A Review of Parent Training in Child Interventions: Applications to Cognitive–Behavioral Therapy for Children with High-Functioning Autism
Rev J Autism Dev Disord
A Review of Parent Training in Child Interventions: Applications to Cognitive-Behavioral Therapy for Children with High-Functioning Autism
Tyler A. Hassenfeldt 0 1
Jill Lorenzi 0 1
Angela Scarpa 0 1
0 J. Lorenzi Marcus Autism Center, Children's Healthcare of Atlanta , Atlanta, GA , USA
1 T. A. Hassenfeldt (
The number of individuals with autism spectrum disorders (ASD) diagnoses is increasing rapidly, indicating a need for multi-faceted interventions. The addition of a parent training component to cognitive-behavioral therapy (CBT) has been effectively used to treat a variety of psychological disorders in children to support generalization of skills and to reduce the burden of intensive therapy by using parents as cotherapists. We review these treatments as applied to childhood anxiety, oppositional/conduct, and attention-deficit/hyperactivity problems, as well as ASD-specific treatments that combine CBT with a parent component. The Stress and Anger Management Program, a 9-week emotion regulation treatment for school-aged children with high-functioning ASD, is described here as one example of a group CBT intervention that includes parent training.
ASD; Cognitive behavioral therapy; Parent training; Intervention; School-aged children
Individuals with autism spectrum Disorders (ASD)
demonstrate social communication difficulties and perseverative/
repetitive interests or behaviors
. Recent estimates from the Centers for Disease
Control and Prevention suggest that 1 in every 68 children
meets criteria for an ASD
(Centers for Disease Control and
. This high prevalence indicates that the need
for timely, developmentally appropriate, and practical
interventions is more critical now than ever before. Behavioral and
cognitive–behavioral treatments have been found to be the
most effective interventions for secondary and comorbid
conditions in individuals with ASD
(Dawson and Burner 2011;
Scarpa et al. 2013a)
. Other co-occurring conditions, such as
anxiety, attention difficulties, disruptive behaviors,
depression, and general issues with emotion dysregulation, are often
seen in children and adolescents with ASD
(Levy et al. 2010;
Mayes et al. 2011; Tonge et al. 1999; White et al. 2009)
The current review focuses only on children formerly
thought of as having high-functioning ASD (HFA), meaning
that they do not have intellectual impairment. Despite an
average or above average level of cognitive functioning, these
children still show difficulties in other areas, such as social
(Landa 2000; Paul et al. 2009)
(e.g., Frankel and Myatt 2003; Frankel et al. 2010;
Laugeson et al. 2012)
, some academic skills
(Minshew et al.
1994; Estes et al. 2011)
, activities of daily living
(Klin et al.
2007; Kanne et al. 2011)
, and social skills that may impact
later school-to-work transitions
(Higgins et al. 2008; Hurlbutt
and Chalmers 2004)
. These children also show more
emotional difficulties than their peers, continuing into
adolescence. For example, researchers found that adolescents with
HFA had more negative thoughts, behavioral problems, and
life interference as compared with typically developing (TD)
peers and peers with anxiety disorders, and the ASD
participants had as much anxiety as their peers with anxiety
(Farrugia and Hudson 2006)
. Therefore, the addition of
cognitive techniques to the traditional behavioral strategies
used to treat symptoms of ASD is necessary, appropriate,
and novel. Though others exist, we discuss the Stress and
Anger Management Program
(STAMP; Scarpa et al. 2013b)
herein as one program example of cognitive–behavioral
therapy (CBT) with a parent training (PT) component.
Over the last several decades, inclusion of parents has been
noted as an integral part of behavioral treatment for children
with ASD (Frankel and Myatt 2003;
Units on Pediatric Psychopharmacology (RUPP) Autism
Network 2007), but less work has been done to include parents as
facilitators of change in cognitive behavioral interventions.
Evidence-based CBT is considered to be the gold standard for
treatment of a variety of psychological disorders and is most
successful for children when it has been modified to be
(Kendall and Chodhury 2003;
Weisz and Kazdin 2010)
. Within CBT, behavioral strategies
seek to modify self-destructive actions, and cognitive
techniques target how an individual thinks about a situation or
processes information. In combination, CBT allows clinicians
to change antecedent conditions and/or pair motivating
reinforcers to help encourage positive behavior and promote new
skills, while also focusing on changing maladaptive
cognitions or thought processes. Additionally, when used to treat
anxiety, CBT often systematically exposes the child to the
feared stimulus in order to confront and overcome the fear.
