Effects of Parent-Mediated Intervention in Teaching Social Communication Skills to Children w ith Autism Spectrum Disorders (ASD): a Systematic ReviewABSTRACT:
Parent-mediated interventions (PMIs) are the most cost-effective way to target social communication and behavioral issues in individuals with Autism Spectrum Disorder (ASD). This research synthesis aims to (a) identify the types of PMI programs that have been used to improve the social communication skills of children with ASD and (b) record the outcomes of these programs that have been reported in previous research on children with ASD and their parents. The PRISMA guidelines were used to identify the published PMI studies from 2004 to 2022. The digital databases Scopus, ERIC, Web of Science, and B-on were screened for relevant publications using the keywords “autism spectrum disorder” AND “home-based intervention” OR “parent-mediated intervention” OR “family-mediated intervention” AND “educational program” OR “training program” AND “social skills” OR “communication skills” in the studies’ titles and/or abstracts. The inclusion criteria were as follows: studies with parent-mediated intervention programs primarily targeting the social communication skills of children with ASD, published in English, and reporting outcomes in children with ASD. The search yielded 462 publications, and only 37 studies were eligible for inclusion in the final analysis. Overall, these studies showed that PMIs were effective in improving social communication and other skills of children with ASD. Additionally, parents showed high fidelity, positive perception, self-efficacy, satisfaction, and a decrease in stress. The limitations of the studies and future implications were discussed.
KEYWORDS:
Parent-mediated intervention; Autism Spectrum Disorder; Social communication skills; Home-based intervention
RESUMO:
As intervenções mediadas pelos pais (Parent-mediatedinterventions – PMIs) são a maneira mais eficaz de atingir problemas de comunicação social e comportamentais em indivíduos com Transtorno do Espectro Autista (TEA). Esta síntese de pesquisa visa (a) identificar os tipos de programas PMI que foram usados para melhorar as habilidades de comunicação social de crianças com TEA e (b) registrar os resultados desses programas que foram relatados em pesquisas anteriores sobre crianças com TEA e seus pais. Foram utilizadas as diretrizes PRISMA para identificar os estudos sobre PMI publicados entre 2004 e 2022. Os bancos de dados digitais Scopus, ERIC, Web of Science e B-on foram rastreados para publicações relevantes, utilizando as palavras-chave “autism spectrum disorder” AND “home-based intervention” OR “parent-mediated intervention” OR “family-mediated intervention” AND “educational program” OR “training program” AND “social skills” OR “communication skills” nos títulos e/ou resumos dos estudos. Os critérios de inclusão foram os seguintes: estudos com programas de intervenção mediados pelos pais, que visassem principalmente as competências de comunicação social de crianças com TEA, publicados em inglês e que relatassem resultados em crianças com TEA. A pesquisa identificou 462 estudos, dos quais 37 foram elegíveis para inclusão na análise final. No geral, esses estudos mostraram que os PMIs foram eficazes na melhoria da comunicação social e de outras competências das crianças com TEA. Além disso, os pais demonstraram elevada fidelidade na implementação das intervenções, bem como uma perceção positiva, autoeficácia, satisfação e uma diminuição do stress. Foram discutidas as limitações dos estudos e as implicações futuras.
PALAVRAS-CHAVE:
Intervenção mediada pelos pais; Transtorno do Espectro Autista; Habilidades de comunicação social; Intervenção familiar
1 Introduction
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by two core symptoms: social communication difficulties and behavioral problems (American Psychiatric Association [APA], 2021). This population might also present cognitive and language impairments, which are not required for ASD diagnosis (APA, 2021). Many individuals with ASD show a lack of eye contact, sharing interest, initiating or maintaining conversations, abnormal facial expressions, turn-taking, and joint attention (Thomeer et al., 2019).
In the last decade, the prevalence rate of individuals with ASD has increased dramatically and was estimated at 11 sites in the United States of America (USA) to be 1 in 54 children at the age of eight – Centers for Disease Control and Prevention MMWR (Maenner et al., 2020). Globally, the prevalence rate of ASD is estimated to be 62 in 10,000 (Elsabbagh et al., 2012); this increase can be due to social awareness or the development of diagnostic criteria (Crawford, 2016). Consequently, the World Health Organization ([WHO], 2014) declared ASD a public health issue that requires enhancing access to appropriate support services by delivering training to families, caregivers, and other service providers to meet the needs of individuals with ASD and other developmental disabilities. Legally, parents’ participation in their special-needs children’s intervention programs was mandated by the Individuals with Disabilities Education Act ([IDEA], 2024), which states that parents must be active and equal members of Individual Educational Program (IEP) teams and participate in developing IEPs for their children with disabilities to ensure that their children obtain sufficient support to achieve suitable progress in general education.
