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1.  Non-Specialist Psychosocial Interventions for Children and Adolescents with Intellectual Disability or Lower-Functioning Autism Spectrum Disorders: A Systematic Review 
PLoS Medicine  2013;10(12):e1001572.
In a systematic review, Brian Reichow and colleagues assess the evidence that non-specialist care providers in community settings can provide effective interventions for children and adolescents with intellectual disabilities or lower-functioning autism spectrum disorders.
Please see later in the article for the Editors' Summary
The development of effective treatments for use by non-specialists is listed among the top research priorities for improving the lives of people with mental illness worldwide. The purpose of this review is to appraise which interventions for children with intellectual disabilities or lower-functioning autism spectrum disorders delivered by non-specialist care providers in community settings produce benefits when compared to either a no-treatment control group or treatment-as-usual comparator.
Methods and Findings
We systematically searched electronic databases through 24 June 2013 to locate prospective controlled studies of psychosocial interventions delivered by non-specialist providers to children with intellectual disabilities or lower-functioning autism spectrum disorders. We screened 234 full papers, of which 34 articles describing 29 studies involving 1,305 participants were included. A majority of the studies included children exclusively with a diagnosis of lower-functioning autism spectrum disorders (15 of 29, 52%). Fifteen of twenty-nine studies (52%) were randomized controlled trials and just under half of all effect sizes (29 of 59, 49%) were greater than 0.50, of which 18 (62%) were statistically significant. For behavior analytic interventions, the best outcomes were shown for development and daily skills; cognitive rehabilitation, training, and support interventions were found to be most effective for improving developmental outcomes, and parent training interventions to be most effective for improving developmental, behavioral, and family outcomes. We also conducted additional subgroup analyses using harvest plots. Limitations include the studies' potential for performance bias and that few were conducted in lower- and middle-income countries.
The findings of this review support the delivery of psychosocial interventions by non-specialist providers to children who have intellectual disabilities or lower-functioning autism spectrum disorders. Given the scarcity of specialists in many low-resource settings, including many lower- and middle-income countries, these findings may provide guidance for scale-up efforts for improving outcomes for children with developmental disorders or lower-functioning autism spectrum disorders.
Protocol Registration
PROSPERO CRD42012002641
Please see later in the article for the Editors' Summary
Editors' Summary
Newborn babies are helpless, but over the first few years of life, they acquire motor (movement) skills, language (communication) skills, cognitive (thinking) skills, and social (interpersonal interaction) skills. Individual aspects of these skills are usually acquired at specific ages, but children with a development disorder such as an autism spectrum disorder (ASD) or intellectual disability (mental retardation) fail to reach these “milestones” because of impaired or delayed brain maturation. Autism, Asperger syndrome, and other ASDs (also called pervasive developmental disorders) affect about 1% of the UK and US populations and are characterized by abnormalities in interactions and communication with other people (reciprocal socio-communicative interactions; for example, some children with autism reject physical affection and fail to develop useful speech) and a restricted, stereotyped, repetitive repertoire of interests (for example, obsessive accumulation of facts about unusual topics). About half of individuals with an ASD also have an intellectual disability—a reduced overall level of intelligence characterized by impairment of the skills that are normally acquired during early life. Such individuals have what is called lower-functioning ASD.
Why Was This Study Done?
Most of the children affected by developmental disorders live in low- and middle-income countries where there are few services available to help them achieve their full potential and where little research has been done to identify the most effective treatments. The development of effective treatments for use by non-specialists (for example, teachers and parents) is necessary to improve the lives of people with mental illnesses worldwide, but particularly in resource-limited settings where psychiatrists, psychologists, and other specialists are scarce. In this systematic review, the researchers investigated which psychosocial interventions for children and adolescents with intellectual disabilities or lower-functioning ASDs delivered by non-specialist providers in community settings produce improvements in development, daily skills, school performance, behavior, or family outcomes when compared to usual care (the control condition). A systematic review identifies all the research on a given topic using predefined criteria; psychosocial interventions are defined as therapy, education, training, or support aimed at improving behavior, overall development, or specific life skills without the use of drugs.
What Did the Researchers Do and Find?
The researchers identified 29 controlled studies (investigations with an intervention group and a control group) that examined the effects of various psychosocial interventions delivered by non-specialist providers to children (under 18 years old) who had a lower-functioning ASD or intellectual disability. The researchers retrieved information on the participants, design and methods, findings, and intervention characteristics for each study, and calculated effect sizes—a measure of the effectiveness of a test intervention relative to a control intervention—for several outcomes for each intervention. Across the studies, three-quarters of the effect size estimates were positive, and nearly half were greater than 0.50; effect sizes of less than 0.2, 0.2–0.5, and greater than 0.5 indicate that an intervention has no, a small, or a medium-to-large effect, respectively. For behavior analytic interventions (which aim to improve socially significant behavior by systematically analyzing behavior), the largest effect sizes were seen for development and daily skills. Cognitive rehabilitation, training, and support (interventions that facilitates the relearning of lost or altered cognitive skills) produced good improvements in developmental outcomes such as standardized IQ tests in children aged 6–11 years old. Finally, parental training interventions (which teach parents how to provide therapy services for their child) had strong effects on developmental, behavioral, and family outcomes.
What Do These Findings Mean?
Because few of the studies included in this systematic review were undertaken in low- and middle-income countries, the review's findings may not be generalizable to children living in resource-limited settings. Moreover, other characteristics of the included studies may limit the accuracy of these findings. Nevertheless, these findings support the delivery of psychosocial interventions by non-specialist providers to children who have intellectual disabilities or a lower-functioning ASD, and indicate which interventions are likely to produce the largest improvements in developmental, behavioral, and family outcomes. Further studies are needed, particularly in low- and middle-income countries, to confirm these findings, but given that specialists are scarce in many resource-limited settings, these findings may help to inform the implementation of programs to improve outcomes for children with intellectual disabilities or lower-functioning ASDs in low- and middle-income countries.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Bello-Mojeed and Bakare
The US Centers for Disease Control and Prevention provides information (in English and Spanish) on developmental disabilities, including autism spectrum disorders and intellectual disability
The US National Institute of Mental Health also provides detailed information about autism spectrum disorders, including the publication “A Parent's Guide to Autism Spectrum Disorder”
Autism Speaks, a US non-profit organization, provides information about all aspects of autism spectrum disorders and includes information on the Autism Speaks Global Autism Public Health Initiative
The National Autistic Society, a UK charity, provides information about all aspects of autism spectrum disorders and includes personal stories about living with these conditions
The UK National Health Service Choices website has an interactive guide to child development and information about autism and Asperger syndrome, including personal stories, and about learning disabilities
The UK National Institute for Health and Care Excellence provides clinical guidelines for the management and support of children with autism spectrum disorders
The World Health Organization provides information on its Mental Health Gap Action Programme (mhGAP), which includes recommendations on the management of developmental disorders by non-specialist providers; the mhGAP Evidence Resource Center provides evidence reviews for parent skills training for management of children with intellectual disabilities and pervasive developmental disorders and interventions for management of children with intellectual disabilities
PROSPERO, an international prospective register of systematic reviews, provides more information about this systematic review
PMCID: PMC3866092  PMID: 24358029
2.  Clinical outcomes of an early intervention program for preschool children with Autism Spectrum Disorder in a community group setting 
BMC Pediatrics  2013;13:3.