Emerging evidence suggests that, when modified to a
child’s developmental level, CBT can be an appropriate and
effective intervention for a variety of psychopathologies
(Weisz and Kazdin 2010; Sofronoff et al. 2005; Scarpa and
Lorenzi 2013; Kendall et al. 2008)
. When modifying CBT for
children, it is often recommended to introduce parents as a
valuable piece of the therapeutic process. We propose that this
is equally, if not more, true for children with ASD, for whom
initiative for change and awareness of difficulties may be
intrinsically low, and generalizability of skills to settings
outside the clinic can be especially problematic.
Due to the oft-noted importance of parent inclusion in ASD
interventions and the need for further refinement of PT,
specifically in cognitive–behavioral programs for ASD, we aim
to review behavioral and cognitive–behavioral PT
interventions for children with and without ASD, noting components
that appear to be most helpful. While this is not a
comprehensive review, we present an overview of these treatments with
the goal of summarizing the most effective content and
delivery factors. We will end with a brief description of the
development of PT within STAMP, a caregiver-assisted CBT
intervention for the treatment of emotion dysregulation in young
children with ASD, as a program example that may help guide
future work in this area. While there are other successful CBTs
for children with ASD that include family involvement
Reaven and Blakeley-Smith 2013; Sofronoff et al. 2007)
STAMP is notable for filling the need for an emotion
regulation treatment with PT for children young children (ages 5–
7 years) for whom parent involvement is critical.
Importance of PT
Including PT in child-focused treatments is a common
modification for a wide range of childhood disorders. However,
there is variability with regard to the structure of PT and level
and nature of parental involvement. Some of the common
diagnostic areas in which parents are often involved in
treatment include children with disruptive/oppositional behaviors,
tics, attention-deficit/hyperactivity disorder (ADHD), anxiety
disorders, eating disorders, and ASD (which will be discussed
in a later section). Despite the variability associated with PT
components of treatment, many programs have asserted the
importance of this modification.
Parent management training (PMT) and behavioral parent
training (BPT) are two commonly used terms that both
generally refer to instructing parents to modify their child’s
behavior in the home. For the purposes of this paper, any type of
treatment that includes parent instruction will be considered a
PT program. Although the child is the target of treatment,
many programs that include PT do not directly involve the
child in every session. When the child is not present,
information and skills that are learned by parents in sessions are
then applied in the home.
PT with Oppositional/Conduct Problems
In a meta-analysis of 26 studies that included 36 comparisons
between experimental (i.e., BPT) and control (e.g., wait-list
control or therapy other than BPT) groups for preschool/
elementary school-age children with antisocial behavior
(e.g., aggression, tantrums, noncompliance), positive effect
sizes (ES) were found for all five outcome variables analyzed:
overall child outcome (mean ES=0.86), parental report of
child outcome (mean ES = 0.84), observer report of child
outcome (mean ES=0.85), teacher report of child outcome
(mean ES=0.73), and parental adjustment (mean ES=0.44)
(Serketich and Dumas 1996)
. Overall, the average child
whose parent participated in a BPT program was better
adjusted after treatment than the average child whose parent
received another treatment or no treatment. This evidence
supports the involvement of parents when children are the
focus of treatment.
A separate meta-analysis compared the effectiveness of
BPT and CBT for youth with antisocial behavior between
the ages of 3 and 12 years
(McCart et al. 2006)
metaanalysis of 71 published outcome studies considered BPT to
be training that instructed parents/caregivers in the use of
behavior management concepts (e.g., differential
reinforcement) and CBT to be therapy targeting maladaptive social–
cognitive processes in youth to address topics such as social
skills training, problem solving, or anger management.
Results indicated that BPT was more effective for young children
(preschool to school-age), while CBT was more effective for
older children. This suggests that developmental issues are
important to consider when determining the appropriateness
of a particular intervention for any given child, with parent
involvement potentially more beneficial in early childhood.
However, this meta-analysis did not include programs that
combined BPT and CBT approaches and cautioned that a
number of studies have indicated that broad-based
interventions (e.g., involvement of schools, parents, and youth) are
more powerful than either BPT or CBT alone
and Borduin 1990; Webster-Stratton and Hammond 1997)
Scahill et al. (2006)
investigated an intervention for 24
children between the ages of 6 and 12 years who had both
tics and disruptive behaviors. Participants were randomly
assigned to either 10-week PMT combined with treatment
as usual (e.g., clinical services including parent education,
monitoring of symptoms, medication management, and/or
child psychotherapy) or treatment as usual only.
Participants that received the combination of PMT and treatment
as usual were more likely than those who received only
treatment as usual to be rated as “much improved” or
“very much improved” by clinicians that were blind to
group assignment (64 % of children in combination
group, 17 % of children in control group). Additionally,
the group that also received PMT evidenced a 51 %
decline in parent-reported disruptive/oppositional
behavior, while the control group only evidenced a 19 %
decline (effect size = 0.96). Thus, the addition of parent
management to treatment as usual in this group of
children with tics and disruptive behavior disorders led to
significant improvements in behavior.