The significance of parent-mediated interventions (PMIs) for children with ASD and their parents has been well-documented in the literature. Numerous studies have indicated that PMIs yield promising outcomes for children with ASD, including improvements in social communication skills (Ingersoll & Wainer, 2013a), language skills (Hardan et al., 2015; Siller et al., 2013), a decrease in ASD severity (Pickles et al., 2016), restricted and repetitive behaviors (Lin & Koegel, 2018), and sleeping disorders (Delemere & Dounavi, 2018). Most parents of this population experience a high level of stress, which is associated with their child’s social deficiency, self-efficacy, and social support (Li, Xu et al., 2022). However, PMIs were found to be effective in reducing parental stress (Kasari et al., 2015), increasing parents’ satisfaction and self-efficacy (Kurzrok et al., 2021), and overall increasing their knowledge of ASD.
Parent training in ASD is a common term that refers to intervention programs designed to address the needs of individuals with ASD and their parents. Bearss et al. (2015) distinguished between two forms of parent-training programs: “parent support,” and “parent-mediated intervention.” Parent support describes the programs aimed at promoting the knowledge of parents about their child’s diagnosis and treatments “knowledge-focused programs” include psychoeducation and care coordination, with the child being the indirect beneficiary. In contrast, PMIs refer to intervention programs designed to be delivered by parents to their children with ASD, where the child is a direct beneficiary. PMIs can be used to target the core symptoms of ASD, such as social communication, imitation, and play, or to focus on maladaptive behaviors such as feeding, toileting, and disruptive behaviors (Bearss et al., 2015).
Several PMIs are based on the Naturalistic Developmental and Behavioral Intervention Model (NDBI), which focuses on constructing a naturalistic learning environment similar to everyday situations to enhance social communication skills and facilitate developmental progress in children with ASD. This approach emphasizes individualized interventions based on children’s interests, initiations, and natural motivations. NDBIs often include training in joint attention, reciprocal interactions, play activities, and functional communication. The NDBI model aims to support a child’s holistic development while addressing social and communication challenges within the natural context (Schreibman et al., 2015). This intervention model allows children with ASD to practice their skills in their naturalistic settings, including home and community, which enhances their capability to generalize and maintain the acquired skills in various contexts (Conrad et al., 2021).
Many NDBI programs have been developed to target several skills of individuals with ASD, including Parents as Communication Teachers (ImPACT) (Ingersoll & Wainer, 2013b), Reciprocal Imitation Training (RIT) (Ingersoll, 2010a), Joint Attention, Symbolic Play, Engagement, and Regulation Intervention (JASPER) (Kasari et al., 2006), the Early Start Denver Model (ESDM) (Dawson et al., 2010), and Pivotal Response Treatment (PRT) (Koegel & Koegel, 2006). In contrast, some PMIs emerged from the Developmental Social-Pragmatic (DSP) model, which emphasizes that children acquire both language and social communication skills through effective social engagement with caregivers during natural interactions. This model focuses on the use of language in a social context and functional communication, supports the development of joint attention skills to enhance social interaction, and uses play-based activities to promote social engagement (Binns & Cardy, 2019). Examples of PMIs that use the DSP model to promote the social communication skills of children with ASD are DIR/Floortime (Greenspan & Wieder, 2009) and Hanen More Than Words (Sussman, 2012).
Although the NDBIs and DSP interventions have many similarities, they differ in terms of direct prompting. In the NDBI approach, direct prompting varies according to child initiation, such as providing explicit instruction. However, the DSP model does not define this strategy. In addition, the DSP model defines the use of facilitative strategies that aim to increase adult responsiveness to children’s behaviors in order to enhance social communication development. In contrast, the NDBI approach does not define or consider these strategies as an active part of treatment. Instead, it utilizes one or more of these strategies to motivate and develop a relationship with the child through intervention. Finally, both models use different methods to άsscss the effectiveness of the interventions (Ingersoll, 2010b).
We identified some systematic reviews that showed positive outcomes of PMIs on the social communication skills of children with ASD and their parents; however, these reviews included only studies with a single-subject research design (Patterson et al., 2012), targeted preschool children (Meadan et al., 2009; Pacia et al., 2022), or reported the effects of specific intervention programs, such as JASPER (Waddington et al., 2021). The present review attempts to extend these reviews by exploring the effects of PMIs on the social communication skills of children with ASD or at risk of ASD and their parents by synthesizing the research papers that have been published since the issue of the IDEA Act 2004-2022 to (a) identify the sorts of PMI programs that have been used to improve the social communication skills of children with ASD; (b) report the intensity and duration of these interventions; (c) record the outcomes of PMIs on children with ASD and their parents; and (d) highlight the limitations of these studies and write recommendations for future research.
2 Method
The current systematic review was conducted following the guidelines described in the PRISMA statement (Moher et al., 2009) to identify the scientific studies published between 2004 and 2022 in international journals. The digital databases Scopus, ERIC, Web of Science, and B-on were used to identify relevant publications, using the search terms “autism spectrum disorder” AND “home-based intervention” OR “parent-mediated intervention” OR “family mediated intervention” AND “educational program” OR “training program” AND “social skills” OR “communication skills” in the studies’ titles and/or abstracts. The search was limited to autism and social communication skills. The search results revealed 462 publications across all databases.