Available evidence indicates that early intervention programs, such as the Early Start Denver Model (ESDM), can positively affect key outcomes for children with Autism Spectrum Disorder (ASD). However, programs involving resource intensive one-to-one clinical intervention are not readily available or deliverable in the community, resulting in many children with ASD missing out on evidence-based intervention during their early and most critical preschool years. This study evaluated the effectiveness of the ESDM for preschool-aged children with ASD using a predominantly group-based intervention in a community child care setting.
Participants were 26 children (21 male) with ASD with a mean age of 49.6 months. The ESDM, a comprehensive early intervention program that integrates applied behaviour analysis with developmental and relationship-based approaches, was delivered by trained therapists during the child’s attendance at a child care centre for preschool-aged children with ASD. Children received 15–20 hours of group-based, and one hour of one-to-one, ESDM intervention per week. The average intervention period was ten months. Outcome measures were administered pre- and post-intervention, and comprised a developmental assessment - the Mullen Scales of Early Learning (MSEL); and two parent-report questionnaires - the Social Communication Questionnaire (SCQ) and Vineland Adaptive Behaviours Scales–Second Edition (VABS-II).
Statistically significant post-intervention improvements were found in children’s performance on the visual reception, receptive language and expressive language domains of the MSEL in addition to their overall intellectual functioning, as assessed by standardised developmental quotients. Parents reported significant increases in their child’s receptive communication and motor skills on the VABS-II, and a significant decrease in autism-specific features on the SCQ. These effects were of around medium size, and appeared to be in excess of what may have been expected due to maturation. Nonetheless, these results need to be confirmed in a controlled study.
This study suggests community dissemination of the ESDM using predominantly group-based intervention may be an effective intervention. Making the ESDM accessible to the wider ASD community in child care settings has the potential for significant clinical and economic benefits. Further studies are indicated in this area, including those with younger children, and which incorporate a control group and standardised ASD assessments.
Trial registration
This trial is registered with the Australian New Zealand Clinical Trials Registry: Registry number ACTRN12612000461897.
PMCID: PMC3631131  PMID: 23294523
Autism; Behavioral intervention; Early intervention; Cognitive function; Developmental outcomes
3.  Intervention Targeting Development of Socially Synchronous Engagement in Toddlers with Autism Spectrum Disorder: A Randomized Controlled Trial 
Social and communication impairments are core deficits and prognostic indicators of autism. We evaluated the impact of supplementing a comprehensive intervention with a curriculum targeting socially synchronous behavior on social outcomes of toddlers with autism spectrum disorders (ASD).
Fifty toddlers with ASD, ages 21 to 33 months, were randomized to one of two 6-month interventions: Interpersonal Synchrony or Non-Interpersonal Synchrony. The interventions provided identical intensity (10 hours per week in classroom), student-to-teacher ratio, schedule, home-based parent training (1.5 hours per month), parent education (38 hours), and instructional strategies, except the Interpersonal Synchrony condition provided a supplementary curriculum targeting socially engaged imitation, joint attention, and affect sharing; measures of these were primary outcomes. Assessments were conducted pre-intervention, immediately post-intervention, and, to assess maintenance, at six-month follow-up. Random effects models were used to examine differences between groups over time. Secondary analyses examined gains in expressive language and nonverbal cognition, and time effects during the intervention and follow-up periods.
A significant treatment effect was found for socially engaged imitation (p=0.02), with more than doubling (17% to 42%) of imitated acts paired with eye contact in the Interpersonal Synchrony group after the intervention. This skill was generalized to unfamiliar contexts and maintained through follow-up. Similar gains were observed for initiation of joint attention and shared positive affect, but between-group differences did not reach statistical significance. A significant time effect was found for all outcomes (p<0.001); greatest change occurred during the intervention period, particularly in the Interpersonal Synchrony group.
This is the first ASD randomized trial involving toddlers to identify an active ingredient for enhancing socially engaged imitation. Adding social engagement targets to intervention improves short-term outcome at no additional cost to the intervention. The social, language, and cognitive gains in our participants provide evidence for plasticity of these developmental systems in toddlers with ASD.
PMCID: PMC3059234  PMID: 21126245
Autistic Disorder; Intervention
4.  Effects of 2 Prevention Programs on High-Risk Behaviors Among African American Youth 
To test the efficacy of 2 programs designed to reduce high-risk behaviors among inner-city African American youth.
Cluster randomized trial.
Twelve metropolitan Chicago, Ill, schools and the communities they serve, 1994 through 1998.
Students in grades 5 through 8 and their parents and teachers.
The social development curriculum (SDC) consisted of 16 to 21 lessons per year focusing on social competence skills necessary to manage situations in which high-risk behaviors occur. The school/community intervention (SCI) consisted of SDC and school-wide climate and parent and community components. The control group received an attention-placebo health enhancement curriculum (HEC) of equal intensity to the SDC focusing on nutrition, physical activity, and general health care.
Main Outcome Measures
Student self-reports of violence, provocative behavior, school delinquency, substance use, and sexual behaviors (intercourse and condom use).
For boys, the SDC and SCI significantly reduced the rate of increase in violent behavior (by 35% and 47% compared with HEC, respectively), provoking behavior (41% and 59%), school delinquency (31% and 66%), drug use (32% and 34%), and recent sexual intercourse (44% and 65%), and improved the rate of increase in condom use (95% and 165%). The SCI was significantly more effective than the SDC for a combined behavioral measure (79% improvement vs 51%). There were no significant effects for girls.
Theoretically derived social-emotional programs that are culturally sensitive, developmentally appropriate, and offered in multiple grades can reduce multiple risk behaviors for inner-city African American boys in grades 5 through 8. The lack of effects for girls deserves further research.
PMCID: PMC2386246  PMID: 15066879
5.  Effects of a parental program for preventing underage drinking - The NGO program strong and clear 
BMC Public Health  2011;11:251.
The present study is an evaluation of a 3-year parental program aiming to prevent underage drinking. The intervention was implemented by a non-governmental organization and targeted parents with children aged 13-16 years old and included recurrent activities during the entire period of secondary school. The program consisted of four different types of group and self-administered activities: parent meetings, family dialogues, friend meetings, and family meetings.
A quasi-experimental design was used following parents and children with questionnaires during the three years of secondary school. The analytic sample consisted of 509 dyads of parents and children. Measures of parental attitudes and behaviour concerning underage drinking and adolescents' lifetime alcohol consumption and drunkenness were used. Three socio-demographic factors were included: parental education, school, and gender of the child. A Latent Growth Modelling (LGM) approach was used to examine changes in parental behaviour regarding youth drinking and in young people's drinking behaviour. To test for the pre-post test differences in parental attitudes repeated measures ANOVA were used.
The results showed that parents in the program maintained their restrictive attitude toward underage drinking to a higher degree than non-participating parents. Adolescents of participants were on average one year older than adolescents with non-participating parents when they made their alcohol debut. They were also less likely to have ever been drunk in school year 9.
The results of the study suggested that Strong and Clear contributed to maintaining parents' restrictive attitude toward underage drinking during secondary school, postponing alcohol debut among the adolescents, and significantly reducing their drunkenness.
