# data[].attributes.headline
Some non-profit organizations  that support autistic individuals and their families

# data[].attributes.subject
Some non-profit organizations  that support autistic individuals and their families

# data[].attributes.body
Autism Speaks- A Company that is dedicated to making a more inclusive world for people with autism. They focus on advocacy, services supporting, research, innovation, and advances in care for autistic individuals and their families. Founded in 2005, they merged with 3 top leading autism organizations. (website:https://www.autismspeaks.org)

Autism Society - started in 1965 to connect people to the resources they need through education, advocacy, resources, and community. Their mission is to create meaningful connections, empower everyone in the community with the resources they need to live to their full potential. Their vision is to create a world where everyone in the autistic community is connected to the support they need, when they need it. (website: https://autismsociety.org/who-we-are/)

National Autism Association : (website: https://nationalautismassociation.org) This organization offers a voice program that provides access to communication methods for autistic individuals who are both verbal and nonverbal. In 2011, NAA created the big red safety box, which includes a kit to prevent autistic individuals from wandering out, which can be dangerous. This organization also provides big red safety booklets for teachers.NAA also created autism Atrium, which is a training course and educational initiative to keep caregivers and others properly educated on how to help guide caring for or working with an individual with autism.

Surfing for Autism (website: https://surfingforautism.org/about-us/) is a non-profit event held to give autistic children free surfing lessons. I have volunteered at the event in outerbanks, NC. This event brings together families with autistic children while raising money to help families in need pay for services. Each child is paired with 2 surfing instructors, a skilled therapist or teacher who is educated in asd. I included a photo of a postcard from the event I attended in Kitty Hawk, North Carolina.

# data[].attributes.body
Beneficial activities to help someone with

Arts: Painting, drawing, and tracing

Crafts: building blocks, Play-Doh, clay

Individual sports:  Golf, Cycling, track, skiing, and  hiking

Structured: Swimming, martial arts, and horseback riding

Music: singing and dancing

Gaming: board games and video games

Outdoor adventures: nature walks or walks at a beach during non-busy times

Storytelling

Some autistic individuals prefer having structured schedules and activities, in which structured sports can be beneficial.

Individual sports offer confidence-building while providing exercise.

Arts and crafts can improve fine motor skills, encourage self-expression, and address sensory issues.

Music and dancing can help with challenging behaviors, reduce anxiety, be beneficial in social interaction with others, and boost self-confidence.

Board games can help with problem-solving, understanding rules, narrative abilities, and communication skills.

Video games can teach rules, teach skill sets, multi-tasking skills, and time management.

Outdoor activities can include beach walks or nature hikes, which can be beneficial for sensory relaxation skills and encourage observation skills.

Story-telling can encourage creativity, encourage imagination, and help with communication skills.

# data[].attributes.body
Anthony Hopkins (Welsh actor)

Andy Warhol (visual artist, film producer, and film director)

Bill Gates (co-founder of Microsoft Corporation)

Charles Darwin (naturalist, biologist, and geologist)

Elon Musk (owner of X (Twitter) and Tesla)

Jerry Seinfeld (Comedian, actor, & Producer)

Lionel Messi (famous soccer player)

Satoshi Tajiri (Pokémon creator)

Sir Issac Newton (known for astronomy and mathematics)

Susan Boyle (Scottish singer)

Tim Burton (well-known Producer)

# data[].attributes.body
Early detection enables quicker access to therapies and early interventions, which are most effective when started early and can significantly improve development outcomes. Many of these interventions such as seeing occupation therapists and speech-language therapists can help with development to a more “normal” life. In my county, San Mateo County, there is a San Mateo County Family Resource Center where they provide special education services from early childhood to age 22, parent training, support groups, and advocacy groups that can help with resources.

# data[].attributes.body
While there is no true prevention for individuals that get diagnosed with ASD there is early screening and diagnosis that will help with faster intervention. Early screening and diagnosis aim to identify signs of autism in children as early as possible, ideally before age 2. Tools like the M-CHAT are used during routine pediatric checkups to flag potential concerns. M-CHAT or modified checklist is a screening tool used by healthcare professionals to help identify a child early.

# data[].attributes.headline
Technology in Treatments that Aid Individuals With Autism

# data[].attributes.subject
Technology in Treatments that Aid Individuals With Autism

# data[].attributes.body
VR headsets: these devices can be used by an individual with ASD to perform various skill building activities like cleaning up a room, counting objects or even math and measuring. This treatment device can aid the user by allowing them to literally see icons/apps/VR in order to complete or even add skill to a certain achievement. Limitations may include funding for VR glasses, and user/teacher error.