2.1 Inclusion criteria
The eligibility criteria for the review were set as follows: the focus of the study was on parent-mediated interventions; the study primarily targeted the social communication skills of children with ASD; the study involved an intervention program; the study was published between 2004 and 2022; the study was published in English; the study reported the outcomes of children with ASD.
2.2 Screening and selection of studies
As shown in Figure 1, at the first stage, the researchers identified a total of 462 articles across all databases: Scopus (57), ERIC (88), Web of Science (263), and B-on (54). In the next step, the duplicate articles were excluded, which reduced the sample size to 440 articles. The articles’ titles and abstracts were screened considering the eligibility criteria. A list was made for the studies about which we were uncertain whether they met the eligibility criteria to be reviewed and discussed in depth. A total of 70 full-text articles were assessed for eligibility, which led to the selection of the remaining 37 articles to be included in the final analysis. The excluded articles were those with no intervention programs (theoretical), targeting other ASD skills (sensory, behavior, and language), or having no child outcomes (parental studies) or follow-up studies.
2.3 Data extraction and coding
The data from studies included in this review were extracted and summarized in terms of (1) study descriptions, including country, participants’ characteristics, research design, dependent variables, and child-parent measures, as shown in Table 1; and (2) intervention details, including intervention program, format, setting, duration, and intervention outcomes on children with ASD and their parents as shown in Table 2.
3 Results
The results of the studies identified through the database search are presented in Table 1.
3.1 Studies descriptions
3.1.1 Country of publication
Most of these studies were carried out in the USA (67.6%), Canada (8.1%), India (8.1%), the United Kingdom (UK) (5.4%), Australia (2.7%), Brazil (2.7%), Serbia (2.7%), and China (2.7%).
3.1.2 Participants
A total of 1,119 children in the intervention group and 427 in the control group, with a mean age of 43.80 months and gender distribution (male = 78.66%)—three studies did not report the gender (Green et al., 2017; Schertz et al., 2013; Shire et al., 2022)—were included in this review. Most of these children were diagnosed with ASD (n = 1,029; 91.96%) or were at risk of ASD (n = 90; 8.04%) (Green et al., 2017; Killmeyer et al., 2019; Stahmer et al., 2020; Yoder et al., 2021). The total number of primary parents/caregivers was higher because of the participation of both parents in the intervention group (1,162: mothers = 92.94%, fathers = 5.85%, other caregivers = 1.21%). Caregivers’ age was reported in 13 studies (mean age = 36.178 years); level of education was reported for only 888 caregivers in 26 studies (less than college = 29.28%; college or above = 70.72%). Also, one family had two children with ASD (Ingersoll & Wainer, 2013b).
3.1.3 Setting
Five studies took place in an online format (Ingersoll et al., 2016; Li, Wu et al., 2022; Meadan et al., 2016; Wainer et al., 2021; Wainer & Ingersoll, 2013), and at home (Liao et al., 2022); six studies were conducted at a center/clinic (Bagaiolo et al., 2017; Hernandez-Ruiz, 2018; Laugeson et al., 2009; Shire et al., 2017; Stadnick et al., 2015; Tripathi et al., 2022), and at home (Carter et al., 2011; Klein et al., 2021; Roberts et al., 2011; Rogers et al., 2019; Sengupta et al., 2020; Shire et al., 2022; Stahmer et al., 2020; Turner-Brown et al., 2019), or at a special school (Ingersoll & Wainer, 2013b), and at home (Glumbic et al., 2022; Prelock et al., 2011; Sengupta et al., 2021); the rest of the studies were conducted solely in home settings.
3.1.4 Research design
Ten out of 37 studies were conducted using randomized control trials (RCTs) with a pre-posttest-follow-up design, and five were RCTs with only a pre-posttest design. Additionally, nine were pilot studies with a pre-post-test design and follow-up (Brian et al., 2016; Tripathi et al., 2022), and two were pilot randomized studies with a pre-posttest-follow-up design (Ingersoll et al., 2016; Shire et al., 2022). Seven studies used an experimental method with a multiple baseline design; three were quasi-experimental with a pre-posttest design (Bagaiolo et al., 2017; Sengupta et al., 2020) and a follow-up (Stahmer et al., 2020); and one was conducted with a mixed-method pre-posttest design (Sengupta et al., 2021). Furthermore, 15 studies were conducted with a control group, and five with a comparison group, such as online ImPACT therapist-assisted vs. self-directed (Ingersoll et al., 2016), or comparing three groups: center-based program vs. home-based program vs. waitlist group (Roberts et al., 2011), or JASPER training vs. psycho-education (Shire et al., 2017), or Parent-Early Start Denver Model (P-ESDM) vs P-ESDM++ (received additional procedures) (Rogers et al., 2019), or JASPER coaching vs. observe with coaching (Shire et al., 2022), or Naturalistic Developmental Behavioral Intervention (NDBI) vs. NDBI with Video Feedback (VF) (Klein et al., 2021).
