Effectiveness of modified parent training for mothers of children with Pervasive Developmental Disorder on parental confidence and children’s behavior

Brain & Development 33 (2011) 152–160 www.elsevier.com/locate/braindev

Original article

Effectiveness of modified parent training for mothers of children with Pervasive Developmental Disorder on parental confidence and children’s behavior Hiroko Okuno a,b,*, Toshisaburo Nagai a,b, Saeko Sakai b, Ikuko Mohri b, Tomoka Yamamoto b, Arika Yoshizaki b, Kumi Kato b, Masaya Tachibana b, Hidemi Iwasaka c, Masako Taniike b b

a Course of Health Science, Graduate School of Medicine, Osaka University, Japan Molecular Research Center for Children’s Mental Development, Graduate School of Medicine, Osaka University, Japan c Special Support Education Research Center, Nara University of Education, Japan

Received 29 October 2009; received in revised form 18 March 2010; accepted 20 March 2010

Abstract Aim: This study used parent training (PT), with modifications to smaller groups and shorter schedules (PTSS), for mothers of children with Pervasive Developmental Disorder (PDD). The usefulness of PTSS was evaluated according to the parent’s confidence and child’s behavior by questionnaire. Method: PTSS was used on 14 mothers of 14 children with PDD of preschool to elementary school age, and performed in small groups of 3–4 mothers each. One PTSS course comprised six consecutive sessions and was completed within three months. The sessions consisted mainly of training for parenting skills, understanding the children’s inappropriate behaviors, and helping the children adapt to school. The effectiveness of PTSS was assessed by changes in the scores for confidence degree questionnaire for families (CDQ) and the child behavior checklist (CBCL), determined before and after each course. Results: The average CDQ scores increased for 17 of 18 items after completion of the PTSS course in all 14 mothers. The change was statistically significant in five items. Increases in average CDQ scores were also seen in 10 of 18 items assessed in fathers, although none were significant. The CBCL total T-score decreased in 10 of 14 children (71.4%). The remaining four children showed an increased CBCL total T-score. Conclusion: These results indicated that PTSS is useful based on changes in the parents’ CDQ scores and children’s CBCL scores. Ó 2010 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved. Keywords: Parent training; Pervasive Developmental Disorder; Confidence degree questionnaire; CBCL

1. Introduction The prevalence of Pervasive Developmental Disorder (PDD) was recently estimated at 60 per 10,000 children *

Corresponding author at: Hiroko Okuno, Division of Children’s and Women’s Health, Course of Health Science, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka 5650871, Japan. Tel./fax: +81 6 6879 2539. E-mail address: [email protected] (H. Okuno).

[1]. PDD is subclassified into Autistic Disorder (AD), Asperger’s Disorder (Asp), and Pervasive Developmental Disorder not otherwise specified (PDD-NOS), according to the Diagnostic and Statistical Manual of Mental Disorders, version VI (DSM-VI). In addition, 50–70% of children with PDD show high intellectual ability, often referred to as high-functioning PDD [2,3]. Since 50–70% of children with PDD also show severe behavioral and emotional problems [4,5] if they do not receive optimal treatment, early intervention

0387-7604/$ - see front matter Ó 2010 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.braindev.2010.03.007