A similar study compared the PMT-Oregon Model
(PMTO; Patterson 2005)
to regular services (described as
being an active and appropriate alternative to PMTO that
was offered by therapists in the comparison group; actual
services received included family therapy, behavior therapy,
cognitive therapy, humanistic-existential therapy, and other/
eclectic therapy) in a total sample of 112 children between the
ages of 4 and 12 years with conduct problems
. The purpose of PMTO is to use ecological and
transactional principles to break patterns of interaction
between children and parents that escalate disruptive behavior,
and for parents to learn more effective discipline and problem
solving. Results indicated that children of parents that
received PMTO demonstrated better teacher-reported social
competence and fewer parent-reported externalizing
symptoms than those children who received regular services.
Additionally, parents who received PMTO were found to use
better disciplinary skills post-treatment than those whose
children had received regular services. These results support using
parents as the agent to improve outcomes for their children
with conduct problems, with some evidence of generalization
from the home to the school. Similar to the study by McCart
and colleagues (2006), children in the younger age group
(4–7 years) seemed to benefit more from PMTO than did
children in the older age group (8–12 years).
Another well-known program designed for parents of
children (ages 2–8 years) with noncompliance problems is a
curriculum known as Parenting the Strong-Willed Child
(PSWC; Long and Forehand 2002)
. This program trains
parents to increase positive attention for good behavior, provide
appropriate consequences, provide clear instructions, and
other basic concepts related to behavior modification. In an
independent evaluation of 71 parents who participated in the
PSWC program, results indicated significant improvements in
child behavior problems (both frequency and intensity, as
reported by parents) and self-reported parenting behavior
(Conners et al. 2007)
. As such, this study also provides
evidence for effectively treating children through a parent
The Incredible Years Program
has evidenced success in both preventing and treating
behavior problems in children ages 2–12 years. In this
program, parents learn to teach children important skills through
play, reduce critical and violent discipline, improve parental
self-control and problem solving, increase social support, and
improve involvement in school-related activities. Many
randomized controlled trials have demonstrated evidence of
improvements in child behavior across various contexts
following the implementation of this treatment program
Webster-Stratton 1990; Miller and Rojas-Flores 1999; Taylor
et al. 1998)
Foster et al. (2007)
acceptability curves to analyze the various components of
IYP, finding that the most cost-effective treatment involved a
combination of components. For problems at school, the
combination of parent and teacher training was found to be
the most cost-effective; for problems at home, the
combination of child, parent, and teacher training was found to be the
most cost-effective. Finally, in one study of the IYP in
twentyfive 2- to 5-year-old children with developmental delay,
preliminary evidence supported the efficacy of this program in
reducing negative child and parent behavior
PT with ADHD
ADHD is another childhood disorder for which parents are
commonly involved in treatment, often in the form of PT.
Fabiano et al. (2012)
) used a wait-list controlled trial to
investigate the efficacy of an 8-week BPT program designed
for fathers of children with ADHD. In this study, participants
included 55 fathers of children with ADHD between the ages
of 6 and 12 years. The intervention consisted of BPT during
the first half of each session on topics related to attending to
positive behavior, issuing effective commands, problem
solving, and using time out, while the second half of each session
allowed the fathers to interact with their children and practice
the skills they had just learned, while receiving feedback from
clinicians. Compared with the wait-list control group, the
fathers in the treatment group demonstrated lower rates of
negative talk and higher rates of praise during parent–child
interactions. Additionally, fathers reported a reduction in the
intensity of their child’s problem behaviors. However,
maintenance of these gains was somewhat limited at 1-month
follow-up. Future research might investigate strategies for
maximizing treatment gains over time in PT programs.
BPT in combination with routine clinical care was directly
compared with routine clinical care alone in a randomized
controlled study of 94 children with ADHD between the ages
of 4 and 12 years
(van den Hoofdakker et al. 2007)
combination of BPT and routine clinical care was superior to
routine clinical care alone in improving both internalizing and
behavioral problems. Interestingly, children assigned to the
routine care alone condition were prescribed more medication.
Thus, BPT over and above routine clinical care resulted in an
enhancement of the effectiveness of routine clinical care by
improving behavioral and internalizing problems, and
potentially by also limiting the need for medication in children with
Another study on children with ADHD targeted social
competency and friendship quality in this population rather
than behavioral problems
(Mikami et al. 2010)
. Mikami and
colleagues included 62 parents of children with ADHD (ages
6–10 years) and assigned half to a parental friendship
coaching intervention and half to a no-treatment control
group. Parents of 62 children without ADHD served as TD
comparisons. The parental friendship coaching component
(treatment group) used the parent as the agent of change and
topics of training included teaching children good play skills,
inviting a peer to have a playdate, and meeting new friends.