PMCID: PMC3103453  PMID: 21510858
Adolescent; underage drinking; alcohol; parental program; prevention
6.  Online Group Course for Parents With Mental Illness: Development and Pilot Study 
Children of parents with mental illness (COPMI) are at greater risk of developing mental disorders themselves. Since impaired parenting skills appear to be a crucial factor, we developed a facilitated 8-session preventative group course called KopOpOuders (Chin Up, Parents) delivered via the Internet to Dutch parents with psychiatric problems. The goal was to promote children’s well-being by strengthening children’s protective factors via their parents. To reach parents at an early stage of their parenting difficulties, the course is easily accessible online. The course is delivered in a secure chat room, and participation is anonymous.
This paper reports on (1) the design and method of this online group course and (2) the results of a pilot study that assessed parenting skills, parental sense of competence, child well-being, and course satisfaction.
The pilot study had a pre/post design. Parenting skills were assessed using Laxness and Overreactivity subscales of the Parenting Scale (PS). Sense of parenting competence was measured with the Ouderlijke Opvattingen over Opvoeding (OOO) questionnaire, a Dutch scale assessing parental perceptions of parenting using the Feelings of Incompetence and Feelings of Competence subscales. Child well-being was assessed with the total problem score, Emotional Problems, and Hyperactivity subscales of the Strengths and Difficulties Questionnaire (SDQ). Paired samples t tests were performed, and Cohen’s d was used to determine effect sizes. Intention-to-treat analyses and analyses of completers only were both performed. Course satisfaction was evaluated using custom-designed questionnaires.
The sample comprised 48 parents with mental illness. The response rate was 100% (48/48) at pretest and 58% (28/48) at posttest. Significant improvements were found on PS Laxness and Overreactivity subscales (P < .01) and on the OOO Feelings of Incompetence and Competence subscales (P < .01) in analysis of completers only as well as by intention-to-treat analysis. Effects were moderate on the PS (d = .52 and d = .48) and were large and moderate on the OOO (d = 0.61 and d = 0.46). At pretest, 75% and 64% of PS scores were in the clinical range, which declined to 43% and 39% at posttest. No significant changes were found for child well-being. Scores for approximately two thirds of children were not in the clinical range at both pretest and posttest. The mean course satisfaction score was 7.8 on a 10-point scale. Of all participants, 20% (10/48) followed all the sessions.
This online group course on parenting skills is innovative in the field of e-support and among interventions for mentally ill parents. The pilot results are promising, showing moderate to large effects for parenting skills and parental sense of competence. Test scores at baseline indicating parenting problems were largely in the clinical range, and baseline scores indicating problems among the children were in the nonclinical range, suggesting that parents were reached at an early stage. Course satisfaction was high. Future research should focus on cost effectiveness and course adherence.
PMCID: PMC3057319  PMID: 21169178
Parenting support; health promotion; parents with mental illness; online group course; Internet
People with spinal cord injury (SCI) access educational resources during their inpatient rehabilitation, but they can be overwhelmed by the amount of information they need to assimilate during ever-shorter stays. This project created e-learning courses to fill the knowledge needs of SCI consumers and evaluated user satisfaction and knowledge transfer.
A needs assessment of 83 consumers and 99 staff identified information needs for people with SCI (Toronto Rehabilitation Institute – UHN and CPAO, 2008). Key topics were selected for the creation of 10 online patient education courses, collectively called Spinal Cord Injury – University (SCI-U), and housed on the Spinal Cord Connections website ( Course content was developed collaboratively by over 100 consumers and professionals, from healthcare and community service organizations across Canada. Each course uses adult learning principles and presents key information on healthy living with SCI, in an accessible and engaging way. A team of professionals created multimedia courses using Articulate software, incorporating video, animation and interactivity. The courses show the positive faces of SCI, each one featuring 3 video presenters (all people with SCI), and video testimonials where consumers talk about their experience living with SCI and managing their health. Users are encouraged to complete course quizzes to reinforce their learning. A pilot study enrolled consumers and clinicians (n = 25) and evaluated knowledge acquisition and retention, as well as perceived utility and satisfaction with the first 3 courses in the series: SCI and You, Bladder and Bowel.
Knowledge acquisition and retention: across-group mean pre-course, post-course and 1-month post-course scores were “SCI & You” (score/14) 8.19, 10.67, 10.75; “Bladder” (score/13) 5.73, 8.69, 7.09; and “Bowel” (score/12) 6.68, 9.23, 9.00. Perceived utility and satisfaction: across-group mean global satisfaction scores (/5) were “SCI & You” 4.25, “Bladder” 3.89, and “Bowel” 3.94. Across-group mean global effectiveness scores (/5) were “SCI & You”□ 4.16, “Bladder” 4.36, and “Bowel” 4.28. Visits to the SCI-U home page were 773 (2010), 2084 (2011) and 803 (as of March 2012).
SCI-U is an effective tool for patient education, and integrating e-learning into SCI rehabilitation programs has the potential to improve the effectiveness of knowledge transfer.
Rick Hansen Institute Grant Number: 2010-77.
PMCID: PMC3459571
8.  Preliminary Efficacy of a Cognitive-Behavioral Treatment Program for Anxious Youth with Autism Spectrum Disorders 
Journal of autism and developmental disorders  2009;10.1007/s10803-009-0801-9.
Anxiety is a commonly occurring psychiatric concern in adolescents with autism spectrum disorders (ASD). This pilot study examined the preliminary efficacy of a manual-based intervention targeting anxiety and social competence in four adolescents with high-functioning ASD. Anxiety and social functioning were assessed at baseline, midpoint, endpoint, and 6 months following treatment. Treatment consisted of cognitive-behavioral therapy, supplemented with parent education and group social skills training. The treatment program was effective in reducing anxiety in three of the four subjects and improving the social skills in all four subjects. Recommendations for the assessment and treatment of anxiety youth with ASD such as use of self-report measures to complement clinician and parent-reports and adaptations to traditional child-based CBT, are offered.
PMCID: PMC2907432  PMID: 19568924
Cognitive-behavioral therapy; Autism; Treatment; Anxiety
9.  Parents’ perspectives on the value of assistance dogs for children with autism spectrum disorder: a cross-sectional study 
BMJ Open  2014;4(6):e004786.
While there is an emerging literature on the usefulness of assistance dogs for children with autism spectrum disorder (ASD), there is a dearth of quantitative data on the value of assistance dog interventions for the family unit and family functioning. Using previously validated scales and scales developed specifically for this study, we measured parents’/guardians’ perceptions of how having an assistance dog affects: (1) child safety from environmental dangers, (2) public reception of ASD and (3) levels of caregiver strain and sense of competence. We also obtained open-ended response data from parents/guardians on benefits and constraints of having an assistance dog.
This study was based in the primary care setting, within the context of a specific accredited assistance dog centre in Ireland.
A total of 134 parents/guardians with an assistance dog, and 87 parents of children on the waiting list were surveyed.
Primary and secondary outcome measures
The primary outcome measures were scores on environmental hazards and public reception scales. The secondary outcome measures were scores on caregiver strain and competence scales.