H. Okuno et al. / Brain & Development 33 (2011) 152–160

for children with PDD and continuous support for their families is essential. A parent training (PT) program developed more than 20 years ago at the University of California, Los Angeles (UCLA) is reportedly one of the most effective programs for changing parenting behaviors in parents of children with Attention Deficit Hyperactivity Disorder (ADHD) [6]. The PT program for ADHD contains essential information for parents such as characteristics of the disorder and treatment policies. It also seeks to generate acceptance of the disorder by the parent and formation of an excellent relationship between children and their parents. PT has now been used in many countries to instruct parents on dealing with their ADHD children. There are only a few reports on PT in Japan, including that by Iwasaka et al. [7]. The PT program described in their report [7] consisted of 10 sessions of 90 min each, which were held once every 2 weeks for the parents of school-aged Japanese children with ADHD. The program effectiveness was evaluated using the ADHD Rating Scale (ADHD-RS) and the confidence degree questionnaire for families (CDQ). On completion of the PT sessions, most children of the trained parents showed fewer behavioral and emotional problems, while all parents showed markedly reduced parenting stress and increased parenting self-esteem. Improvements were also achieved in the parent–child relationships [7]. Some reports have proposed applying PT for children with PDD and their families [8–11]. Butter et al. [12] and McIntyre [13] reported the effectiveness of a PT program for young children with PDD, although most of the children involved were of low IQ. This study used a modified PT program involving smaller groups and shorter schedules (PTSS) for this study. While the original PT programs often targeted 6–10 parents [14], we planned for smaller groups of 3– 4 people each, because the problems of children with PDD are more varied than for those with ADHD. Moreover, most of the original PT programs are designed for 8–12 sessions of 90–120 min each [14–19], requiring a total period of 5–6 months. The sessions in this study followed a shorter schedule (PTSS) to offer more parents the chance to join the PT program, and the purpose was to evaluate the effectiveness of PTSS for parents and their children with PDD. 2. Subjects and methods 2.1. Subjects Explanatory leaflets about PTSS were distributed to the families of children with PDD at the outpatient clinic of Osaka University Hospital, and 14 mothers subsequently subscribed to join the PTSS program. All their children were diagnosed with PDD in the outpa-

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tient clinic according to the DSM-IV-TR guidelines. Informed consent was obtained from all parents. The children were aged from 4.2 to 9.6 years, and were diagnosed as follows: seven with PDD-NOS, four with Asp, and three with AD. Five children with PDD-NOS or Asp also met the criteria for ADHD. In order to evaluate the definitive effectiveness of PT, the parents were instructed to not start any other medications or to not change the on-going medications for children during PTSS. The parents and children were also directed to not receive any other psychological therapies or training. Guardians or mothers who had previous experience of PT or showed serious psychological conditions, including a history of child abuse or severe cognitive deficit (IQ/DQ lower than 35), were carefully excluded by the attending doctor and the research team. The participation rate among the 14 mothers in the PTSS sessions was 94%. Two of the mothers could not be present in some sessions, and these were individually familiarized with the content and material of the missed sessions. Table 1 details the demographic data of the mothers and their families. All mothers were living with a partner and had an average age of 37.5 years (SD = 4.09). All children were primarily cared for by their mothers. 2.2. Characteristics of children Table 2 lists the clinical characteristics of the children involved in the study. The developmental levels were estimated using one or more developmental test batteries, i.e., the Wechsler Intelligence Scale for Children,

Table 1 Family demographics. Mother (n = 14) Age Mean (range of age) Married Living with partner

37.5 yr (31.0–45.0) 14 14

Level of education No university education University education Working

10 4 4

Father (n = 14) Age Mean (range of age) Working

39.4 yr (31.0–48.0) 14

Siblings Siblings Siblings Siblings Siblings

15 5* 5 6

*

present with developmental disorder quarreling with child having trouble at school

Autistic Disorder: 2; PDD-NOS + ADHD: 1; Asperger’s Disorder + ADHD: 1; Mild MR: 1.

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Table 2 Characteristics of children. Group

HF

Subject no.

Age y/m

Sex

Diagnosis

Main behavioral problems

Test battery (Chronological Age: CA)

IQ/DQ

107 VIQ 115, PIQ 96 sequential processing: 109 ± 8, simultaneous processing: 84 ± 9, cognitive processing: 94 ± 7, achievement: 97 ± 6 96 C-A 100, L-S 93 90 C-A 87, L-S 92 92 C-A 84, L-S 97 sequential processing: 121 ± 9, simultaneous processing: 92 ± 8, cognitive processing: 105 ± 7, achievement: 97 ± 5

FIQ/total DQ

7y 2 m 6y 4 m

M M

PDD-NOS Asp

HI, VF DF, R/A

WISC-III (CA6.10) K-ABC (CA6.1)

3 4 5 6

6y 5y 6y 9y

6m 8m 3m 6m

F F M M

PDD-NOS Asp PDD-NOS PDD-NOS

HI, DF, P P, U HI, DF HI, EI, SP, AlV

KSPD (CA4.0) KSPD (CA5.1) KSPD (CA5.6) K-ABC (CA7.11)

