Improving Children's Participation in Everyday Home Routines: Results from an RCT Assessing the Effectiveness of a Web-Based Parenting Tutorial

Background:  

Daily routines such as snack time and bath time provide opportunities for families to engage in rich social interactions. Children with ASD often experience difficulty participating in these family activities. This study examined the effectiveness of an interactive, web-based parenting tutorial for improving both proximal outcomes (parent and child behaviors during routines) and broad outcomes (parenting efficacy and stress and child social-communication).

Objectives:  

1. To examine the tutorial’s effectiveness in improving child and parent behaviors from baseline (T1) to post-tutorial completion (T2; 4 weeks after T1) and 4-week follow-up (T3; 8 weeks after T1).

2. To examine the extent to which the tutorial’s effect on broad outcomes at T3 is mediated by change in proximal outcomes from T1 to T2.

Methods:  

Parents of children with ASD (2─6 years old) were randomly assigned to the Tutorial (n=52) or Control (n=52) condition after they completed T1 surveys. Parents completed surveys about their children’s positive and negative behaviors during routines, and about their own use of appropriate verbal (e.g., providing praise) and nonverbal strategies (e.g., using visual supports) during routines. Children’s social-communication behavior was assessed using four domains of the Parent Interview for Autism-Clinical Version (PIA-CV): Social Relating, Imitation, Nonverbal Communication, and Language Understanding. Parenting stress was assessed using three subscales from the Parenting Stress Index (PSI-SF): Difficult Child, Parental Distress, and Parent-Child Dysfunction. Parenting efficacy was assessed using the Maternal Efficacy Scale.

Results:  

An intent-to-treat approach was applied using Maximum Likelihood in Hierarchical Linear Models (HLM) and Bayesian estimates in mediation analyses.

There were no group differences for any outcomes at T1. Children’s negative behaviors were significantly lower in the Tutorial group than the Control group at T2 (β=-.32,p=.04) and T3 (β=-.42,p<.01); there were no significant differences for positive behaviors. Parents’ use of appropriate verbal and nonverbal strategies was significantly higher in the Tutorial group than the Control group at T2 (β_VERBAL=.35,p<.01=;β_NONVERB=.39,p<.01) and T3 (β_VERBAL=.24,p<.01;β_NONVERB=.26,p=.03). 

Children’s Social Relating scores on the PIA-CV were significantly higher in the Tutorial group than the Control group at T2 (β=.29,p=.04) and T3 (β=.32,p=.04). Parent-Child Dysfunction on the PSI-SF was significantly lower in the Tutorial group than the Control group at T3 only (β=-3.91,p=.02).  Parenting efficacy tended to be higher in the Tutorial group than the Control group at T2 (β=1.63,p=.08) and T3 (β=1.65,p=.06). No other significant group differences were found.

Increases in parents’ use of appropriate verbal strategies and decreases in children’s negative behaviors during routines significantly mediated the tutorial effect on Parent-Child Dysfunction (indirect β_VERBAL=-3.75,95%CI[-5.70,-1.38];indirect β_NEGBEH=-1.59,95%CI[-3.11,-.56]) and Parenting Efficacy (indirect β_VERBAL=1.94,95%CI[.84,3.30];indirect β_NEGBEH=.71,95%CI[.20,1.44]) at T3. Decreases in child negative behaviors mediated the tutorial effect on Social Relating (indirect β=.10,95%CI[.03,.20]) at T3. No other proximal outcomes were significant mediators.

Conclusions:  

This tutorial was effective in improving key proximal and broad outcomes immediately and one month after its completion. Changes in parents’ verbal strategies and children’s negative behaviors during routines are potential mechanisms by which the tutorial impacted broad outcomes. Overall, the tutorial appears to be a promising, accessible way for empowering parents and improving parent-child interactions.