Parents/guardians of children who have ASD and an assistance dog rate their child as significantly safer from environmental dangers (p<0.001), perceive that the public act more respectfully and responsibly towards their child (p<0.001) and feel more competent about managing their child (p=0.023) compared with parents on the waiting list. There was a concentration of positive feeling towards assistance dog interventions with particular focus on safety and comfort for children, and a sense of freedom from family restrictions associated with ASD. The amount of dedication and commitment required to care for a dog were viewed as the primary constraints.
Our findings indicate that parents perceive that assistance dog interventions can be a valuable intervention for families with children who have ASD.
PMCID: PMC4067897  PMID: 24928583
Epidemiology; Public Health; Primary Care
10.  Behavioral parent training to address sleep disturbances in young children with autism spectrum disorder: a pilot trial 
Sleep medicine  2013;14(10):995-1004.
A large percentage of children with autism spectrum disorders (ASD) have bedtime and sleep disturbances. However, the treatment of these disturbances has been understudied. The purpose of our study was to develop a manualized behavioral parent training (BPT) program for parents of young children with ASD and sleep disturbances and to test the feasibility, fidelity, and initial efficacy of the treatment in a small randomized controlled trial (RCT).
Participants and methods
Parents of a sample of 40 young children diagnosed with ASD with an average age of 3.5 years were enrolled in our study. Participants were randomized to either the BPT program group or a comparison group who were given nonsleep-related parent education. Each was individually administered a 5-session program delivered over the 8-week study. Outcome measures of feasibility, fidelity, and efficacy were collected at weeks 4 and 8 after the baseline time point. Children’s sleep was assessed by parent report and objectively by actigraphy.
Of the 20 participants in each group, data were available for 15 participants randomized to BPT and 18 participants randomized to the comparison condition. Results supported the feasibility of the manualized parent training program and the comparison program. Treatment fidelity was high for both groups. The BPT program group significantly improved more than the comparison group based on the primary sleep outcome of parent report. There were no objective changes in sleep detected by actigraphy.
Our study is one of few RCTs of a BPT program to specifically target sleep disturbances in a well-characterized sample of young children with ASD and to demonstrate the feasibility of the approach. Initial efficacy favored the BPT program over the comparison group and suggested that this manualized parent training approach is worthy of further examination of the efficacy within a larger RCT.
PMCID: PMC3775974  PMID: 23993773
Sleep; sleep disturbances; sleep problems; bedtime problems; autism; autism spectrum disorders; parent training; Modified Simonds and Parraga Sleep Questionnaire; actigraphy; randomized controlled trial
11.  A randomised controlled trial of the efficacy of the ABCD Parenting Young Adolescents Program: rationale and methodology 
The transition to adolescence is a time of increased vulnerability for risk taking and poor health, social and academic outcomes. Parents have an important role in protecting their children from these potential harms. While the effectiveness of parenting programs in reducing problem behavior has been demonstrated, it is not known if parenting programs that target families prior to the onset of significant behavioral difficulties in early adolescence (9-14 years) improve the wellbeing of adolescents and their parents. This paper describes the rationale and methodology of a randomised controlled trial testing the efficacy of a parenting program for the promotion of factors known to be associated with positive adolescent outcomes, such as positive parenting practices, parent-adolescent relationships and adolescent behavior.
One hundred and eighty parents were randomly allocated to an intervention or wait list control group. Parents in the intervention group participated in the ABCD Parenting Young Adolescents Program, a 6-session behavioral family intervention program which also incorporates acceptance-based strategies. Participants in the Wait List control group did not receive the intervention during a six month waiting period. The study was designed to comply with recommendations of the CONSORT statement. The primary outcome measures were reduction in parent-adolescent conflict and improvements in parent-adolescent relationships. Secondary outcomes included improvements in parent psychosocial wellbeing, parenting self-efficacy and perceived effectiveness, parent-adolescent communication and adolescent behavior.
Despite the effectiveness of parenting programs in reducing child behavioral difficulties, very few parenting programs for preventing problems in adolescents have been described in the peer reviewed literature. This study will provide data which can be used to examine the efficacy of a universal parenting interventions for the promotion of protective factors associated with adolescent wellbeing and will add to the literature regarding the relationships between parent, parenting and adolescent factors.
Trial Registration
Australian New Zealand Clinical Trials Registry ACTRN12609000194268.
PMCID: PMC2936870  PMID: 20723219
12.  Study protocol: evaluation of a parenting and stress management programme: a randomised controlled trial of Triple P Discussion Groups and Stress Control 
BMC Public Health  2013;13:888.
Children displaying psychosocial problems are at an increased risk of negative developmental outcomes. Parenting practices are closely linked with child development and behaviour, and parenting programmes have been recommended in the treatment of child psychosocial problems. However, parental mental health also needs to be addressed when delivering parenting programmes as it is linked with parenting practices, child outcomes, and treatment outcomes of parenting programmes. This paper describes the protocol of a study examining the effects of a combined intervention of a parenting programme and a cognitive behavioural intervention for mental health problems.
The effects of a combined intervention of Triple P Discussion Groups and Stress Control will be examined using a randomised controlled trial design. Parents with a child aged 3–8 years will be recruited to take part in the study. After obtaining informed consent and pre-intervention measures, participants will be randomly assigned to either an intervention or a waitlist condition. The two primary outcomes for this study are change in dysfunctional/ineffective parenting practices and change in symptoms of depression, anxiety, and stress. Secondary outcomes are child behaviour problems, parenting experiences, parental self-efficacy, family relationships, and positive parental mental health. Demographic information, participant satisfaction with the intervention, and treatment fidelity data will also be collected. Data will be collected at pre-intervention, mid-intervention, post-intervention, and 3-month follow-up.
The aim of this paper is to describe the study protocol of a randomised controlled trial evaluating the effects of a combined intervention of Triple P Discussion Groups and Stress Control in comparison to a waitlist condition. This study is important because it will provide evidence about the effects of this combined intervention for parents with 3–8 year old children. The results of the study could be used to inform policy about parenting support and support for parents with mental health problems.
Trial registration NCT01777724, UTN: U1111-1137-1053.
PMCID: PMC3852548  PMID: 24066966
13.  A cognitive-behavioral intervention for emotion regulation in adults with high-functioning autism spectrum disorders: study protocol for a randomized controlled trial 
Trials  2013;14:231.
Adults with high-functioning autism spectrum disorders (ASD) have difficulties in social communication; thus, these individuals have trouble understanding the mental states of others. Recent research also suggests that adults with ASD are unable to understand their own mental states, which could lead to difficulties in emotion-regulation. Some studies have reported the efficacy of cognitive-behavioral therapy (CBT) in improving emotion-regulation among children with ASD. The current study will investigate the efficacy of group-based CBT for adults with ASD.
The study is a randomized, waitlist controlled, single-blinded trial. The participants will be 60 adults with ASD; 30 will be assigned to a CBT group and 30 to a waitlist control group. Primary outcome measures are the 20-item Toronto Alexithymia Scale, the Coping Inventory for Stressful Situations, the Motion Picture Mind-Reading task, and an ASD questionnaire. The secondary outcome measures are the Center for Epidemiological Studies Depression Scale, the World Health Organization Quality of Life Scale 26-item version, the Global Assessment of Functioning, State-trait Anxiety Inventory, Social Phobia and Anxiety Inventory, and Liebowitz Social Anxiety Scale. All will be administered during the pre- and post-intervention, and 12 week follow-up periods. The CBT group will receive group therapy over an 8 week period (one session per week) with each session lasting approximately 100 minutes. Group therapy will consist of four or five adults with ASD and two psychologists. We will be using visual materials for this program, mainly the Cognitive Affective Training kit.