ADHD+

7 8 9 10 11

6y 8y 6y 8y 7y

3m 1m 1m 1m 7m

M M M M M

PDD-NOS Asp PDD-NOS PDD-NOS Asp

HI, SP, A HI, SP, AlV DF, R/A HI, EI, SP, DF HI, SP, DF, C, F

WISC-III (CA5.8) WISC-III (CA7.6) KSPD (CA5.3) WISC-III (CA7.6) WISC-III (CA7.4)

MR+

12 13

4y 2 m 6y 5 m

M M

Autistic Disorder Autistic Disorder

LD, HI, DF LD, DF, SI

KSPD (CA3.2) TIDQ (CA3.7)

63 48

14

5y 2 m

F

Autistic Disorder

SI, R

KSPD (CA5.2)

39

74 115 105 104 116

PTTS group

9 19

1 1

14 16 11

3 3 4 4

VIQ 87, PIQ 65 VIQ 118, PIQ 110 C-A 110, L-S 102 VIQ 123, PIQ 83 VIQ 99, PIQ 109

18 31 11 30 22

1 3 3 4 4

P-M 97, C-A 74, L-S 45 Movement: 67.5, reference/operation: 50.5, society: 35, eating, excretion and lifestyle: 36.5, understanding and language: 18.5 P-M 60, C-A 44, L-S 27

41 18

1 2

46

2

WISC- III: Wechsler Intelligence Scale for Children, Third Edition. KSPD: Kyoto Scale of Psychological Development [20]. The KSPD was adapted for children from newborn infants to 14-year-olds. Developmental age was estimated based on observations by the psychologist and according to the distinguishing features of the child’s behavior. K-ABC: Kaufman Assessment Battery for Children (Japanese version). TIDQ: Tsumori-Inage Developmental Questionnaire for children 0–7 years old was answered by the parents, and used to estimate the developmental age of the child [13]. In this case, the TIDQ questionnaire sheet suitable for children aged 3–7 years was used. PARS: The Parents Pervasive Developmental Disorder-Autism Society Japan Rating Scale [22]. The PARS scale incorporates 57 items, which together measure the degree of PDD severity. The questions were posed by an interviewer and answered by the mother or main foster care of a child with PDD. Main signs of childhood behavioral problems. Language delay (LD), hyperactivity/impulsiveness (HI), emotional instability (EI), school problems (SP), difficulty with following directions (DF), violence against friends (VF), restlessness/attention deficit (R/A), aggressiveness (A), use of abusive language and violence at home or at school (ALV), panic (P), uneasiness (U), carelessness (C), flashbacks (F), self-inflicted injury (SI), restlessness (R).

H. Okuno et al. / Brain & Development 33 (2011) 152–160

1 2

PARS score VIQ/PIQ, P-M, C-A, L-S, etc.

H. Okuno et al. / Brain & Development 33 (2011) 152–160

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Third Edition (WISC-III), the Kyoto Scale of Psychological Development (KSPD; a scale used in Japan [20]), the Japanese Kaufman Assessment Battery for Children (K-ABC), and the Tsumori-Inage Developmental Questionnaire for children 0–7 years old (TIDQ), which is also a scale used in Japan [21]. The characteristic features of PDD in the children were evaluated based on the mothers’ answers to questions in the Pervasive Developmental Disorders (PDD) – Autism Society Japan Rating Scale (PARS) [22]. This PARS score was assessed once before starting PTSS to evaluate the degree of PDD severity.

ous sessions. Learn how to cooperate with school and society. PTSS was conducted by a nurse and psychologists trained in the original procedures of PT. To maintain the quality of PTSS, two researchers presented with the leader, monitored the contents of each PTSS session, and recorded the mothers’ remarks and reactions. The record of each session was analyzed and discussed by the researchers, child neurologists, clinical psychologists, and nurse.

2.3. PTSS content

The effectiveness of PTSS was assessed using two scales: the confidence degree questionnaire for families (CDQ) and the child behavior checklist (CBCL). All mothers and their husbands were separately asked to complete these scales on two separate occasions; the first within one month prior to starting PTSS and second within one month after the last PTSS session.

