intellectual Disability Research,
60(5), 464–477. https:// doi. org/ 10. 1111/ jir. 12284
Shire, S. Y., Shih, W., Chang, Y.-C., Bracaglia, S., Kodjoe, M.,
& Kasari, C. (2019). Sustained community implementa-
tion of JASPER intervention with toddlers with autism.
Journal of Autism & Developmental Disorders, 49(5),
1863–1875. https:// doi. org/ 10. 1007/ s10803- 018- 03875-0
Siller, M., Hutman, T., & Sigman, M. (2013). A parent-medi-
ated intervention to increase responsive parental behaviors
and child communication in children with ASD: A rand-
omized clinical trial. Journal of Autism & Developmen-
tal Disorders, 43(3), 540–555. https:// doi. org/ 10. 1007/
s10803- 012- 1584-y
*Stadnick, N. A., Stahmer, A., & Brookman-Frazee, L. (2015).
Preliminary effectiveness of project ImPACT: A parent-
mediated intervention for children with autism spectrum
disorder delivered in a community program. Journal of
Autism & Developmental Disorders, 45(7), 2092–2104.
https:// doi. org/ 10. 1007/ s10803- 015- 2376-y.
*Stahmer, A. C., Rieth, S. R., Dickson, K. S., Feder, J., Burge-
son, M., Searcy, K., & Brookman-Frazee, L. (2020). Pro-
ject ImPACT for toddlers: Pilot outcomes of a commu-
nity adaptation of an intervention for autism risk. Autism,
24(3), 617–632. https:// doi. org/ 10. 1177/ 13623 61319
878080.
Strauss, K., Vicari, S., Valeri, G., D’Elia, L., Arima, S., &
Fava, L. (2012). Parent inclusion in early intensive behav-
ioral intervention: The influence of parental stress, parent
treatment fidelity and parent-mediated generalization of
behavior targets on child outcomes. Research in Devel-
opmental Disabilities, 33(2), 688–703. https:// doi. org/ 10.
1016/j. ridd. 2011. 11. 008
Suppo, J., & Floyd, K. (2012). Parent training for families who
have children with autism: A review of the literature.
Rural Special Education Quarterly, 31(2), 12–26. https://
doi. org/ 10. 1177/ 87568 70512 03100 203
Educ. Treat. Child.
Vol:. (1234567890)
*Vismara, L. A., Colombi, C., & Rogers, S. J. (2009). Can one
hour per week of therapy lead to lasting changes in young
children with autism? Autism, 13(1), 93–115. https:// doi.
org/ 10. 1177/ 13623 61307 098516.
*Vismara, L. A., McCormick, C., Young, G. S., Nadhan, A.,
& Monlux, K. (2013). Preliminary findings of a telehealth
approach to parent training in autism. Journal of Autism &
Developmental Disorders, 43(12), 2953–2969. https:// doi.
org/ 10. 1007/ s10803- 013- 1841-8.
*Vismara, L. A., Young, G. S., & Rogers, S. J. (2012). Tel-
ehealth for expanding the reach of early autism training
to parents. Autism Research & Treatment, 2012, 1–12.
https:// doi. org/ 10. 1155/ 2012/ 121878.
*Waddington, H., van der Meer, L., & Sigafoos, J. (2019). Sup-
porting parents in the use of the early start Denver model
as an intervention program for their young children with
autism spectrum disorder. International Journal of Devel-
opmental Disabilities, 67(1), 1–14. https:// doi. org/ 10.
1080/ 20473 869. 2019. 15856 94.
*Wainer, A. L., Arnold, Z. E., Leonczyk, C., & Valluripalli
Soorya, L. (2021). Examining a stepped-care telehealth
program for parents of young children with autism: A
proof-of-concept trial. Molecular Autism, 12(1), 32.
https:// doi. org/ 10. 1186/ s13229- 021- 00443-9.
*Wainer, A. L., & Ingersoll, B. R. (2015). Increasing access
to an ASD imitation intervention via a telehealth parent
training program. Journal of Autism & Developmental
Disorders, 45(12), 3877–3890. https:// doi. org/ 10. 1007/
s10803- 014- 2186-7.
Wang, Z., Loh, S. C., Tian, J., & Chen, Q. J. (2021). A meta-
analysis of the effect of the early start Denver model in
children with autism spectrum disorder. International
Journal of Developmental Disabilities, 68(50), 587–597.
https:// doi. org/ 10. 1080/ 20473 869. 2020. 18704 19
Weitzman, E. (2013). More than words—The Hanen program
for parents of children with autism spectrum disorder: A
teaching model for parent-implemented language inter-
vention. Perspectives on Language Learning & Educa-
tion, 20(3), 96–111. https:// doi. org/ 10. 1044/ lle20.3. 86
*Williams, M. E., Hastings, R. P., & Hutchings, J. (2020). The
incredible years autism spectrum and language delays
parent program: A pragmatic, feasibility randomized con-
trolled trial. Autism Research, 13(6), 1011–1022. https://
doi. org/ 10. 1002/ aur. 2265.
*Zaghlawan, H. Y., & Ostrosky, M. M. (2016). A parent-
implemented intervention to improve imitation skills by
children with autism: A pilot study. Early Childhood Edu-
cation Journal, 44(6), 671–680. https:// doi. org/ 10. 1007/
s10643- 015- 0753-y.
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