Following treatment, children of parents who received
friendship coaching evidenced more positive parent reports of social
skills, reductions in parent-reported conflict and
disengagement shown on playdates, and improved teacher-reported
social acceptance, with continued improvement at 1-month
follow up. Additionally, the parental friendship coaching
program led to increases in parent facilitation and involvement of
the child’s playgroup and reduced parental criticism of the
child. This evidence suggests that parent training in parent
friendship coaching can have a significant impact on child
PT with Anxiety Disorders
Interventions in children with anxiety disorders have shown
similar findings to many of those previously mentioned in
studies of other childhood disorders. Whereas the prior studies
reviewed above utilized primarily behavioral approaches,
however, these studies emphasize cognitive–behavioral
approaches in the treatment of anxiety and work with both the
child and the parent in therapy (either individually or in
Barrett et al. (1996)
, for example, demonstrated
that the combination of individual CBT with an added family
component was superior to individual CBT alone in young
children with anxiety disorders (ages 7–10 years), but not in
older children (ages 11–14 years), as measured by the
proportion of participants who were diagnosis-free following
treatment. This finding also persisted at 12-month follow-up.
Another CBT PT group intervention with parents of anxious
children, aged 9 years or younger, found that children whose
parents participated in the intervention evidenced less anxiety
post-treatment than children whose parents were in the control
(Cartwright-Hatton et al. 2010)
. These gains were also
maintained at 12-month follow-up.
As demonstrated above, a wide variety of studies on an
extensive range of childhood disorders have evidenced results
supporting PT in many forms. Impacts range from reduced
symptomology or improved quality of peer relationships for
the child to improved adjustment in the parent. Several studies
also demonstrated the superiority of the combination of PT
with routine treatment in comparison to routine treatment
alone, particularly in young children. Thus, there is substantial
evidence in support of the value of behavioral and cognitive–
behavioral PT programs for childhood disorders including
ADHD, anxiety disorders, and disruptive/oppositional
PT with ASD
PT treatments clearly have demonstrated value for children
who suffer from various disorders of childhood; their
counterparts in the field of ASD interventions have developed
more recently, within the past 5–10 years. In the past, autism
was theorized to be caused by parental psychopathology,
especially emotionally detached “refrigerator mothers”
. In contrast, contemporary science recognizes
the structural and functional neural differences in children
with and without ASD
(see Buxbaum and Hof 2013)
parents are embraced and considered to be a valuable part of
the therapy session. Parents are an important, readily
accessible resource and can be co-therapists in the home. For multiple
reasons, including the need to start treatment early and
intensively to maximize benefits, it has become cost-effective to
use parents as a way to practice new skills, generalize skills
between the therapeutic setting and the home, and maintain
It has become increasingly apparent that intensive
behavioral treatment of 20 to 40 h per week leads to the most
positive gains in children with ASD
this represents a significant financial and time investment for
families. While private insurance companies may cover some
portions of these expenses, rarely are families reimbursed for
all treatment expenses
(Anan et al. 2008)
. Families without
private insurance often struggle to acquire any type of therapy
for their child, much less 20–40 h per week.
As a result, using parents as co-therapists has become a
valuable way to increase the intensity of therapy and often
supplements clinician-provided therapies. In this way, the
many social and communication skills that young children
with ASD struggle to learn are taught and practiced across
multiple settings, including the naturalized home
environment. Additionally, once trained, parents are often able to
teach other family members or caretakers to work with the
child, creating further opportunities for learning and a wider
network of co-therapists
(Koegel and Koegel 2006; Koegel
et al. 2010)
. Group therapy formats with PT components have
also been used as a cost-effective and efficacious way of
educating parents (Brookman-Frazee et al. 2009). Groups
allow professionals to provide therapy for more families at
one time, increasing their availability and thereby serving the
community more effectively.
Many children with ASD do not receive a diagnosis until
they are toddlers or preschool age. At this point, prior to
school enrollment, the child is less likely to be involved in
specialized services such as outside therapy or HeadStart.
Therefore, the parent is the “first line of defense” and can
begin to work towards treatment gains starting from the initial
diagnosis. It has been found that treatments are more powerful
when they begin early, as soon as possible after diagnosis
. Before formal or structured programs of
treatment can be arranged, the parent is the child’s window to the
world, and many parents use informal techniques to teach
their child with ASD about the social world around them.
Additionally, while teachers change yearly and therapists have
a high turnover rate, the parent is likely to be the most
consistent figure throughout the child’s development
(McConachie and Diggle 2007; Koegel et al. 2010)
are more likely to have insight into their child’s needs and
motivations, further underscoring the importance of utilizing
parents as a resource in the therapeutic environment.