3.1.5 Dependent variables
Child variables. Four studies targeted social communication skills in general (Hernandez-Ruiz, 2018; Laugeson et al., 2009; Stadnick et al., 2015; Wainer et al., 2021), or targeted specific skills such as social imitation (Penney & Schwartz, 2019; Wainer & Ingersoll, 2013b), or eye contact (Killmeyer et al., 2019), and social engagement, turn-taking, and verbal reciprocity (Rollins et al., 2016), social-emotional functional skills (Solomon et al., 2007), or preverbal social communication (Schertz et al., 2018), or functional verbal utterances (Nefdt et al., 2010), or initiation skills (Meadan et al., 2016; Youn Kang & Kim, 2020), or requesting, asking questions, and spontaneous comments (Liao et al., 2022), or both social communication and ASD severity (Turner-Brown et al., 2019). Eleven studies assessed both social communication and language skills (Brian et al., 2016; Glumbic et al., 2022; Ingersoll et al., 2016; Li, Wu et al., 2022; Prelock et al., 2011; Roberts et al., 2011; Schertz et al., 2013; Sengupta et al., 2020; Shire et al., 2017) and the severity of ASD (Brian et al., 2022; Green et al., 2017).
Some studies examined social and behavioral skills (Sengupta et al., 2021; Stahmer et al., 2020) and ASD severity (Klein et al., 2021; Rogers et al., 2019), or social, play, and behavioral skills (Tripathi et al., 2022), or joint engagement, play, and joint attention (Shire et al., 2022), or social engagement, language, imitation, and play skills (Ingersoll & Wainer, 2013b), or intentional communication, expressive language, play, and motor skills (Yoder et al., 2021), or visual response, imitation skills, and ASD severity (Manohar et al., 2019), or communication and object interest (Carter et al., 2011), or eye contact, joint attention, and disruptive behavior (Bagaiolo et al., 2017). Figure 2 shows the percentage of child variables targeted in these studies.
Parent variables. Seven studies targeted only parental fidelity, and ten studies targeted both parental fidelity and satisfaction. Two studies only examined parental stress (Stadnick et al., 2015; Tripathi et al., 2022), or satisfaction (Prelock et al., 2011; Solomon et al., 2007; Youn Kang & Kim, 2020), and stress (Ingersoll & Wainer, 2013b), and self-efficacy (Li, Wu et al., 2022). One study examined only parents’ perception (Glumbic et al., 2022), and fidelity (Rollins et al., 2016), and stress (Manohar et al., 2019; Sengupta et al., 2021), and self-efficacy (Hernandez-Ruiz, 2018; Ingersoll et al., 2016).
Another study examined perception, stress, and quality of life (Roberts et al., 2011), or fidelity, perception, self-efficacy, and quality of life (Wainer et al., 2021), or stress, fidelity, and quality of life (Turner-Brown et al., 2019). Still another study examined fidelity, parent-child interaction, and social support (Stahmer et al., 2020). Two studies did not report parental variables (Green et al., 2017; Laugeson et al., 2009). Figure 3 shows the percentage of parent variables.
3.1.6 Measures
Child measures. These studies used several assessment tools to evaluate participants’ social communication skills, including observation (video coding) (n = 15), the Social Communication Checklist (n = 4), the Social Responsiveness Scale (n = 4), the Communication Symbolic Behavior Scale (n = 4), the Early Social Communication Scales (ESCS) (n = 2), and the Brief Observation of Social Communication Change (BOSCC) (n = 2). Some studies evaluated behavioral skills using the Vineland Adaptive Behavior Scales (VABS-II; III) (n = 11), the Developmental Behavior Checklist (DBC) (n = 1), the SNAP-IV Scale for ADHD (n = 1), or the Child Behavior Checklist for ages 1-5 (CBCL) (n = 2).
Most of these studies evaluated language abilities using the Mullen Scales of Early Learning (MSEL) (n = 12) or the MacArthur-Bates Communicative Inventory (MCDI) (n = 4). Some studies assessed play skills using the Quality of Play Questionnaire (n = 2), structured play assessment (n = 1), or Developmental Play Assessment (n = 3). In addition, some studies used official tools to assess ASD severity, including the Autism Diagnostic Observation Schedule (n = 5) and the Autism Treatment Evaluation Checklist (n = 2). The remaining studies used different assessment tools to evaluate child outcomes, as shown in Table 1.
Parents measures. Most of these studies assessed parents’ fidelity using observations (n = 10) and/or fidelity checklists or surveys (n = 17), such as the ImPACT checklist, RIT parent fidelity form, or FITT fidelity form. Sengupta et al. (2021) evaluated parents’ fidelity through caregiver-child interaction videos using the Adult-Child Interaction Fidelity Scale and the caregivers’ skills, and knowledge measure (WHO-CST Team) to asscss parents’ knowledge. Also, parental self-efficacy was assessed using the Parent Sense of Competence Scale (PSOC) (Hernandez-Ruiz, 2018; Ingersoll et al., 2016), the Parental Self-efficacy of Competence Scale (Li, Wu et al., 2022), and the Early Intervention Parenting Self-Efficacy Scale (EIPSES) (Wainer et al., 2021). Questionnaires and surveys were used to explore parents’ perceptions of interventions, such as the Family ImPACT Questionnaire (FIQ) (Ingersoll et al., 2016) or the Parent Feedback Form (Glumbic et al., 2022; Turner-Brown et al., 2019).
