Treatment of Behavior Problems Among School-Age Children with Autism Spectrum Disorders

Background:   Disruptive behaviors (e.g., aggression, tantrums, and self-injury) are commonly reported in children with Autism Spectrum Disorder (ASD; Farmer & Aman, 2011; Guttmann-Steinmetz et al, 2009; McClintock et al, 2003; Bauminger et al., 2010; RUPP Autism Network, 2002, 2005) and represent one of the most common reasons for referral to pediatric and mental health clinics (Masse et. al, 2007).  Disruptive behavior often leads to increased use of psychiatric services and medications, suboptimal participation in educational and intervention programs, increased emotional and physical distress in the child and family, and poor social interactions with family members and peers (Brosnan and Healy, 2011; Kanne and Mazurek, 2011; Farmer & Aman, 2011; Aman et al, 2009). A behavioral intervention that has led to improvements in behavior, parent-child interaction and compliance among children with oppositional-defiant behaviors is Parent-Child Interaction Therapy (PCIT).  To date, few studies have been conducted to evaluate the effectiveness of PCIT among children with ASD and disruptive behaviors (Masse, McNeil, Wagner, & Chorney, 2008; Soloman, Ono, Timmer & Goodlin-Jones, 2008).

Objectives:   The purpose of this study was to evaluate the effectiveness of PCIT to reduce disruptive behavior problems among school aged (5-10 years) children with ASD, improve parent-child interactions, and improve parental practices, efficacy and mental health. A secondary objective was to differentiate treatment gains made in the two phases of treatment (Child-Directed Interaction; CDI and Parent-Directed Interaction; PDI) to determine if PCIT should be modified for this population.

Methods:   This prospective randomized clinical trial used a 2x2 quasi experimental design to compare PCIT versus community treatment as usual and medication status (psychiatric medication versus no psychiatric medication). Study participants included thirty female and three male caregivers and their 5-to 10-year-old children. Families were randomly assigned to treatment (TG) or the control group (CG).

Results:   Study children were mostly boys (87%), with a mean age of 7.5 (SD=1.47). Racial/ethnic composition was 20% African American, 63% Caucasian, and 19% other. Fifteen TG and 10 CG families completed the study.  On parent report measures, children in the treatment group demonstrated a significant decline in problem behavior intensity (Wilk’s λ (2,21) = 16.179, p < .001; Partial η² = .606) and externalizing problems (Wilk’s λ (2,19) = 7.571, p = .004; Partial η² = .444) compared to the children in the control group. In addition, treatment families showed a statistically significant time by compliance ratio change (Wilk’s λ (2,17) = 5.35, p = .017; Partial η² = .401), with significant relative improvement occurring at post-test (F(1,18) = 8.48, p = .009).  Exploratory analyses found that children with severe ASD made the greatest treatment gains during CDI with little change after PDI, whereas children with moderate to mild ASD made significant gains across both phases of treatment.

Conclusions:   Families who completed PCIT demonstrated significant improvement in child problem behaviors and parent-child interactions. These results demonstrate that PCIT can be effectively translated to children with ASD and disruptive behavior and may need to be modified based on ASD severity.