Effectiveness and Acceptability of Parent Implemented Behavior Interventions for Children with Autism in Three African American Families.
No studies of parent implemented behavior interventions for children with autism spectrum disorders (ASD) have purposefully examined their effectiveness and acceptability with African American families. The present study used a multiple baseline across participants design to evaluate the effectiveness of parentimplemented differential reinforcement plus visual support to increase appropriate alternatives to problem behavior in three children with ASD from African American families. Parents also rated the social validity of the intervention and were qualitatively interviewed regarding their perceptions of its effectiveness and acceptability. Results indicated the intervention was effective for 2 of 3 dyads, though levels of treatment integrity ranged greatly across participants and over time. In general, all dyads rated the intervention as acceptable and effective. Implications of this study for effectiveness and acceptability of behavior interventions in groups less represented in autism research are discussed. Children diagnosed with autism spectrum disorder (ASD) are at high risk of developing challenging behaviors such as aggression and self injury in comparison to both typical children and children with other developmental disabilities (Baker et al. 2003; Chadwick, Kusel, Cuddy, 2008) These behaviors are often severe and persistent (Emerson et al. 2001; Green, O'Reilly, Itchon, and Sigafoos, 2005) and associated with poor outcomes, such as exclusion from mainstream environments (Allen, Lowe, Moore, Brophy, 2007; Yianni Coudurier et al. 2008) and decreased adaptive skills (Richman Lindauer, 2005) for children, and increased stress (Lecavalier, Leone, Wiltz, 2006) and marital difficulty (Brobst, Clopton, Hendrick, 2009) for parents. Fortunately, decades of research in areas related to applied behavior analysis have led to an evidence base of effective interventions to improve adaptive behavior and decrease problematic behavior in children with ASD (Odom, Collet Klingenberg, Rogers, Hatton, 2010; Rogers Vismara, 2008) In particular, parent involvement, training, and implementation of interventions has been identified as both a means to improve the effectiveness, generalizability, maintenance, and cost of interventions for children with ASD (Matson, Mahan, Matson, 2009) and as an evidence based practice itself (Odom et al. 2010) Specifically, teaching parents to implement interventions can increase intervention dosage by allowing parents to integrate intervention strategies into ongoing daily activities for months or years past the point of training, and during activities and in settings less accessible to another interventionist (Brookman Frazee, Vismara, Drahota, Stahmer, Openden, 2009) Parent participants involved in studies of parent implemented interventions are in the The author would like to thank Shawn Marburger, Deborah Kennedy, Kaylee Wynkoop, and Emily Sobeck for their assistance with this study. Preparation of this manuscript was funded by the Duquesne University Faculty Development Fund and the Barbara A. Sizemore Small Grants Program. The opinions expressed in this article are those of the author and do not necessarily reflect those of the funding agencies. Correspondence concerning this article should be addressed to Rachel E. Robertson, Department of Instruction and Learning, University of Pittsburgh, 5146 Wesley W. Posvar Hall, Pittsburgh, PA 15260. E mail: rachelr@pitt.edu Education and Training in Autism and Developmental Disabilities, 2016, 51(2) 107 121 (c) Division on Autism and Developmental Disabilities African American 107 unique role of being both the recipients of intervention, as researchers must train parents to implement the intervention, as well as the deliverers of the intervention to their child. Because of this dual role, parents themselves are extremely important factors in the success of parent implemented interventions (Brookman Frazee et al. 2009) Further, specific parent characteristics have been associated with increased or decreased effectiveness of parent training. For example, Lundahl, Risser, and Lovejoy (2006) conducted a meta analysis of parent training interventions for parents of children with behavior problems and found these interventions were least effective for economically disadvantaged parents. Unfortunately, the demographic characteristics of parent participants in studies of parent implemented behavior interventions for children with ASD are not fully known, as few studies appear to report race or SES of parent or child participants (Conroy, Dunlap, Clarke, Alter, 2005; McLaughlin, Denney, Snyder, Welsh, 2012) Nevertheless, there is general agreement among many researchers that the evidence bases for both autism intervention and parent training have been developed primarily using participants from middle class Caucasian families (Coard, Wallace, Stevenson, Brotman, 2004; Dyches, Wilder, Sudweeks, Obiakor, Algozzine, 2004; Forehand Kotchick, 1996; Horovitz, Matson, Rieske, Kozlowski, Sipes, 2011) with very few studies purposefully testing the effectiveness of parent implemented behavior interventions for children with ASD in families who are not Caucasian (Cheremshynski, Lucyshyn, Olson, 2012) or who are of lower SES. While it is not yet clear what impact culture, race, SES, or other demographic factors may have on the effectiveness and acceptability of parent implemented behavior interventions for children with ASD, there are reasons to believe such factors are important. Race and culture bring a shared identity, history, and set of values that may shape which skills and competencies parents deem most important for children to learn to ensure their survival and success (Forehand Kotchick, 1996) Race and culture have been shown to affect which behavior management practices a parent may choose to employ (LeCuyer, Christensen, Kearney, Kitzman, 2011) and find acceptable (Njardvic Kelley, 2008) Additionally, lower SES is often associated with a variety of hardships, such as poverty, unemployment, homelessness, single parenthood, community violence, and mental health issues (Bradley Corwyn, 2002) many of which have been found to have negative influences on parenting practices (Klebanov, BrooksGunn, Duncan, 1994) and possibly decrease the treatment integrity and maintenance of interventions (Schertz Odom, 2007) Furthermore, it is likely that race and SES interact to impact the experience of parenting a child with ASD. For example, Carr and Lord (2012) found perceived negative impact of having a child with ASD was reduced in African American mothers with lower educational levels when compared to African American mothers with higher educational levels and Caucasian mothers of all educational levels. Finally, there is mixed evidence on whether behavior interventions yield different effects for Caucasian and non Caucasian groups. Kolko, Cheng, Campo, and Kelleher (2011) compared two treatments for typical children with behavior problems and found that an on site, nurse administered intervention was more effective for Caucasian families, whereas enhanced usual care was more effective for nonCaucasian families. Alternatively, McCabe and Yeh (2009) found that Mexican American families of children with conduct problems benefitted similarly regardless of whether they received Parent Child Interaction Therapy (PCIT) or a culturally adapted version of PCIT. Taken together, there is evidence that race and SES may influence parenting styles and approaches to behavior management; however it is not clear whether or how such differences may influence the effectiveness of parent implemented interventions in children with ASD. African American families in particular appear to have been infrequent participants in autism research (Hilton et al. 2010) and more specifically in studies of parent implemented behavior interventions for children with ASD (e.g. Baker Ericzen et al. 2007) Certainly little to no research in parent training has been purposefully directed towards African American families of children with ASD. For example, a search of the PsychINFO database for "parent training" and "autism" 108 Education and Training in Autism and Developmental Disabilities June 2016 revealed 315 results whereas a search for "parent training" "autism" and "African American" or "black" produced one result (Farber Maharaj, 2005) and this study did not report including parents of children with ASD. There are a variety of reasons why African Americans may be less likely than other groups to participate in autism intervention research, such as the historic exploitation of African Americans in medical research (Skloot, 2010) the delay African Americans may experience in getting an autism diagnosis for their child (Mandell, Ittenbach, Levy, Pinto Martin, 2007) perceived power imbalances between researchers and research participants (Hilton et al. 2010) and traditional recruitment strategies being ineffective in connecting with potential African American participants (Spruill, 2010) The lack of African American participants in parent implemented behavior interventions for children with ASD is concerning given that African American children and Caucasian children may be equally likely to develop ASD (Dyches et al. 2004. and preliminary evidence indicating that African American children with ASD may be more likely to develop challenging behavior (Horovitz et al. 2011) Because research based, parent implemented interventions are likely to reflect the values, preferences, and results of families who have been involved in developing this research base to date, parent implemented behavior management strategies for children with ASD may be less useful, acceptable, or effective for African American families and may need to be adapted to better suit their values and needs. The purpose of this study was to examine the effectiv