Studies that targeted parental stress used the Parenting Stress Index-Short Form (PSI) (n = 7), the Center for Epidemiological Studies-Depression Scale (CES-D) (Stadnick et al., 2015), the K-6 scale for parent mental health (Hernandez-Ruiz, 2018), or the Family Interview for Stress and Coping (FISC) (Manohar et al., 2019). Studies that assessed family quality of life used the Beach Family Quality of Life Scale (FQOL) (Roberts et al., 2011; Wainer et al., 2021) or the RAND-36 Health-related Quality of Life (HRQOL) (Turner-Brown et al., 2019).
Parents’ satisfaction was evaluated using satisfaction surveys (n = 11), interviews (Meadan et al., 2016), or both (Prelock et al., 2011), or satisfaction sub-scale of the Parental Self-efficacy of Competence Scale (Li, Wu et al., 2022). Only one study assessed the level of social support using the Social Support Index (Stahmer et al., 2020). Some studies evaluated parent-child interaction using the Parent Participatory Engagement Measure (Stahmer et al., 2020), Caregiver-Child Interaction (CCX) (Shire et al., 2022), and the Maternal Behavior Rating Scale (MBRS) (Schertz et al., 2018; Shire et al., 2017).
3.2 Intervention details
3.2.1 Intervention programs
These studies were conducted using several intervention programs, including Improving Parents as Communication Teachers (ImPACT) program (n = 7; 18.9%), Reciprocal Imitation Training (RIT) program (n = 4; 10.8%), the Program for the Education and Enrichment of Relational Skills (PEERS) (n = 2; 5.4%), Naturalistic Developmental Behavioral Interventions (NDBI) (n = 2; 5.4%), Joint Attention Mediated Learning (JAML) (n = 2; 5.4%), the Social ABCs (n = 2; 5.4%), Joint Attention, Symbolic Play, Engagement and Regulation intervention (JASPER) (n = 2; 5.4%), Hanen’s More Than Words (HMTW) (n = 2; 5.4%), Parent-Mediated Early Start Denver Model (P-ESDM) (n = 2; 5.4%), the World Health Organization (WHO) program (n = 2; 5.4%), video modeling based on Applied Behavior Analysis (ABA) (n = 1; 2.7%), social stories and video self-modeling (n = 1; 2.7%), Family Implemented TEACCH for Toddlers (FITT) (n = 1; 2.7%), Building Blocks Program (n = 1; 2.7%), Early Identification and Intensive Behavioral and Developmental Intervention (EIBDI) (n = 1; 2.7%), Pivotal Response Treatment (PRT) (n = 1; 2.7%), Multimodal Communication Intervention (n = 1; 2.7%), Internet-Based Parent-Implemented Communication Strategies [i-PiCS] (n = 1; 2.7%), iBASIS-Video Interaction for Promoting Positive Parenting (iBASIS-VIPP) (n = 1; 2.7%), and The PLAY Project Home Consultation (PPHC) (n = 1; 2.7%).
3.2.2 Intervention intensity
The total time of intervention sessions was approximately 1,487 hours (M = 46 hours). However, the weekly intervention session time ranged from lh to 5h (M = 2h/week; n = 31). Most of these studies conducted weekly sessions lasting from lh to 2.5h/week (n =27); some studies lasted from 3h to 5h/week (n= 4), and the longest weekly session time was 15h/week (Solomon et al., 2007).
Five studies did not report the duration of the intervention sessions (Carter et al., 2011; Green et al., 2017; Manohar et al., 2019; Wainer et al., 2021; Youn Kang & Kim, 2020). The total period of intervention was 565 weeks (M =16 weeks). Most of these studies had a total intervention period of 12 weeks (n = 11) or 20-24 weeks (n = 6). The longest duration of intervention was between 40 and 48 weeks (Roberts et al., 2011; Solomon et al., 2007) or 32 weeks (Schertz et al., 2018). In contrast, five studies conducted interventions with a short duration of 4–6 weeks, and two studies did not report the total intervention period (Killmeyer et al., 2019; Nefdt et al., 2010).
3.2.3 Intervention format
Some of these studies involved delivering parent training individually one-to-one (n = 13), training in a group format (n = 5), or both individual and group training (n = 12). Two of these studies delivered individual online training (Meadan et al., 2016; Wainer et al., 2021), online self-directed training (Nefdt et al., 2010; Wainer & Ingersoll, 2013), and therapist-assisted training (Ingersoll et al., 2016), or online group training (Li, Wu et al., 2022).