This trial will hopefully indicate the efficacy of group-based CBT for adults with high- functioning ASD.
Trial registration
This trial was registered in The University Hospital Medical Information Network Clinical Trials Registry No. UMIN000006236.
PMCID: PMC3726296  PMID: 23880333
Autism spectrum disorders; Emotion regulation; High-functioning adults; Cognitive-behavioral therapy; Randomized controlled trial
14.  A Brief Parenting Intervention to Enhance the Parent–Child Relationship in Hong Kong: Harmony@Home 
There is a dearth of high-level evidence for brief programs designed to promote positive parent–child relationships in nonwestern cultures. We present a pilot randomized controlled trial of a four-session intervention to enhance the parenting skills that promote a positive relationship with pre-adolescent children in Hong Kong. Our intervention, Harmony@Home, utilized Cunningham’s culturally appropriate coping modeling, problem-solving approach to change parental behavior. Our objective was to evaluate the feasibility, acceptability and initial evidence of benefit of the intervention. We blindly randomized 150 Hong Kong parents of children 10–13 years of age to (a) a Harmony@Home intervention group, (b) a waitlist control group, or (c) a third active intervention which shared the control group. Immediately following the intervention, we report increases in satisfaction with the parent–child relationship, one of the targeted parenting behaviors and family harmony, for the Harmony@Home group versus control group. However, only the results from satisfaction with the parent–child relationship were significant at 3-months post intervention. Most respondents reported high levels of program satisfaction. The results provide preliminary evidence that this parenting intervention is culturally acceptable for a nonwestern general population, is feasible for implementation in a community setting and shows evidence of benefit. This intervention is concordant with public health priorities because of the global importance of the parent–child relationship as a protective factor for adolescent outcomes, the need for culturally-appropriate interventions for nonwestern populations, and design characteristics that promote dissemination.
PMCID: PMC3679413  PMID: 23772172
Parenting; Parent–child relationships; Nonwestern culture; Family; Prevention
15.  The Long-Term Effects of a Peer-Led Sex Education Programme (RIPPLE): A Cluster Randomised Trial in Schools in England 
PLoS Medicine  2008;5(11):e224.
Peer-led sex education is widely believed to be an effective approach to reducing unsafe sex among young people, but reliable evidence from long-term studies is lacking. To assess the effectiveness of one form of school-based peer-led sex education in reducing unintended teenage pregnancy, we did a cluster (school) randomised trial with 7 y of follow-up.
Methods and Findings
Twenty-seven representative schools in England, with over 9,000 pupils aged 13–14 y at baseline, took part in the trial. Schools were randomised to either peer-led sex education (intervention) or to continue their usual teacher-led sex education (control). Peer educators, aged 16–17 y, were trained to deliver three 1-h classroom sessions of sex education to 13- to 14-y-old pupils from the same schools. The sessions used participatory learning methods designed to improve the younger pupils' skills in sexual communication and condom use and their knowledge about pregnancy, sexually transmitted infections (STIs), contraception, and local sexual health services. Main outcome measures were abortion and live births by age 20 y, determined by anonymised linkage of girls to routine (statutory) data. Assessment of these outcomes was blind to sex education allocation. The proportion of girls who had one or more abortions before age 20 y was the same in each arm (intervention, 5.0% [95% confidence interval (CI) 4.0%–6.3%]; control, 5.0% [95% CI 4.0%–6.4%]). The odds ratio (OR) adjusted for randomisation strata was 1.07 (95% CI 0.80–1.42, p = 0.64, intervention versus control). The proportion of girls with one or more live births by 20.5 y was 7.5% (95% CI 5.9%–9.6%) in the intervention arm and 10.6% (95% CI 6.8%–16.1%) in the control arm, adjusted OR 0.77 (0.51–1.15). Fewer girls in the peer-led arm self-reported a pregnancy by age 18 y (7.2% intervention versus 11.2% control, adjusted OR 0.62 [95% CI 0.42–0.91], weighted for non-response; response rate 61% intervention, 45% control). There were no significant differences for girls or boys in self-reported unprotected first sex, regretted or pressured sex, quality of current sexual relationship, diagnosed sexually transmitted diseases, or ability to identify local sexual health services.
Compared with conventional school sex education at age 13–14 y, this form of peer-led sex education was not associated with change in teenage abortions, but may have led to fewer teenage births and was popular with pupils. It merits consideration within broader teenage pregnancy prevention strategies.
Trial registration:
ISRCTN (ISRCTN94255362).
Judith Stephenson and colleagues report on a cluster randomized trial in London of school-based peer-led sex education and whether it reduced unintended teenage pregnancy.
Editors' Summary
Teenage pregnancies are fraught with problems. Children born to teenage mothers are often underweight, which can affect their long-term health; young mothers have a high risk of poor mental health after the birth; and teenage parents and their children are at increased risk of living in poverty. Little wonder, then, that faced with one of the highest teenage pregnancy rates in Western Europe, the Department of Health in England launched a national Teenage Pregnancy Strategy in 2000 to reduce teenage pregnancies. The main goal of the strategy is to halve the 1998 under-18 pregnancy rate—there were 46.6 pregnancies for every 1,000 young women in this age group in that year—by 2010. Approaches recommended in the strategy to achieve this goal include the provision of effective sexual health advice services for young people, active engagement of health, social, youth support, and other services in the reduction of teenage pregnancies, and the improvement of sex and relationships education (SRE).
Why Was This Study Done?
Although the annual under-18 pregnancy rate in England is falling, it is still very high, and it is extremely unlikely that the main goal of the Teenage Pregnancy Strategy will be achieved. Experts are, therefore, looking for better ways to reduce both teenage pregnancy rates and the high rates of sexual transmitted diseases among teenagers. Many believe that peer-led SRE—the teaching (sharing) of sexual health information, values, and behaviours by people of a similar age or status group—might be a good approach to try. Peers, they suggest, might convey information about sexual health and relationships better than teachers. However, little is known about the long-term effectiveness of peer-led SRE. In this randomized cluster trial, the researchers compare the effects of a peer-led SRE program and teacher-led sex education given to13- to 14-y-old pupils on abortion and live birth numbers among young women up to age 20 y. In a cluster randomized trial, participants are randomly assigned to the interventions being compared in “clusters”; in this trial, each “cluster” is a school.
What Did the Researchers Do and Find?
Twenty-seven schools in England (about 9,000 13- to 14-y-old pupils) participated in the RIPPLE (Randomized Intervention of PuPil-Led sex Education) trial. Each school was randomly assigned to peer-led SRE (the intervention arm) or to existing teacher-led SRE (the control arm). For peer-led SRE, trained 16- to 17-y-old peer educators gave three 1-h SRE sessions to the younger pupils in their schools. These sessions included practice with condoms, role play to improve sexual negotiating skills, and exercises to improve knowledge about sexual health. The researchers then used routine data on abortions and live births to find out how many female study participants had had an unintended pregnancy before the age of 20 y. One in 20 girls in both study arms had had one or more abortions. Slightly more girls in the control arm than in the intervention arm had had live births, but the difference was small and might have occurred by chance. However, significantly more girls in the intervention arm (11.2%) self-reported a pregnancy by age 18 than in the intervention arm (7.2%). There were no differences between the two arms for girls or boys in any other aspect of sexual health, including sexually transmitted diseases.