Targets of programs designed for children/adolescents with
ASD that incorporate PT include social skills
(Reaven et al. 2012; Sofronoff et al.
2005; Storch et al. 2013; Wood et al. 2009)
, anger (Sofronoff
et al. 2007), and both anxiety and social skills
(White et al.
. However, CBT programs for children with ASD that
include PT are generally lacking in the early childhood (i.e.,
5–7-year-old) age range.
Additional Factors Contributing to the Success of PT in Children with ASD
The Positive Influence of PT on Parents
Brookman-Frazee et al. (2009)
noted that parents who are
intentional and dedicated to treatment, and who consistently
attend sessions, are found to elicit more improvements in their
children. Parents with clinically significant levels of stress in
their life (e.g., marital discord, depression, negative affect,
etc.) showed poorer child outcomes as compared with parents
without clinically elevated levels of stress
(Robbins et al.
. Although these types of stress may inhibit the parent’s
ability to serve as a co-therapist, these stressors are not
typically targets of treatment in PT. Parental stress often
accompanies an ASD diagnosis, and decreases in parental stress are
viewed as positive secondary outcomes as the child achieves
(Koegel et al. 1996; Rezendes and Scarpa
Conversely, when treating disruptive behavior disorders, it
is thought that parental psychopathology may exacerbate the
child’s externalizing behaviors and that treating the source of
the parent’s mental health issues may result in fewer child
(Brookman-Frazee et al. 2009)
. In fact,
PT in treatment of children with ASD has been to shown to be
associated with not only improved child outcomes, but with
improvements in parental mental health and adjustment
(Tonge et al. 2006)
, including increased positive affect
(Koegel et al. 1996; Schreibman et al. 1991)
, reduced stress
(Moes 1995), reduced symptoms of depression in mothers
(Blackledge and Hayes 2006; Bristol et al. 1993)
increased feelings of parent self-efficacy and confidence
(Sofronoff and Farbotko 2002; Pillay et al. 2011)
. As parents
of children with ASD are more likely to have parenting stress
than the parents of TD children
(Sanders and Morgan 1997;
Dabrowska and Pisula 2010; Estes et al. 2013)
, children with
(Sanders and Morgan 1997)
, or children with
(Estes et al. 2013)
, any potential stress
relief for parents would be beneficial.
In a meta-analysis of 17 PT programs for developmental
disabilities, four of which were autism-specific,
Singer et al.
found evidence that PT successfully decreased parental
stress, especially depressive symptoms. Parent–child
interactions also improved after PT interventions. For example,
Koegel et al. (2002)
implemented a short-term, intensive PT
program for families who were geographically distant from
the autism center. After 25 h of training, parents returned
home to implement the pivotal response treatment (PRT) skills
they had learned. On follow-up (ranging from 3 to 12 months
after completion), the authors found that parents had
successfully generalized and maintained the PRT skills in the home
environment. Participation in the PT program led to
improvements in child expressive language, parent affect during
parent–child interactions, and parent fidelity in treatment
Laski et al. (1988)
found that parents were able
to generalize the skills they had learned through ASD-specific
PT to TD siblings. These studies suggest that parental factors,
such as stress and affect, are important to consider and may
improve when PT is included in the treatment of children with
In treatment of ASD symptoms, the lack of focus on
parenting style and techniques directly contrasts with
treatment models for other externalizing disorders
(BrookmanFrazee et al. 2009), which aim to specifically identify
maladaptive patterns of parenting and correct them. Although the
PT interventions for both sets of disorders provide direct
instruction to build skills in parents, they differ in their
rationale for PT. That is, parenting behaviors are viewed as a
possible source of child difficulties in the externalizing
disorders, whereas parents are viewed as agents of change in ASD.
In fact, in models such as PRT ; Koegel et al. 2010), parents
are not viewed simply as a possible resource, but rather as
eventually becoming the primary clinician. Once parents have
been taught the key skills needed to shape the child’s behavior,
they are able to put as much work into the process as they
With regard to specific child factors that may be implicated,
Puleo and Kendall (2011)
investigated the use of CBT to treat
children with TD who had been diagnosed with an anxiety
disorder. In this study, the authors also measured subclinical
symptoms of ASD in child participants through parent report.
Puleo and Kendall concluded that TD children with moderate
levels of ASD symptomology responded better to family CBT
than to individual CBT. As such, parent involvement may
serve as a necessary bridge to successful skill acquisition in
children with at least moderate levels of parent-reported ASD
symptomology. Future empirical research should continue to
explore the function of parent involvement and training in
Specific delivery factors have been implicated in the success
of PT in ASD samples, separate from content. Findings
regarding the fidelity of parent-implemented treatment are
mixed. Some studies urge caution when using PT models, as
efficacy can be hindered by the quality of parent-implemented
treatment, especially as compared with clinician-implemented
(Bibby et al. 2001; Mudford et al. 2001; Symes et al.