The PTSS content used in this study was formulated based predominantly on the original report of PT programs by Frankel et al. [23], Barkley [15], and Iwasaka et al. [7], in conjunction with some new items recommended for parents of PDD children. According to the characteristic features of PDD children, and with reference to the programs by Butter et al. [12], the following contents, “Preventively adjust the environment and use the daily schedule to reduce the inappropriate behaviors” and “learn the crisis management and selfcontrol procedure” were added in the fourth and fifth sessions, respectively. 2.4. PTSS procedure PTSS was conducted for four small groups of candidates. Each group consisted of 3–4 persons selected in order of application. The schedule of one course comprised six consecutive sessions and was completed within 3 months. Each session lasted 90 min and was held every 1–2 weeks. Each session included group discussion, roleplay, viewing a videotape of their sessions, and weekly homework assignments [7,24]. The contents and points of intervention in six sessions were as follows. Session 1: Understand the general features of PDD and the principles of behavior management. Identify good behavior in the child and understand techniques to give praise. Session 2: Make a behavior checklist and pay attention to the child’s good behavior at home. Session 3: Notice and monitor appropriate behaviors of the child. Reward child for his/her appropriate behavior through giving praise, giving attention, and making physical contact. Session 4: Prepare an environment that aims to reduce inappropriate behaviors. Develop daily schedule and token economy. Session 5: Develop rules at home to reduce the child’s inappropriate behaviors by ignoring and using non-physical discipline techniques. Utilize the techniques of time-out, crisis management, and self control for emotional management. Session 6: Review all previ-

2.5. Evaluation methods

2.5.1. Confidence degree questionnaire for families (CDQ) The CDQ comprised 18 items, as listed in Table 3, which were developed with a few modifications of the original report by Iwasaka et al. [7] to incorporate the parents of PDD children. Each CDQ item was answered on a five-point scale. Since this scale has not been standardized, changes in each sub-item score were used for evaluation. When the CDQ score was increased after PTSS compared with before, the parent’s confidence to correspond to their children was considered to be increased. 2.5.2. Child behavior checklist (CBCL: Japanese version) The CBCL is a scale designed to evaluate child behavioural problems [25], (PDD ref.). The CBCL total T-score is usually regarded as “improved” when the score has decreased by five points or more compared with that recorded before PTSS and “slightly improved” if the decrease was less than five points [13]. It was regarded as “worse” when the score has increased by five points or more and “slightly worse” when the increase was less than five points. The children with PDD were also divided into three groups to discuss the effectiveness of PTSS in changing the CBCL score. The HF+ group comprised six children, four with PDD-NOS and two with Asp; none showed developmental delay. The ADHD+ group comprised five children, having PDD-NOS or Asp, but who also met the criteria of ADHD, and also showed no developmental delay. All children in these two groups recorded an IQ/DQ level over 70. The third, called the MR+ group, comprised three children with AD consistent with mental retardation (IQ/DQ lower than 70).

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Table 3 CDQ questions. How much confidence do you have in the following matters? Please circle the number applicable to the present feeling on a scale from 1 to 5, as indicated below. 1: I am not confident, 2: I am slightly not confident, 3: I am neither, 4: I am slightly confident, 5: I am confident. Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15 Q16 Q17 Q18

Do you watch your child’s growth without becoming impatient? Do you accept your child’s diagnosis of PDD? Do you let your child do what he/she can do by him/herself? Do you praise your child once or more a day? Do you prepare a place where your child can relax? Do you help your child to make friends? Can you cope with your child’s inappropriate behavior? Do you communicate adequately with the school about your child’s problems in school? Do you blame yourself less for having a child with PDD? Are you less worried about your child? Do you spend time on your own health or enjoyment? Do you quarrel less with your family due to your child’s behavior? Do you ask your family members to assist your child? Do you consult your family or friends about your troubles and not worry by yourself? Do you share your feelings with families who have children with a similar problem? Do you utilize medical facilities, and school and consultative organizations if required? Do you understand your child’s behavior and ideas/feelings/thoughts? Do you feel happy being with your child?