Robot-Assisted Therapy: These can aid ASD by creating a friend like assistant who can help with day to day routine and tasks. Limitations may include funding for a robot, user interaction error, etc. I have seen a real friend robot used in my old special education classroom and the particular ASD child was able to thrive on this treatment including completing day to day activities without being asked.

Auditory prompting devices: Similar to AAC devices, these can be used by an ASD individual particularly in need of auditory intervention and speech therapy. This technology can be a treatment to help ASD people communicate with friends, family, teaching staff and so on! Limitations can include funding, age group, and usage.

# data[].attributes.body
AAC Device: these devices can be used by a SLP or SLPA in order to provide communication skills (type of treatment) to individuals with ASD. AAC devices are designed so a user can tap or press on an icon in order to nonverbally communicate. Limitations may include funding for traditional iPad AAC’s, and user-teacher error with how to properly teach how to use an AAC.

# data[].attributes.headline
We Do Not Know the Cause But Prenatal Care is Always Necessary!

# data[].attributes.subject
We Do Not Know the Cause But Prenatal Care is Always Necessary!

# data[].attributes.body
Another preventative measure for ASD is good prenatal care. There is no correct way to prevent ASD but by monitoring the pregnancy and taking the correct steps to stay healthy, there is a less likelihood of a child having ASD at birth. Challenges can of course arise including financial difficulties with getting prenatal care as well as normal pregnancy abnormalities and complications.

# data[].attributes.headline
Daily Reinforcements and Teaching Alternative Behaviors

# data[].attributes.subject
Daily Reinforcements and Teaching Alternative Behaviors

# data[].attributes.body
One preventative measure that can be used in treating and preventing ASD is the use of daily reinforcements. These daily reinforcements can help change behaviors that we see in the video. People with ASD sometimes have trouble managing behavior due to sensory overload/issues. Daily reinforcements can aid an individual by giving them “something to look forward to” , something to distract the brain from a certain feeling or emotion or behavior. Challenges come in all shapes and sizes for reinforcing behavior however with the correct help from a BCBA or other professional, positive reinforcing can help the individual flourish more in the real day to day world especially when coming into contact with things that can be over stimulating like a busy environment, stressful situations, or even a different lunch.

# data[].attributes.attachment_link.title
Teaching Alternative Behaviors To Decrease Or Stop Inappropriate Challenging Behaviors

# data[].attributes.body
Individuals from rural communities, lower socioeconomic status, and minority populations face a disproportionately higher risk of remaining undiagnosed due to limited access to healthcare services, resulting in delayed recognition and intervention in many cases. After getting diagnosed, this increases the need for health care as the individual needs more to support a life surrounding their new life with autism.

# data[].attributes.body
Autism spectrum disorder (ASD) can occur in individuals of any gender; however, it is diagnosed approximately three times more frequently in males than in females. Emerging research suggests that females often exhibit subtler or less stereotypical symptoms, contributing to delayed or missed diagnoses.

# data[].attributes.body
Another specific lifestyle change for ASD includes diet. A nutritionist can come alongside an individual with ASD to further help their behavior, weight, and overall health via what they eat. The patient may have a hard time adapting to diet change especially if "routine" is already established but if the correct diet is mandated at a young age the adaptation may be easier.

# data[].attributes.body
A specific lifestyle that individuals with ASD can engage in is specific routines. An example of a routine can be as simple as "On Monday, I get up, go downstairs and eat the breakfast mom puts on the blue table place for me, go upstairs and brush my teeth with my yellow brush, put on my pink shirt and blue shorts, go downstairs and put on my shoes, go to school, etc." Patients with ASD will be able to make this lifestyle change very easily with the help of the caregivers around them. Professionals that can also support this change are BCBA professionals (Behavior Analyst)

# data[].attributes.attachment_link.readable_text
. Author manuscript; available in PMC: 2019 Apr 1.

Published in final edited form as: Autism Res. 2018 Jan 7;11(4):667-678. doi: 10.1002/aur.1919

Abstract

Children with Autism Spectrum Disorder (ASD) often experience difficulty participating in everyday home routines, such as bed time or bath time. This randomized controlled trial examined the efficacy of an interactive, web-based parenting tutorial for improving children's engagement in daily routines (i.e., proximal outcomes) as well improving children's social communication and parenting efficacy and stress (i.e., broad outcomes). Parents of children with ASD between 18 and 60 months were randomly assigned to the Tutorial group ( n = 52) or the Control group ( n = 52). All parents completed questionnaires at baseline (T1), 1 month after T1 (T2; post-tutorial completion), and 2 months after T1 (T3). Relative to the Control group, parents in the Tutorial group reported significantly higher use of evidence-based instructional strategies and higher levels of child engagement during routines at T2 and T3. In addition, parents in the Tutorial group reported significantly lower parenting stress and higher parenting efficacy at T3, as well as higher ratings of child social communication at T2 and T3, compared to the Control group. Parents reported being highly satisfied with both the clinical content and technical aspects of the tutorial. These improvements in both proximal and broad parent-child outcomes suggest that this tutorial may be a promising and accessible way for empowering some parents and improving parent-child interactions.