What Do These Findings Mean?
These findings indicate that the peer-led SRE program used in this trial had no effect on the number of teenage abortions but may have led to slightly fewer live births among the young women in the study. This particular peer-led SRE program was very short so a more extended program might have had a more marked effect on teenage pregnancy rates; this possibility needs to be tested, particularly since the pupils preferred peer-led SRE to teacher-led SRE. Even though peer-led SRE requires more resources than teacher-led SRE, this form of SRE should probably still be considered as part of a broad teenage prevention strategy, suggest the researchers. But, they warn, their findings should also “temper high expectations about the long-term impact of peer-led approaches” on young people's sexual health.
Additional Information.
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by David Ross
Every Child Matters, a Web site produced by the UK government, includes information on teenage pregnancy, the Teenage Pregnancy Strategy, and teenage pregnancy statistics in England
Directgov, an official government Web site for UK citizens, provides advice for parents on talking to children about sex and teenage pregnancyand advice for young people on sexual health and preventing pregnancy
Teachernet, a UK source of online publications for schools, also provides information for parents about sex and relationships education and the UK government's current guidance on SRE in schools
Avert, an international AIDS charity, also provides a fact sheet on sex education
The Sex Education Forum in the UK is the national authority on Sex and Relationships Education
PMCID: PMC2586352  PMID: 19067478
16.  Behavioural and skill-based early interventions in children with autism spectrum disorders 
Autism spectrum disorders (ASD) comprise typical or infantile autism (Kanner syndrome), Asperger’s disorder and atypical autism or pervasive developmental disorder - not otherwise specified. The syndrome is characterized by deficits in (1) verbal and nonverbal communication, (2) reciprocal social interaction and (3) repetitive patterns of behaviour, interests and activities.
Early behavioural interventions are based on learning theory and behaviour therapy. They take into account specific deficits in perception, emotional reactions, social interaction and communication. In Germany, these comprehensive models are not widely evaluated and implemented.
Research questions
What are the clinical effectiveness and safety of early behavioural or skills-based early interventions in autism compared to other interventions or to treatment as usual?What are specific factors responsible for the effectiveness?What are the cost-effectiveness and cost consequences of different early interventions in autism?Which legal, social and ethical aspects are relevant with regard to the implementation of the respective interventions in persons with autism?
Following a systematic review of the literature, controlled studies on early behavioural or skills-based interventions published since 2000 in English or German with children until the age of twelve are included and critically appraised. Studies must have at least ten participants per intervention group.
In total, 15 publications based on 14 studies, eight systematic reviews and one health economic study are included. Most studies evaluate early interventions based upon the Lovaas model (Early intensive behavioural treatment (EIBT), Applied behavioural analysis (ABA)). Other evaluate pragmatic interventions or interventions based on other theoretical models like specific parent interventions, responsive education and prelinguistic milieu teaching, joint attention, symbolic play, and picture exchange communication system. Behaviour analytic interventions referring to the Lovaas model remain the most empirically evaluated early interventions in autism. Preschool children with autism can achieve improvements in cognitive and functional domains when treated within behavioural interventions with a frequency of at least 20 hours per week. It is not clear which is the minimum duration of effective interventions, and which active components are necessary for the effectiveness. There was no high quality evidence for other comprehensive early interventions. The identified health economic study is not suitable to evaluate the cost-effectiveness or cost consequences of early interventions. No publications concerning legal, ethical or social aspects were identified. The financial situation of persons with autisms and their families will be improved through the implementation of the “Pflege-Weiterententwicklungsgesetz” (Pf-WG). Further questions concern the organisation of care and the legal representation of autistic patients. Ethical questions arise mainly in the context of the equal supply of care to each individual patient in all regions of the country and the situation of the caregivers.
There are only a few studies with high methodology evaluating early interventions in children with autism. Most studies have a short duration with a lack of blinded outcome assessment in many cases. The lack of high quality comparative studies does not allow answering questions of comparative effectiveness of early interventions in autism. It can be concluded that interventions referring to the Lovaas model seem to have the highest effectiveness. This seems to be especially true when they are run clinic-based. However, there was no solid evidence with regard to factors responsible for the effectiveness of programms according to the ABA model. With regard to communication improvement, a systematic parent training seems to be superior to treatment as usual where a mixture of therapeutic elements is used. As well for clinical and health economic studies there is a substantial problem of generalisability into the German context. The identified health economic study is not suitable to evaluate the cost-effectiveness or cost consequences of early interventions.
Based on the available studies, there is no sufficient evidence for any of the evaluated behavioural early intervention programmes. Studies suggest that preschool children with autism in behavioural intervention programmes with a frequency of at least 20 hours per week can achieve improvements in cognitive and functional domains. There is no evidence that in a substantial portion of the children a normal development can be achieved by early interventions. Most research evidence is available for ABA. A minimal necessary intensity of interventions to achieve positive outcomes cannot be derived from literature. There are no valid statements possible as to cost-effectiveness or consequences of these interventions. Effective early interventions may reduce total autism costs in the long run. This may be achieved when the initial high treatment expenditures are more than compensated later if persons with this disorder have better social functioning.
PMCID: PMC3011283  PMID: 21289897
17.  The effects and costs of the universal parent group program – all children in focus: a study protocol for a randomized wait-list controlled trial 
BMC Public Health  2013;13:688.
In recent decades, parents have been involved in programs that aim to improve parenting style and reduce child behavior problems. Research of preventive parenting programs has shown that these interventions generally have a positive influence on both parents and children. However, to our knowledge there is a gap in the scientific literature when it comes to randomized controlled trials of brief, manual-based structured programs which address general parenting among the population, and focus on promoting health. A four-session universal health promotion parent group program named All Children in Focus was developed. It aims at promoting parental competence and children’s positive development with the parent–child relationship as the target. There is currently no randomized controlled trial existing of the program.
A prospective multicenter randomized wait-list controlled trial is being conducted. Approximately 600 parents with children ranging in age from 3–12 years have been recruited in eleven municipalities and city districts in the County of Stockholm, Sweden. Parents are randomized at baseline to an intervention group, which receives the program directly, or to a waiting-list control group, which participates in the program six months later. Changes in parenting and child health and development are assessed with measures immediately post-intervention and six months after the baseline. Observations of a minor group of parents and children are conducted to explore possible relations between parental reports and observed behaviors, as well as changes in the interaction between parent and child. Further, data collected within the evaluation will also be applied to evaluate the possible cost-effectiveness of the program.
This paper describes a study protocol of a randomized controlled trial. Except for the quantitative outcome measures to evaluate the effectiveness of All Children in Focus, this protocol also describes health economic and qualitative analyses to deepen the knowledge of the program. We further discuss some issues regarding the implementation of the program in municipalities and city districts.