2.6. Ethical considerations The research protocol was approved by the Ethics Committee of the Department of Medicine of Osaka University. The research purpose and guarantee to protect privacy were explained orally and in written form to participants by the pediatrician. 2.7. Statistical analysis Data were analyzed with SPSS12.0 for Windows (SPSS, Japan). The CDQ and CBCL scores were compared using Student’s T test for nonparametric data. A P value of .05 or less was considered to be statistically significant. 3. Results 3.1. Changes in CDQ scores 3.1.1. Mothers The average CDQ scores increased for 17 of 18 items following the entire PTSS course in all 14 mothers. The increases were significant for five items: Q1: “Do you watch your child’s growth without becoming impatient?” [t(13) = 2.86, P < .05 ], Q5: “Do you prepare a place where your child can relax?” [t(13) = 3.31, P < .05], Q7: “Can you cope with your child’s inappropriate behavior?” [t(13) = 2.35, P < .05], Q15: “Do you share your feelings with families who have children with a similar problem?” [t(13) = 3.31, P < .05], and Q17: “Do you understand your child’s behavior and ideas/feelings/thoughts?” [t(13) = 3.23, P < .05] (Table 4).

1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5 1-2-3-4-5

3.1.2. Fathers Since four fathers did not reply to the post-PTSS questionnaire, their data was not included and the number of fathers in the final analysis was 10. Among the total of 18 items, the average CDQ score increased in 10 items after PTSS, however, no significant difference was seen in the overall CDQ score for fathers between pre- and post-PTSS evaluations. 3.2. Changes in CBCL T-scores 3.2.1. Changes of the individual CBCL T-scores Table 5 indicates the changes in CBCL total T-scores, as well as the Internalized and Externalized T-scores for each child. There were no significant differences in these scores among groups. However, the absolute score decreased in 10 of 14 children (71.4%), and of these, six children showed an “improvement” (one in the HF group, three in the ADHD+ group, and two in the MR+ group); four children showed “slight improvement”; and “slightly worse” was recorded for four children. Both the Internalized and Externalized T-scores showed similar changes to those as seen in the CBCL total T-scores. None of the children showed “worse” in their CBCL total T-scores. 3.2.2. Comparison among three groups Changes in average CBCL total T-score were compared among the three groups. The average total Tscore decreased for the ADHD+ group (69.0 ? 66.0) and MR+ group (64.7 ? 60.3), but slightly increased for the HF group (68.5 ? 68.8). The CBCL T-score subscores, called Internalizing and Externalizing, were also compared (Fig. 1.). The average Internalizing T-score decreased for all three groups: 65.2 ? 64.0 for the HF

H. Okuno et al. / Brain & Development 33 (2011) 152–160 Table 4 Total CDQ scores and subscale scores for mothers and fathers. CDQ subscale

Pre

Post

T-score

SD

Mean

SD

Mother (n = 14) Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15 Q16 Q17 Q18

3.29 3.93 3.86 4.07 3.43 3.43 3.21 3.64 3.08 2.79 3.36 3.21 2.93 4.14 3.71 4.29 3.00 4.14

0.73 0.73 0.66 0.10 0.51 0.94 0.89 0.74 0.64 1.05 0.74 0.89 0.92 0.66 0.73 0.73 1.04 0.86

3.93 4.29 4.07 4.43 4.00 3.86 4.00 3.86 3.39 3.50 3.79 3.79 3.36 4.50 4.29 4.00 3.64 4.50

0.83 0.91 0.47 0.76 0.68 0.86 0.88 0.77 1.19 0.76 0.58 0.43 1.22 0.52 0.61 1.36 0.93 0.52

2.86** 2.11* 0.90* 1.44* 3.31* 1.58** 2.35** 1.00* 1.48* 1.86* 1.58* 2.10* 1.15* 1.80* 3.31** 0.89 3.23** 2.11**

Father (n = 10) Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15 Q16 Q17 Q18

3.70 3.90 3.70 3.60 3.70 3.00 3.40 3.60 3.67 2.70 3.00 3.50 2.30 2.80 3.20 3.60 3.20 3.90

0.68 0.57 0.82 1.35 0.68 1.15 1.17 1.07 1.41 1.06 1.05 0.71 1.25 1.23 1.03 1.26 0.63 0.99

3.60 3.90 3.90 3.80 3.70 2.90 3.40 3.70 3.67 3.30 3.20 3.80 2.70 3.20 3.20 3.80 3.00 4.30

0.67 0.99 0.57 0.79 0.68 0.99 0.97 0.82 1.12 1.25 1.32 1.14 1.25 1.32 1.23 0.92 0.82 0.67

0.56 0.00 1.00* 0.61* 0.00 0.23 0.00 0.25* 0.00 1.96* 0.69* 0.67* 1.18* 1.50* 0.00 0.69* 1.00 1.50*

* **

Table 5 Total CBCL T-score, Internalized and Externalized T-scores for each child before (pre) and after (post) PTSS. Subject no.