. Other studies have conversely found high fidelity in PT
(e.g., Koegel et al. 2002; Koegel et al. 1996; Koegel
et al. 1991; Laski et al. 1988)
It is thought that improvements in training, such as
intensive, “hands-on” models and significant follow-up, may
improve treatment fidelity (Research Units on Pediatric
Psychopharmacology (RUPP) Autism Network 2007). Having
parents model new skills in vivo during therapy sessions has been
shown to have larger treatment effects than interventions that
did not emphasize practice during the session, when
controlling for content and delivery approach
et al. 2008)
. Kaminski and colleagues, as well as others
(Ingersoll and Dvortcsak 2006; Kaiser and Hancock 2003)
have suggested that clinician feedback is a crucial piece of
insession practice; feedback that was concise, mostly positive,
frequent, and immediate was most successful. The actual
practice itself has also been found to be more helpful than
merely modeling a skill (Ingersoll and Dvortcsak 2006).
Multiple therapist factors may be important when working
closely with parents. Although not proven, a number of
variables have been suggested for further investigation, including
a responsive and cooperative teaching format, firm knowledge
of the treatment protocol, ability to provide immediate
feedback, personalization of the protocol to each family,
acknowledging parent feelings as valid, and listening to parent
feedback and concerns
(Kaiser and Hancock 2003; Ingersoll and
. When building rapport, it also might be
important that the therapist not align him-/herself with one
specific parent in the family, at the cost of possibly alienating
the other parent (Ingersoll and Dvortcsak 2006).
STAMP as a Program Example
(Scarpa et al. 2013a)
is a 9-week group-based CBT
program that treats emotional dysregulation in children with
HFA. This program serves children between the ages of 5 and
7 years and is a developmental modification of the Exploring
Feelings CBT program
(Attwood 2004a, b)
, which targets
children with ASD between the ages of 9 and 13 years
(Sofronoff et al. 2005, 2007)
. Self-regulation of emotions is
targeted through teaching cognitive, social, physical, and
relaxation skills (presented as tools in a metaphorical emotional
toolbox) to the children, in combination with affective
education. In addition, parents meet simultaneously to become more
knowledgeable about the skills that their children are learning
and to help promote the generalization of skills in the home.
The overall goal of the PT portion of STAMP is to
generalize skills from the child sessions to settings outside of the
clinic using instruction, modeling, and home practice. Parents
are in an optimal position to scaffold learning because they
accompany their child throughout their daily routines at home
and other settings where skills may be practiced (e.g., church,
grocery store, transporting child between activities, etc.).
Generalization is supported by (1) training parents on the skills
that are being taught to their children and (2) providing
homework assignments that promote the use of skills. The
parent therapist reviews and reinforces the coping skills that
are taught in STAMP rather than teaching parents to directly
change their child’s behavior, as is seen in many other
behavioral therapies with parental involvement. Instruction is
provided through discussion with the parents and viewing the
child session through a television monitor. In this way, the
parent is able to directly view child therapists modeling the
tools with their child (e.g., teaching the child about
relaxation), and the parents have immediate access to the parent
therapist to address any questions or concerns.
STAMP is designed to teach emotion-based self-regulatory
skills to young children with ASD. That is, the focus is to
teach children what they themselves can do to help understand
and manage their emotions so that they can problem-solve,
reduce distress, avoid punishment or injury, and develop
friendships. STAMP does not teach extrinsic factors to
regulate emotions (e.g., parental comforting), except insofar as it
instructs the children on how to seek those extrinsic factors if
needed (e.g., asking for help). As such, parents are viewed as
facilitators of change (i.e., coaches) through their help with
practice and generalization, but they are not considered the
causes of change.