3.2.4 Intervention outcomes
Child outcomes. Out of 37 studies, 27 reported that parent-mediated intervention programs showed a significant effect on social communication skills; seven studies showed an improvement or increase in social communication skills; one study showed a moderate increase in social skills and object interest; and two studies showed high to moderate increases in eye contact (Killmeyer et al., 2019; Rollins et al., 2016). Eight studies showed a significant effect of the intervention on language skills; two studies indicated that children with ASD showed an improvement in vocabulary development (Prelock et al., 2011) and expressive language (Yoder et al., 2021); two studies reported no significant effect on the language domain (Green et al., 2017; Li, Wu et al., 2022); and the rest did not target language skills. Two studies indicated a significant effect of the intervention on play skills (Shire et al., 2022; Tripathi et al., 2022), an improvement (Yoder et al., 2021), or no significant effect (Ingersoll & Wainer, 2013b).
Three studies showed a significant effect on adaptive behavior skills (Klein et al., 2021; Rogers et al., 2019; Sengupta et al., 2021), a decrease in behavioral problems (Bagaiolo et al., 2017; Tripathi et al., 2022), or no effect on adaptive behavior (Ingersoll et al., 2016; Stahmer et al., 2020). Four studies showed no significant effects on motor skills (Ingersoll et al., 2016; Yoder et al., 2021) or imitation skills (Ingersoll & Wainer, 2013b; Wainer et al., 2021). Five studies showed that intervention programs were effective in decreasing ASD severity (Brian et al., 2022; Green et al., 2017; Klein et al., 2021; Manohar et al., 2019; Rogers et al., 2019), and two studies reported no effect on ASD severity (Solomon et al., 2007; Turner-Brown et al., 2019).
Most of the studies that conducted follow-up tests reported that participants maintained their gains after intervention completion. However, some studies indicated that participants did not maintain improvement in their behavioral skills (Tripathi et al., 2022), language, and communication skills (Brian et al., 2016), or showed a moderate decrease in communication and object interest during the follow-up phase (Carter et al., 2011).
Parent outcomes. Out of 37 studies, 27 targeted parents’ fidelity and showed that parents had high fidelity in implementing intervention programs. Nine studies showed that parents demonstrated positive perceptions of the intervention programs and rated them as feasible and acceptable. Only four studies that examined parents’ self-efficacy showed that parents demonstrated high competence and self-efficacy in implementing intervention programs (Hernandez-Ruiz, 2018; Ingersoll et al., 2016; Li, Wu et al., 2022; Wainer et al., 2021). Additionally, parents were highly satisfied with the intervention program in 14 out of 15 studies, and only one study showed no significant effect on parental satisfaction (Li, Wu et al., 2022). Eleven studies that evaluated parental stress showed that the intervention effectively decreased parental stress, and only one study reported that parents did not maintain this gain at follow-up (Tripathi et al., 2022). Two out of three studies showed that the intervention program was effective in improving parents’ quality of life (Roberts et al., 2011 ; Turner-Brown et al., 2019), and only one study showed no difference in quality of life between parents in the intervention and control groups (Wainer et al., 2021).
Finally, Stahmer et al. (2020) found no significant differences between parents in the ImPACT program group and the usual care group in the social support domain. In addition, parents in the intervention group showed greater improvements in positive parent-child interactions compared to the control group (Schertz et al., 2018; Stahmer et al., 2020) or the psycho-education group (Shire et al., 2017). Similarly, Shire et al. (2022) reported that the increase in caregivers’ JASPER strategy use was associated with an increase in the child’s initiations and joint engagement for both the coaching group and the observation-plus- coaching group.
3.2.5 Limitations
These studies have reported several limitations, including a small sample size (n = 22), modest sample size (Green et al., 2017), lack of control or comparison groups (n = 5), lack of randomization for the participants (n = 2), sample diversity (n = 4), heterogeneity of groups (n = 4), or withdrawal of participants from the studies. For example, Sengupta et al. (2020) reported the departure of 18 families from the intervention, and some families dropped out of the intervention due to the pandemic (Glumbic et al., 2022). Additionally, there was a lack of follow-up data (n = 13), short-term follow-up data (n = 6), or data were partially obtained for some of the participants due to a reduction in specialists (Shire et al., 2022), which led to incomplete data information about the maintenance and generalization of the skills. Furthermore, the absence of data on parents’ characteristics, such as educational level, age, and background (n = 10), might have impacted the intervention outcomes. For instance, Meadan et al. (2016) indicated that all the parents who participated in the study had previous experience in special education. Likewise, data on parents’ mental health, wellness, and access to resources were not obtained (Brian et al., 2022). In addition, there was a lack of data on participants’ website skills, which might have impacted their access to or engagement with online training (Wainer et al., 2021). Furthermore, there was a lack of parents’ fidelity data (n = 10), or the sample size was too small to measure parents’ fidelity (Carter et al., 2011).
Some studies have reported limitations in the assessment tools, including the use of parents’ and specialists’ self-reports (n = 15), non-individualized evaluations (Nefdt et al., 2010), and non-blinded assessments (Brian et al., 2022) to evaluate the intervention outcomes, which can impact the studies’ findings due to evaluators’ biases. Furthermore, using multiple measures due to changes in participants’ age throughout the study (Green et al., 2017) or using video recording as an assessment tool could invade families’ privacy (Yoder et al., 2021). Moreover, some interventions can be challenging for some caregivers and require significant effort, such as filling out numerous evaluation forms (Sengupta et al., 2020), or traveling to participate in the program (Sengupta et al., 2021), or providing them with a high dosage of video feedback (Klein et al., 2021).