Mean

Increase: not significant. Significant increase P < .05.

group, 61.2 ? 57.6 for the ADHD+ group, and 54.7 ? 53.3 for the MR+ group. The average Externalizing T-score also decreased markedly for the ADHD+ group (69.8 ? 64.4) and slightly for the MR+ group (60.3 ? 58.3), but not for the HF group (62.5 ? 64.5). 4. Discussion 4.1. Changes in parents’ CDQ score 4.1.1. Mothers The average CDQ scores increased in 17 of 18 items following PTSS in all 14 mothers, with five of these increases reaching statistical significance. The data presented here suggested that the degree of confidence in all mothers increased as a result of the PTSS course.

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CBCL total T-score

Internalizing T- score

Externalizing T- score

Pre

Post

Pre

Post

Pre

Post

HF 1 2 3 4 5 6

65 79 63 63 68 73

59** 83 62* 67 70 72*

68 70 68 45 72 68

63** 75 65* 49 73 59**

58 71 46 65 69 66

53** 74 42* 74 69 75

ADHD+ 7 8 9 10 11

74 77 72 56 66

69** 81 67** 55* 58**

70 75 58 45 58

58** 83 56* 42* 49**

67 70 86 61 65

62** 71 76** 57* 56**

MR+ 12 13 14

67 64 63

61** 59** 61*

54 52 58

52* 52 56*

65 56 60

59** 57 59*

* **

Slightly improved. Improved.

The single item not showing an increase was “Do you utilize medical facilities, and school and consultative organizations if required?”. This item measures ability with social connections, which take longer to establish compared to direct correspondence on behalf of their children. All mothers expressed an increased confidence in their ability to take care of their children. Iwasaka et al. [7] reported that the mother’s CDQ scores increased after 10 sessions, regardless of changes in their child’s behavior. The average CDQ scores of fathers also increased in 10 of 18 items after PTSS, although none of the changes were statistically significant. However, these results suggested that PTSS also had some favorable effects on fathers of children with PDD. In addition, throughout the sessions, the mothers were encouraged to explain the contents of the sessions to fathers and do the practice at home. In this study, the fathers showed no significant change between pre- and post-assessments. PTSS was done for mothers, and was indirectly conducted for fathers through the mothers. This process might account for the limited effect of PT on CDQ scores of fathers compared with the change seen for mothers. However, the increased CDQ scores of some fathers hinted that direct training would be more effective for making a difference with fathers. Mclntyre [13] proposed that families with autistic children tend to show more negative/inappropriate parent–child interactions than those with a child suffering from other developmental disabilities. He therefore emphasized the importance of training parents to focus

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Fig. 1. Changes to average CBCL scores for all children and for three subdivided groups in each score of total T, Internalizing and Externalizing, before and after PTSS.

on altering parent–child interactions [13]. In our study, most of the mothers expressed unease when instructed to praise their children at the beginning of the PTSS course, but they became more confident in parenting as the PTSS sessions proceeded.

[26], due primarily to an ongoing significant and pervasive deficit in social interaction skills [27,28]. Therefore, in the present case showing a high CBCL Externalizing T-score, some additional approaches such as social skill training or medications might be needed.