Trial registration
Current Controlled Trials ISRCTN70202532
PMCID: PMC3729493  PMID: 23890316
Parenting programs; Parental self-efficacy; Child health; Development; Health promotion; Universal
18.  Effectiveness of a universal health-promoting parenting program: a randomized waitlist-controlled trial of All Children in Focus 
BMC Public Health  2014;14(1):1083.
Parenting programs have been highlighted as a way of supporting and empowering parents. As programs designed to promote children’s health and well-being are scarce, a new health-promotion program, All Children in Focus, has been developed. The purpose of this trial was to evaluate the potential effectiveness of the program in promoting parental self-efficacy and child health and development, as well as to investigate possible moderators of these outcomes.
A multicenter randomized waitlist-controlled trial was conducted. The trial included 621 parents with children aged 3–12 years. Parents were randomized to receive the intervention directly or to join a waitlist control group. Parents completed questionnaires at baseline, 2 weeks after the intervention, and 6 months post-baseline. To evaluate potential effects of the program, as well as any moderating variables, multilevel modeling with a repeated-measures design was applied.
Parents in the intervention group reported that their self-efficacy (p < .001), as well as their perceptions of children’s health and development (p < .05), increased 6 months post-baseline when compared with parents in the control group. One variable was found to moderate both outcomes: parents’ positive mental health. Furthermore, parents’ educational level and number of children moderated parental self-efficacy, while the children’s age moderated child health and development. Having a poor positive mental health, a university-level education, more than one child in the family, and older children, made the families benefit more.
In the first randomized controlled trial of All Children in Focus, we found that the program appears to promote both parental self-efficacy and children’s health and development in a general population. Additionally, we found that families may benefit differently depending on their baseline characteristics. This contributes to an existing understanding of the advantages of offering universal parenting programs as a public health approach to strengthening families. However, further research is needed to investigate long-term effects and mediating variables, as well as the potential cost-effectiveness of the program.
Trial registration
Current Controlled Trials: ISRCTN70202532. November 7th 2012.
PMCID: PMC4210619  PMID: 25326710
ABC program; Child health and development; Health promotion; Parenting program; Parental self-efficacy; Randomized controlled trial; Universal
19.  Changes in adolescents' intake of sugar-sweetened beverages and sedentary behaviour: Results at 8 month mid-way assessment of the HEIA study - a comprehensive, multi-component school-based randomized trial 
Inconsistent effects of school-based obesity prevention interventions may be related to how different subgroups receive them. The aim of this study was to evaluate the effect of an intervention program, including fact sheets to parents and classroom components, on intake of sugar-sweetened beverages (SSB) and screen time. Further, to explore whether potential effects and parental involvement varied by adolescents' gender, weight status (WS) and parental educational level.
In total, 1465 11-year-olds participated at the pre-test and the 8 month mid-way assessment of the HEIA study. Parents (n = 349) contributed with process evaluation data. Self-reported intake of SSB was collected from the 11-year-olds assessing frequency and amount, while time used on watching TV/DVD and computer/game-use (weekday and weekend day) were assed by frequency measures. Data on awareness of the intervention and dose received were collected from parents. Covariance analyses (ANCOVA) were conducted testing for effects by gender and for moderation by WS and parental education.
Time spent on TV/DVD (week p = 0.001, weekend p = 0.03) and computer/game-use (week p = 0.004, weekend p <.001), and the intake of SSB during weekend days (p = 0.04), were significantly lower among girls in the intervention group compared to the control group girls after 8 months. Girls' WS did not moderate these findings. However, no significant effects of the intervention were found for boys, but moderation effects were found for WS (week days: TV/DVD, p = 0.03 and computer/games, p = 0.02). There were no moderating effects of parental education for neither boys nor girls with respect to intake of SSB, time used for watching TV/DVD and computer/game-use. Parental awareness of the intervention was significantly higher among the parents of girls, while the parents of boys were more satisfied with the fact sheets.
The preventive initiatives appeared to change behaviour in girls only. This study suggests that exploration of potential beneficial or negative effects of intervention in subgroups is important. In formative evaluation of obesity prevention studies it seems warranted to include issues related to gender, WS and parental involvement in order to enhance the effectiveness of preventive initiatives.
PMCID: PMC3141615  PMID: 21679476
20.  “Everyone just keeps their eyes closed and their fingers crossed”: Sexual health communication among black parents and children in Nova Scotia, Canada 
Black Canadian youth remain disproportionally affected by an array of social and health issues, including sexually transmitted infections. While research exists in support of the involvement of parents as a key means to prevent or modify harmful behaviours among youth, less is known about how parent–child communication can serve as a prevention intervention strategy within Black families in Canada. This study explores sexual health communication between Black parents and youth in Nova Scotia and identifies facilitators, obstacles and issues that families face in dialoguing about sexual health.
Focus groups and in-depth interview sessions were held with a diverse sample of parents of Black youth, health and education professionals, and Black youth in Nova Scotia, as part of a larger study aimed at exploring parent–child communication on sexual health and HIV. The research team worked in partnership with and received feedback from key informants and a community advisory committee throughout the various stages of this study. All sessions were audio-taped with permission and thematic analysis was carried out on the verbatim transcripts.
Six key themes emerged from the data analysis in relation to parent–child communication within Black families in Nova Scotia: 1. the gendered nature of [sexual] health communication; 2. fear and uncertainty as obstacles; 3. open and honest dialogue from an early age as a facilitator; 4. media as both a catalyst and a barrier; 5. peers as a catalyst; and 6. time constraints as an obstacle.
The findings of this study reveal that parent–child communication regarding sexual health promotion within Black families in Nova Scotia remains varied and is heavily affected by a myriad of intersecting determinants of health faced by Black youth and their parents. Health promotion interventions aimed at fostering and supporting parent–child communication on sexual health must simultaneously target both parents and youth and further, such efforts must engage a high level of cultural competency in order to better meet the needs of this population.
PMCID: PMC3765904  PMID: 23876177
Sexual health; Black youth; Parents; Qualitative research; Nova Scotia; Communication
21.  PLAY Project Home Consultation Intervention Program for Young Children With Autism Spectrum Disorders: A Randomized Controlled Trial 
To evaluate the effectiveness of the Play and Language for Autistic Youngsters (PLAY) Project Home Consultation model, in combination with usual community services (CS), to improve parent-child interaction, child development, and autism symptomatology in young children with autism spectrum disorders (ASDs) compared with CS only.
Children (N = 128) with autism or PDD-NOS (DSM-4 criteria) aged 2 years 8 months to 5 years 11 months and recruited from 5 disability agencies in 4 US states were randomized in two 1-year cohorts. Using videotape and written feedback within a developmental framework, PLAY consultants coached caregivers monthly for 12 months to improve caregiver-child interaction. CS included speech/language and occupational therapy and public education services. Primary outcomes included change in parent-child interactions, language and development, and autism-related diagnostic category/symptoms. Secondary outcomes included parent stress and depression and home consultant fidelity. Data were collected pre- and post-intervention.
Using intent-to-treat analysis (ITT), large treatment effects were evident for parent and child interactional behaviors on the Maternal and Child Behavior Rating Scales. Child language and developmental quotient did not differ over time by group, although functional development improved significantly. PLAY children improved in diagnostic categories on the Autism Diagnostic Observation Schedule (ADOS). PLAY caregivers' stress did not increase, and depressive symptomatology decreased. Home consultants administered the intervention with fidelity.