Meadan et al. (2016) indicated that the effect of coaching alone was not examined in relation to the intervention outcomes (Meadan et al., 2016). Some interventions were conducted with low intensity (Roberts et al., 2011; Stadnick et al., 2015; Turner-Brown et al., 2019), or over a short period (Li, Wu et al., 2022; Prelock et al., 2011; Wainer & Ingersoll, 2013). Solomon et al. (2007) suggested that the intervention outcomes might have been impacted by parent-child interaction or the child’s enrollment in other programs rather than the parents’ training. Additionally, some interventions were limited in scope, targeting only social imitation (Penney & Schwartz, 2019; Wainer & Ingersoll, 2013), eye-contact (Killmeyer et al., 2019), or a few specific skills, such as saying “You try,” “Thank you,” sharing, and eye contact (Youn Kang & Kim, 2020). Finally, some interventions were limited to participants who had access to the Internet (Wainer & Ingersoll, 2013), DVD devices in their homes (Bagaiolo et al., 2017), or lived in urban areas (Glumbic et al., 2022).
4 Discussion
This review aimed to synthesize PMI studies conducted in the last 18 years to identify the types of PMI programs that have been used to improve the social communication skills of children with ASD and report the outcomes of these intervention programs on children with ASD and their parents. The results of the search revealed a total of 37 articles after the inclusion and exclusion criteria were applied, and the data of the identified articles were extracted into two tables: study descriptions and intervention details.
The results of these studies showed that ImPACT was the most widely used program (n = 7; 18.9%), followed by RIT (n = 4; 10.8%). Also, most PMIs significantly improved social communication, language, adaptive behavior, and play skills, as well as decreased behavioral problems and ASD severity. Moreover, some studies have shown that children achieved high to moderate increases in eye contact (Killmeyer et al., 2019; Rollins et al., 2016) or moderate improvement in social communication skills (Carter et al., 2011). In contrast, some studies reported no significant effect on language abilities (Green et al., 2017; Li, Wu et al., 2022), play skills (Ingersoll & Wainer, 2013b), adaptive behavior (Ingersoll et al., 2016; Stahmer et al., 2020), motor skills (Ingersoll et al., 2016; Yoder et al., 2021), imitation skills (Ingersoll & Wainer, 2013b; Wainer et al., 2021), or ASD severity (Solomon et al., 2007; Turner-Brown et al., 2019). This may be related to the nature of the intervention programs, which were designed to enhance the social communication skills of children with ASD (Ingersoll & Dvortcsak, 2019). Therefore, all these studies indicated positive outcomes in the social communication skills domain.
Ingersoll et al. (2016) found that children in both ImPACT groups, self-directed and self-directed with therapist assistance, gained significant improvements in language skills; however, the therapist-assisted group achieved greater gains over the self-directed group in social skills. This indicates the importance of supporting parents during the training and implementation of this type of intervention to obtain more satisfactory results. Likewise, Roberts et al. (2011) indicated that participants in the center-based group showed more significant improvement compared to home-based and waitlist groups. This may be related to the higher intensity of the intervention delivered to the center-based group, which received 80 hours, whereas the home-based group received only 40 hours.
Klein et al. (2021) reported no significant differences between participants in the NDBI and NDBI with video feedback groups, with both groups achieving meaningful gains in social, language, and ASD severity. Nevertheless, the NDBI + VF group achieved additional improvements in adaptive behaviors and a decrease in restricted and repetitive behaviors. Additionally, Shire et al. (2022) indicated that participants in both the coaching-only group and the observation-plus-coaching group showed a significant increase in joint engagement, play, and joint attention. However, there were site differences, as some participants improved more through coaching only, while others improved more through observation with coaching. This was related to the lack of group homogeneity (e.g., age and skills).
Most of these studies showed that parents gained high fidelity, self-efficacy, satisfaction, positive perceptions, and a decrease parental stress level. However, some studies indicated no significant effect of the intervention on parents’ satisfaction (Li, Wu et al., 2022), quality of life (Wainer et al., 2021), or social support (Stahmer et al., 2020). Furthermore, Tripathi et al. (2022) reported that parents did not maintain a decrease in stress levels during the follow-up phase. Ingersoll et al. (2016) indicated that online self-directed with therapist-assisted group parents achieved higher fidelity and more positive perceptions than those in the self-directed group. Similarly, parents in the JASPER group showed high fidelity and responsivity compared to the psychoeducation group, and parents’ responsiveness was associated with their children’s joint engagement (Shire et al., 2017). Also, parents in the P-ESDM++ (additional procedures) group showed more significant interaction skills than those in the basic (P-ESDM) group (Rogers et al., 2019). In turn, there was no difference in parental fidelity between the coaching group and the observation-plus-coaching group, with all practitioners and parents in both groups showing high fidelity (Shire et al., 2022).