4.2. CBCL scores

4.3. The usefulness of smaller groups and shorter schedules used in PTSS

Individual improvements in CBCL total T-score were identified in 10 children, including clear improvement in six children and slight improvement in four, with no deterioration observed among the children. These results confirmed the effectiveness of PTSS, not only for the mother’s confidence, but also for the PDD child’s behavior. However, none of the changes were significant in statistical terms. 4.2.1. Difference among three groups The 10 children who showed improvements in CBCL total T-score comprised three of the six children in the HF group, four of five in the ADHD+ group, and all three in the MR+ group. The reason why fewer children in the HF group showed improvements remains unclear. To explore this result, we also measured two subscores, the Internalizing T-score and Externalizing T-score. In the above HF group, the average CBCL Internalizing T-score improved slightly in the HF group, whereas no improvements were found in the CBCL Externalizing T-scores. The CBCL Externalizing T-score assesses delinquency behavior and aggressive behavior separately. The children with high-functioning autism spectrum disorders (HFASDs; i.e., high-functioning autism [HFA], Asperger’s, and PDD-NOS) demonstrated a number of core features that significantly affect social performance and serve as the basis for interventions

This study involved conducting sessions with smaller groups of 3–4 people, which was different from the original PT report. PT provides a chance for parents to meet and talk together, feel sympathy, and enhance their own self-esteem. However, some parents in this study reported difficulty interacting with other parents in a group, although all parents expressed satisfaction after PTSS. Small group training might make it easier for parents to join in the group sessions. Earlier intervention for children with PDD has been associated with a better prognosis [29]. To this end, PTSS might be able to shorten the waiting period for parents of children with PDD for the intervention program to begin. Most reported PT programs comprise 8–12 sessions over more than six months, and have a dropout rate of 30% or more [14]. In contrast, this study had only one dropout among 14 mothers. This suggests that the parents were easily able to complete the PTSS sessions. This study included new PTSS contents to those previously reported, primarily for the parents of PDD children. These additions were “Preventively adjust the environment and use the daily schedule to reduce the inappropriate behaviors” in the fourth session and “learn the crisis management and self-control procedure” in the fifth session. The findings suggested that

H. Okuno et al. / Brain & Development 33 (2011) 152–160

these new contents were useful for the study participants. Since the present study was uncontrolled, we could not reach any conclusions on the possible benefits of this PTSS course over the original PT. However, it can be stated that the PTSS is a useful program for the target participants as reported for the PT. This study is the first to assess PTSS effects on the parents of children with PDD, and the results showed it to be effective for improving the parent’s confidence and the child’s behavior. 5. Conclusion This research evaluated the effectiveness of PTSS according to changes in the parents’ CDQ scores and children’s CBCL scores. The results provided the first study of parent training in smaller groups and with shorter schedules than previously reported, as well as of parents with PDD children. The results showed positive changes in both parents and children. The number of cases in the present study was too small to draw definitive conclusions about behavioral changes in PDD children, and further studies will be needed.

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

Acknowledgments The authors thank the parents involved in this research project for their outstanding cooperation. We also appreciate the support and guidance provided by staff members of the Molecular Research Center for Child Mental Development, Graduate School of Medicine, Osaka University. This paper was presented at the 52nd Annual Meeting of the Japanese Child Neurology Congress in Yonago, Japan.

[15] [16] [17]

[18] [19]

References [20] [1] Fombonne E. Epidemiological surveys of autism and other pervasive developmental disorders: an update. J Autism Dev Disord 2003;33:365–82. [2] Baird G, Simonoff E, Pickles A, Chandler S, Loucas T, Meldrum D, et al. Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet 2006;368(9531):210–5. [3] Gillberg C, Cederlund M, Lamberg K, Zeijlon L. Brief report: “the autism epidemic”. The registered prevalence of autism in a Swedish urban area. J Autism Dev Disord 2006;36:429–35. [4] Gadow KD, DeVincent CJ, Pomeroy J, Azizian A. Psychiatric symptoms in preschool children with PDD and clinic and comparison samples. J Autism Dev Disord 2004;34:379–93. [5] Tonge BJ, Einfeld SL. Psychopathology and intellectual disability: the Australian child to adult longitudinal study. In: Glidden LM, editor. International review of research in mental retardation, vol. 26. San Diego, CA: Academic; 2003. p. 61–91. [6] Pelham Jr WE, Lang AR, Atkeson B, Murphy DA, Gnagy EM, Greiner AR, et al. Effects of deviant child behavior on parental

[21]

[22]

[23]

[24]

[25]