The parent therapist also has the opportunity to elicit more
information from the parent in order to individualize skills to
the child (e.g., what motivates or calms the child, which skills
were most helpful). After receiving training on a full array of
emotion regulation strategies, parents are encouraged to
practice them with their child and monitor which strategies are
particularly effective for their child. Knowledge and practice
of all the tools promotes their flexible use, which is needed
because their effectiveness may change across time and
contexts. Finally, home practice assignments are provided each
week, with a large portion of each session devoted to
discussing these assignments. Parents are asked to help their
child work through the home projects and note any areas of
difficulty. By sharing this insight with the group, the therapist
is then able to tailor the treatment to the individual child’s
It is also important to note what is not included in the
PT portion of STAMP. Although parents are often
supportive of one another and provide helpful suggestions,
STAMP is not designed to be a support group. Most of
the session is spent on learning skills directly related to
emotion management and reviewing homework, rather
than discussing developmental issues or other child or
family difficulties related to ASD. STAMP also does not
use ABA as the primary approach, though some
behavioral strategies are indeed used and integrated with
cognitive strategies. As a CBT, this group focuses instead on
affective education and proactive skill-building that can
be used to cope with intense negative emotions and
prevent the escalation of outbursts, rather than the typical
functional analysis of antecedent–behavior–consequences
used in ABA. Lastly, parents are clearly told that this
program is not intended to cure autism but will provide
tools to increase success in understanding and managing
As such, we present STAMP as an example of an
innovative program that uses both cognitive and
behavioral elements within a group setting. To our knowledge,
STAMP was the first program to use a CBT approach to
treat emotional dysregulation symptoms in young children
with ASD. STAMP aims to fill this need for young
children with ASD who struggle to control their anger
and anxiety and may serve as a model for the
development of similar CBT programs that wish to include a PT
component. Current and future projects are examining the
“active ingredients” of STAMP, especially the PT focus,
as we seek to apply STAMP principles to other settings
(e.g., schools) and populations (e.g., nonverbal children,
The Development of STAMP
STAMP is based on the Exploring Feelings program
(Attwood 2004a, b)
, and was developmentally adapted for
5–7-year-old children with HFA by including shorter sessions,
longer program duration, inclusion of parents, and games/
activities designed for young children. In addition, the CBT
approach was adapted for verbally limited children to include
pictures and visual supports such that every verbal concept in
the intervention is accompanied by a visual aid.
Proof-ofconcept for STAMP’s effectiveness was performed in two
steps. The first step included development of an initial
working manual through therapy with a group of four children. At
this time, the main goal was to modify the Exploring Feelings
program with consideration to the cognitive level and
preferred activities of early school-aged children.
In the second step, the manual was used in a
betweengroups efficacy study, which included 11 children with ASD
(two girls, nine boys) randomly assigned to treatment (n=5) or
to a wait-list (n=6) condition
(Scarpa and Reyes 2011)
Outcome measures were taken pre- and immediately
postintervention for both conditions, and then again for the
waitlist group after receiving treatment. Measures included parent
observations of frequency (i.e., episodes per hour) and
duration (in minutes) of behavioral outbursts, parent-reported
emotional lability and regulation on the Emotion Regulation
(Shields and Cicchetti 1997, 1998)
, and child
generation of coping strategies in response to vignettes made for
this research study. Finally, parents were asked to rate their
level of confidence in themselves to manage their child’s
emotions and their confidence in their child to manage his/
her own emotions, and to rate their satisfaction with the
program. Overall results supported benefits of STAMP.
Compared with the wait-list group, children in STAMP exhibited a
trend towards shorter outbursts (ES =0.45 and 0.46,
respectively) and significantly increased knowledge of appropriate
coping strategies after treatment (ES= 0.65). Parents also
reported improved confidence in themselves and their child to
manage anger and anxiety relative to the control group (ES=
0.63 to 0.89). When comparing the whole sample from pre- to
post-treatment in a within subjects analysis, both groups also
demonstrated significantly less negative affect, paired t(10)=
2.03, p< .10, and a trend towards better emotion regulation,
paired t(10)= 1.45, p< .05, after treatment.
In a consumer satisfaction survey, all parents reported
being satisfied to very satisfied with the STAMP program.
Qualitative feedback from parents after the program’s
completion described previous attempts at emotion
labeling but referred to STAMP as the “missing piece” that
instructed the parent in how to help her child reduce his
level of anger or anxiety. Parents reported enjoying
learning the “tools” and benefiting from the discussion in the
PT portion of treatment. Parents were also appreciative of
the setup that allowed them to concurrently observe the
child session from the PT/observation room. Parent
feedback has been incorporated into the iterative development
of STAMP over time and has improved the program’s
design and outcome.