The results must be interpreted with caution due to the limitations highlighted by these studies. First, methodological limitations include a small sample size, lack of sample diversity, sample heterogeneity, and lack of a control group. In addition, the absence of follow-up data, short-term follow-up, or partially obtained data for some participants might have led to inadequate information regarding the maintenance and generalization of the targeted skills. Second, a lack of data on parents’ characteristics, such as educational level, age, mental health, access to resources, and skills, may have been an important indicator of intervention outcomes. Furthermore, some evaluation tools were based on parents’ or specialists’ self-reports, or the assessment was not individualized (Nefdt et al., 2010) or blinded (Brian et al., 2022), which may have impacted the findings due to evaluators’ biases or the paucity of individualized measures. Moreover, these intervention programs can be challenging for some caregivers due to evaluation procedures that may invade their privacy, such as video recording, or require significant effort to fill out multiple assessment forms, travel, or have access to Internet and technological devices. This may deprive many families from low socioeconomic levels, rural areas, or those without Internet access from participating in these intervention programs. Finally, some interventions were conducted with low intensity or over a short period of time.
5 Limitations
This review had some limitations. First, this systematic review might have excluded some important studies that could provide more valuable data about the effects of PMIs due to the use of specific search terms, strict criteria, and a limited search period. Second, some of the included articles did not provide complete information about intervention intensity, which would have allowed for more accurate data regarding the effects of these intervention programs on children with ASD and their parents. For example, five studies (13.51%) did not report the duration of the sessions, and two studies (5.40%) did not report the total intervention period (Killmeyer et al., 2019; Nefdt et al., 2010; Rollins et al., 2016). Therefore, it was impossible to calculate the overall intervention intensity for these programs and determine whether the intensity of the intervention was associated with outcomes for children with ASD. Another limitation is that some studies did not report parental outcomes, such as fidelity or self-efficacy, which are important indicators of intervention outcomes.
6 Future directions
Future research should address these limitations by: (1) Implementing parent-mediated interventions with an appropriate sample size and a control group; (2) Conducting long-term follow-up data to check the generalization and maintenance of acquired skills after intervention completion; (3) Using valid assessment tools to measure children and parents’ outcomes, avoiding bias in evaluation; (4) Obtaining parents’ demographic information, such as education level, age, and skills, as these factors might impact treatment responses; (5) Examining parents’ self-efficacy and fidelity, as they are important indicators of successful intervention; (6) Conducting high-intensity interventions to obtain more satisfactory results; and (7) Facilitating and motivating parents’ participation in these programs by providing them with support, training, and accessible resources.
7 Conclusion
The results of the current systematic review showed that PMIs were effective in improving social communication and other skills of children with ASD. Parents who participated in their children’s interventions demonstrated high fidelity, positive perception, self-efficacy, satisfaction, and a decrease in stress levels. The findings of these studies highlighted the importance of parental participation in their children’s interventions, which contributed to the improvement of their children’s skills and enhanced parents’ mental health. Therefore, it is essential to involve parents more actively in their children’s interventions by providing training, support, and accessible resources. Furthermore, future studies should address the methodological limitations of prior research, including sample size, comparison groups, assessment tools, intervention intensity, and collecting more data about children’s maintenance and generalization of the acquired skills.
Acknowledgment
This work was funded by National Funds through the FCT – Fundação para a Ciência e a Tecnologia, LP., under the scope of the project UIDP/05198/2020 (Centre for Research and Innovation in Education, inED).
Data availability statement
The authors confirm that the data supporting the findings of this study are available within the article.
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Publication Dates
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Publication in this collection
09 May 2025 -
Date of issue
2025
History
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Received
26 Sept 2023 -
Reviewed
13 Mar 2024 -
Accepted
19 Mar 2024
Accessibility note: Flowchart composed of rectangular text boxes connected by arrows. On the left side, vertically distributed, the steps: “Identification”, “Screening”, “Eligibility” and “Included”. The first step, “Identification”, comprises: “Articles identified through databases searching (462)”, “Scopus (57)”, “ERIC (88)”, “Web of Science (263)” e “B-on (54)”, “Duplicates (22)”. The second step, “Screening” indicates: “Articles screened with title and abstract (440)”. “Articles excluded (367)”, “Assessment in ASD (44)”, “Descriptive studies (95)”, “Professional-mediated intervention (118)”, “Peer-mediated intervention (15)”, “Typically-developed intervention (7)”, “Other disabilities intervention (5)”, “Reviews (57)”, “Meta-analysis (9)”, “Medical studies (2)”, “Books & guides (14)” e “No access (4)”. The third step indicates: “Full-text articles assessed for eligibility (70)” e: “Full-text articles excluded with reason (33)”, “Behavioral skills (20)”, “Language (9)”, “Sensory (1)” e “Follow-up studies (3)”. The last step refers to “Articles included in synthesis (37)”.
Accessibility note: Horizontal bar graph in gray. The vertical axis shows the variables and the horizontal axis shows the percentage scale from 0 to 80: “Quality of Life”, 8.1; “Self-efficacy”, 10.8; “Satisfaction”, 37.8; “Perception”, 24.3; “Stress”, 29.7 and “Fidelity”, 70.3.