PLAY intervention demonstrated substantial changes in parent-child interaction without increasing parents' stress/depression. ADOS findings must be interpreted cautiously because results do not align with clinical experience. PLAY offers communities a relatively inexpensive effective intervention for children with ASD and their parents.
PMCID: PMC4181375  PMID: 25264862
developmental outcomes; early intervention; parent-mediated intervention
22.  Systematic review of parenting interventions in European countries aiming to reduce social inequalities in children’s health and development 
BMC Public Health  2014;14(1):1040.
Early child development influences many aspects of wellbeing, health, competence in literacy and numeracy, criminality, and social and economic participation throughout the life course. Children from disadvantaged groups have less possibilities of achieving full development. By providing a positive start for all children across the social gradient, improved developmental outcomes will be seen during later childhood and throughout their lives. The objective of this systematic review was to identify interventions during early childhood in countries from the World Health Organisation European Region in 1999–2013 which reduced inequalities in children’s health and development.
A systematic review was carried out adhering to the PRISMA guidelines. The review examined universal, targeted and proportionate universalism interventions, programs and services using an electronic search strategy in PubMed and the International Bibliography of the Social Sciences [IBSS] databases. A further search was performed in the grey literature. Interventions were included only if they were aimed at children or their parents and had been evaluated.
We identified 23 interventions in total: 6 in the PubMed data base, 5 in IBSS and 12 in grey literature. All but 1 intervention-delivered in Sweden-were carried out in the United Kingdom and the Republic of Ireland. These aimed to improve parenting abilities, however, some had additional components such as: day-care provision, improving housing conditions and speech or psychological therapies. Programmes offering intensive support, information and home visits using a psycho-educational approach and aimed at developing parent’s and children’s skills showed more favourable outcomes. These were parenting behaviours, overall children’s health and higher level of fine motor skills and cognitive functioning. Child injuries and abuse were also reduced. Two interventions were universally proportionate and all others were aimed at a specific target population.
Interventions with better outcomes and a higher level of evidence combined workshops and educational programmes for both parents and children beginning during early pregnancy and included home visits by specialised staff. Further evaluation and publication of early years interventions should be carried out also within a wider range of countries than just the UK and Ireland.
PMCID: PMC4203958  PMID: 25287010
Review; Early intervention; Parenting; Inequalities; Health; Child development
23.  Parents of preterm-born children; sources of stress and worry and experiences with an early intervention programme – a qualitative study 
BMC Nursing  2013;12:28.
Preterm-born children are at increased risk of adverse developmental outcomes, and their parents may experience increased stress levels. The Mother–Infant Transaction Program (MITP) is an early intervention that aims to enhance the parent–infant relationship and child development. The present study investigated differences in parents’ experience of stress and concerns about caring for their preterm-born child according to whether they participated in the programme. Parental satisfaction with the intervention was also explored.
As part of a follow-up study at 36 months, a randomized controlled trial of the MITP—14 parents of 11 children from the intervention group, and 17 parents of 14 children from the control group were interviewed by the use of semi-structured focus group interviews. The interviews were analysed thematically.
The intervention parents reported that the knowledge, advice, guidance and emotional support given during the intervention made them feel less stressed and more confident, competent and secure caring for their preterm born child than they would otherwise have been. The control parents described feeling less involved and emotionally supported, and seemed more anxious about their child’s development than the intervention parents. All parents were vigilant and alert to their child’s needs and monitored developmental milestones carefully.
This qualitative exploration of the influences of the MITP revealed a positive impact of the intervention and seems to be an important educational and supportive initiative. Thus, reducing parental stress and enhancing confidence in the parental role.
PMCID: PMC3879424  PMID: 24313957
Early intervention; Focus group interviews; Neonatal intensive care unit; NICU; Parental stress; Preterm infant; Public health nurses; Thematic analyses
24.  Application of integrated yoga therapy to increase imitation skills in children with autism spectrum disorder 
International Journal of Yoga  2010;3(1):26-30.
Children with autism exhibit significant deficits in imitation skills, which impede the acquisition of more complex behavior and socialization. Imitation is often targeted early in intervention plans and continues to be addressed throughout the child’s treatment. The use of integrated approach to yoga therapy (IAYT) as a complementary therapy for children diagnosed with autism spectrum disorder (ASD) is rarely reported and little is known on the effectiveness of such therapies. This study investigated IAYT as a treatment method with children with ASD to increase imitative skills.
Materials and Methods:
Parents and six children with ASD participated in a 10-month program of 5-weekly sessions and regular practice at home. Pre, mid and post treatment assessments included observers and parent ratings of children’s imitation skills in tasks related to imitation skills such as gross motor actions, vocalization, complex imitation, oral facial movements and imitating breathing exercises.
Improvement in children’s imitation skills especially pointing to body, postural and oral facial movements. Parents reported change in the play pattern of these children with toys, peers and objects at home.
This study indicates that IAYT may offer benefits as an effective tool to increase imitation, cognitive skills and social-communicative behaviors in children with ASD. In addition, children exhibited increased skills in eye contact, sitting tolerance, non-verbal communication and receptive skills to verbal commands related to spatial relationship.
PMCID: PMC2952122  PMID: 20948898
Autism; Yoga; Imitation
25.  The group-based social skills training SOSTA-FRA in children and adolescents with high functioning autism spectrum disorder - study protocol of the randomised, multi-centre controlled SOSTA - net trial 
Trials  2013;14:6.
Group-based social skills training (SST) has repeatedly been recommended as treatment of choice in high-functioning autism spectrum disorder (HFASD). To date, no sufficiently powered randomised controlled trial has been performed to establish efficacy and safety of SST in children and adolescents with HFASD. In this randomised, multi-centre, controlled trial with 220 children and adolescents with HFASD it is hypothesized, that add-on group-based SST using the 12 weeks manualised SOSTA–FRA program will result in improved social responsiveness (measured by the parent rated social responsiveness scale, SRS) compared to treatment as usual (TAU). It is further expected, that parent and self reported anxiety and depressive symptoms will decline and pro-social behaviour will increase in the treatment group. A neurophysiological study in the Frankfurt HFASD subgroup will be performed pre- and post treatment to assess changes in neural function induced by SST versus TAU.
The SOSTA – net trial is designed as a prospective, randomised, multi-centre, controlled trial with two parallel groups. The primary outcome is change in SRS score directly after the intervention and at 3 months follow-up. Several secondary outcome measures are also obtained. The target sample consists of 220 individuals with ASD, included at the six study centres.
This study is currently one of the largest trials on SST in children and adolescents with HFASD worldwide. Compared to recent randomised controlled studies, our study shows several advantages with regard to in- and exclusion criteria, study methods, and the therapeutic approach chosen, which can be easily implemented in non-university-based clinical settings.
Trial registration
ISRCTN94863788 – SOSTA – net: Group-based social skills training in children and adolescents with high functioning autism spectrum disorder.
PMCID: PMC3561169  PMID: 23289935
Social skills training; Neural function; Moderating factors; Autism spectrum disorder

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