159

alcohol consumption: stress-induced drinking in parents of ADHD children. Am J Addict 1998;7:103–14. Iwasaka H, Shimizu T, Iida J, Kawabata Y, Chikaike M, Onishi T, et al. Efficacy of a parenting program as attention deficit/ hyperactivity disorder (AD/HD) therapy (in Japanese). Jido Seinen Seishin Igaku To Sono Kinsetsu Ryoiki 2002;43:483–97. Harris SL, Handleman JS, Arnold MS, Gordon RF. The Douglass developmental disabilities center: two models of service delivery. In: Handlemann JS, Harris SL, editors. Preschool education programs for children and their families. 2nd ed. Austin: Pro-Ed; 2000. p. 233–60. Lvaas OI, Smith T. Early and intensive behavioral intervention in autism. In: Kazdin AE, Weisz J, editors. Evidence-based psychotherapies for children and youth. New York: Guildford; 2003. p. 325–40. Committee on Educational Intervention for Children with Autism. Educating children with autism. Washington DC: National Academy Press; 2001. Romancyk R, Lockshin S, Matey L. The children’s unit for treatment and evaluation. In: Handelmann JS, Harris SL, editors. Preschool education programs for children and their families. 2nd ed. Austin: Pro-Ed; 2000. p. 49–94. Butler EM, Aman MG, et al. (Research Units on Pediatric Psychopharmacology [RUPP] Autism Network). Parent training for children with pervasive developmental disorders: A multi-site feasibility trial. Behav Interv 2007;22:179–99. Mclntyre LL. Parent training for young children with developmental disabilities: randomized controlled trial. Am J Ment Retard 2008;113:356–68. Scott S. Parent training programmes. In: Rutter M, Taylor E, editors. Child and adolescent psychiatry. Oxford: Blackwell; 2002. p. 949–67. Barkley RA. Defiant children: a clinician’s manual for parent training. 2nd ed. New York: Guilford Press; 1987. Sanders MR, Dadds MR. Behavioral family intervention. Boston, MA: Allyn and Bacon; 1993. Webster-Stratton C, Herbert M. Troubled families-problem children: working with parents: a collaborative process. Chichester [England]: J. Wiley; 1994, [chapter 4, Working with parents who have children with conduct disorders: a collaborative process. p. 105–65]. Hembree-Kigin TL, McNeil CB. Parent–child interaction therapy. New York: Plenum Press; 1995. Forehand RL, McMahon RJ. Helping the noncompliant child: a clinician’s guide to parent training. New York: Guilford Press; 1981. Shimazu M, Ikuzawa M, Nakase A. Manual of the Kyoto Scale of Psychological Development (in Japanese). Kyoto: Kyoto Kokusai Shakai Fukushi Center; 1983. Tsumori M, Inage N. Diagnostic techniques for mental development in infant and early childhood (in Japanese). Tokyo: DaiNippon Tosho; 1961. Adachi J, Yukihiro R, Inoue M, Tsujii M, Kurita H, Ichikawa H, et al. Reliability and validity of short version of Pervasive Developmental Disorders Autism Society Japan Rating Scale (PARS); a behavior checklist for people with PDD (in Japanese). Seishin Igaku 2008;50:431–8. Frankel F, Myatt R, Cantwell DP, Feinberg DT. Parent-assisted transfer of children’s social skills training: effects on children with and without attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1997;36:1056–64. Webster-Stratton C. The incredible years training series. OJJDP Juv Justice Bull. 2000 June: 1–23. Available from: http://www. ncjrs.gov/pdffiles1/ojjdp/173422.pdf. Achenbach TM, Edelbrock C. Manual for the child behavior checklist and revised child behavior profile. Burlington, VT: T.M. Achenbach; 1983.

160

H. Okuno et al. / Brain & Development 33 (2011) 152–160

[26] Lopata C, Thomeer ML, Volker MA, Nida RE, Lee GK. Effectiveness of a manualized summer social treatment program for high-functioning children with autism spectrum disorders. J Autism Dev Disord 2008;38:890–904. [27] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. text revision. Washington, DC; 2000.

[28] Church C, Alisanski S, Amanullah S. The social, behavioral, and academic experiences of children with Asperger syndrome. Focus Autism Other Dev Disabil 2000;15:12–20. [29] Sugiyama T. Infant and preschool developmental screening for early care (in Japanese). Nyuyoji Igaku Shinrigaku Kenkyu 1996;5:1–18.