After collecting data from participants in the feasibility
study and small RCT described above, the protocol was
modified based on parent and therapist input. For
example, the story and video used at the end of the 9-week
program were lengthened. The story and video are created
with the children as characters who are displaying or
practicing the various STAMP tools and then distributed
to each child to aid in maintenance of skills after
treatment has ended. Therapists also suggested ways to
enhance the teaching of cognitive tools through card games,
because perspective-taking and reappraisal skills are
particularly difficult for children with ASD. Finally, parents
and therapists suggested the addition of more role-plays in
order to practice the skills in session. These suggestions
have improved the program and were incorporated in the
manual as it was being developed and refined; the manual
was published in 2013
(Scarpa et al. 2013b)
Some specific lessons have been learned by including parents
in STAMP. First, the philosophical stance behind parent
inclusion and the goals of STAMP was clarified. We believe that
children with ASD can be directly taught
cognitive–behavioral strategies of emotion regulation through affective
education, skill-building, and cognitive restructuring, so they can
learn to self-soothe in emotional situations. By the same
token, it is inherently challenging for children with ASD to
generalize skills to outside the setting in which those skills are
taught. As such, we firmly believe that parents are critical
facilitators of generalization by promoting and reinforcing
practice of the child’s self-regulatory skills in the home and
Second, STAMP uses a CBT framework. Therefore,
parents with extensive involvement in ABA treatments had to be
reminded that STAMP does not use the principles of
traditional ABA (e.g., errorless learning, physical prompting,
functional behavior analysis). Whereas a traditional ABA
approach might focus on understanding the antecedents and
consequences that initiate and maintain the child’s behavior,
STAMP uses strategies to teach children how to manage the
emotion that may underlie the behavior. For example, if a
child typically tantrums when taking a test at school, ABA
may focus on differential reinforcement that ignores tantrums
while reinforcing test-taking. STAMP, on the other hand,
would focus on teaching the child to recognize signs of
anxiety that may underlie the behavior and utilize tools to
manage the anxiety. We found it important to discuss these
differences in approach and to emphasize proactive
prevention and skill-building in STAMP rather than a focus on
changing consequences after the behavior.
Third, it was clear that home assignments needed to be
individualized throughout treatment in order to fit the
preferences and learning styles of different children. For example,
for one child who loved numbers, we used number labels in as
many homework assignments as possible. For another child
that had a special interest in road signs, the parent found
miniature road signs from a train set to use during especially
stressful activities. One child seemed to comprehend material
better from experiential learning than from pictures, and his
parents began to use charades games to teach him about
emotions. We found that such individualization was best done
through discussion of the home practice assignments and
asking all parents to provide suggestions on how to
personalize activities to be more appropriate for each child.
Lastly, although not a focus of the PT component in
STAMP, different parenting characteristics had to be
addressed in the PT groups. Some parents, for example, had
low confidence in their child’s abilities and needed to be
challenged to try some new strategies. Others had high
expectations and viewed their child’s behavior as failure despite
small steps being made toward improvement; these parents
benefited from reminders to look at the full process of change.
In some cases, parents inadvertently reinforced anxiety or
aggression in their child by succumbing to persistent child
requests/demands, and these parents were encouraged instead
to remind their child to use the STAMP tools to help their child
cope in those situations. In sum, the parents with whom we
have had the privilege to work have taught us invaluable
lessons about the goals and philosophy of STAMP as well as
its effective implementation or delivery.
foster continued development of similar combined programs
for young children with ASD.
STAMP shows a number of differences when compared
with pre-existing treatments with a PT component,
highlighting its unique contribution to the field. A
pivotal difference is the use of both cognitive and
behavioral strategies throughout the course of treatment, while
other treatments are predominantly behaviorally based.
In STAMP, parents are viewed as co-facilitators and
stakeholders in the treatment, rather than individuals
who need to be corrected in their parenting techniques.
As discussed in depth above, treating parents as
cotherapists allows them to take an active role in
treatment and helps generalize and maintain skills from
therapy sessions to the home. While the STAMP parent
group is not a support group, it does employ a
welcoming and non-critical atmosphere, in order to encourage
open discussion and troubleshooting between parents.
This is a departure from other interventions, whose
specific aims are to “fix” a parent’s ways of teaching
his or her child.
Additionally, STAMP incorporates work directly with
the child, while many behavior therapy models often work
only through parent components. We believe that the use
of both parent and child groups is one of the key
ingredients that makes STAMP valuable, but additional trials
with larger sample sizes and more diverse participants are
required to explore this idea further. Moreover, it is
possible that STAMP can be used in other settings (e.g.,
schools), where parents are not available. In these cases,
caregiver-based assistance by other school personnel may
take on more importance. The utility of the parent
component across ages, diagnoses, functional severity, and
developmental stages also remains to be seen, as does
the utility of an expanded range of measures that might
reduce reliance on parent report. Home practice
assignments are another important aspect of STAMP, as they
create opportunities for parents and children to review and
practice skills that were learned in session. This review
aids in making the skills concrete and applicable to the
Greater focus on the use of PT in CBT will result in
improvements in the way we are able to address oppositional,
emotional, and behavioral difficulties in young children with
ASD. It is our hope through this review of PT in general and
discussion of STAMP in particular to show the merit of
combining CBT strategies with a PT component and thus to
Conflict of Interest
of the STAMP manual.
Dr. Scarpa receives royalties from the publication
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