Keywords: daily routines, randomized control trial, parent training/coaching, parenting stress, parenting efficacy, social communication

Introduction

As the prevalence of Autism Spectrum Disorders (ASD) has increased, the gap between the number of children receiving this diagnosis and the availability of specialized community-based services for them has widened [ Chiri & Warfield, 2012]. State early intervention programs have reported critical shortages of providers that deliver ASD-related services, including behavioral therapists and speech-language pathologists [ Bailey, 2008; Wise, Little, Holliman, Wise, & Wang, 2010], and most providers working with young children are not trained sufficiently to provide ASD-specialized services [ Stahmer & Mandell, 2007; Wise et al., 2010]. Although recent years have seen a dramatic increase in the availability of evidence-based interventions for young children with ASD [i.e., "Naturalistic Developmental Behavioral Interventions"; Schreibman et al., 2015], their implementation in community settings has been limited. Importantly, the success of these interventions highlights the significance of teaching young children within the context of their daily routines, and of coaching parents in the use of strategies for promoting their child's development.

Daily routines such as bath time, snack/meal time, bed time, and play time represent meaningful family rituals that provide context, structure, and frequent opportunities for rich social interactions that can support early social-emotional development [ Spagnola & Fiese, 2007]. In fact, daily routines confer several unique advantages for learning new behaviors relative to other situations, such as the presence of natural reinforcers (e.g., preferred food during snack time) as opposed to arbitrary reinforcers [ Schreibman et al., 2015]. For these reasons, embedding the delivery of intervention services within daily routines is emphasized in the guidelines and practices of state educational/intervention programs (e.g., IDEA Part C). However, completion of daily routines often presents significant challenges for children with ASD and has been described as a specific and significant stressor by parents [ Marquenie, Rodger, Mangohig, & Cronin, 2011]. Therefore, providing parents with strategies for improving their child's functioning during routines may help reduce parenting stress and improve parenting efficacy by mitigating a prominent and common stressor. Furthermore, teaching parents to use evidence-based strategies within the context of daily routines may increase the likelihood of their use, as the regularity of these routines offers multiple opportunities for repetition and practice [ Schreibman, et al., 2015].

Numerous studies have shown that parents of children with ASD can be taught to successfully implement comprehensive behavioral interventions that lead to both improvements in child behavioral outcomes and parenting stress and parenting efficacy/empowerment [ Ingersoll, Wainer, Berger, Pickard, & Bonter, 2016; Kasari et al., 2015; Minjarez, Mercier, Williams, & Hardan, 2013]. Several of these interventions have been embedded within naturalistic activities/routines and have examined child behaviors during a specific routine (i.e., snack time) as an outcome [ Ingersoll & Wainer, 2013; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Rogers et al., 2012; Schreibman et al., 2015; Wetherby et al., 2014]. However, none have evaluated the efficacy of a parent-implemented intervention specifically targeting child and parent behaviors during daily routines as the primary outcomes. The dissemination and scalability of these interventions is hindered by barriers such as a shortage of ASD interventionists/trainers, lack of child care or access to transportation, and high costs [ Wainer & Ingersoll, 2015]. However, increasingly widespread access to the internet and the advent of new technologies such as web-based, distance learning may provide a potential solution for enhancing the knowledge and skills of parents.

Self-directed, web-based training (e.g., online course/tutorial) has the potential to: (a) increase the dissemination and quality of instruction for those parents who experience barriers to accessing services; and (b) act as supplemental training for families already receiving other intervention services. This approach offers several advantages to traditional instructional methods, including 24-hr accessibility, standardization of training, personalization/individualization (e.g., self-paced), widespread reach, risk free environment, and the opportunity for interactive exercises and multimedia components, which have been found to enhance knowledge retention [ Ballew et al., 2013]. Web-based training is cost-effective and overcomes geographical, transportation, and child care constraints. Most importantly, it facilitates access to training that most likely would be unavailable and overcomes the shortage of ASD interventionists. Given these advantages, several web-based trainings aiming to improve parenting competencies (non-ASD specific/targeted) have been developed over that last two decades and been found to have a significant medium effect on parenting and child outcomes [ Nieuwboer, Fukkink, Hermanns, 2013].

Several self-directed, web-based parent training programs that teach behavioral strategies specifically for ASD have been developed over the last few years and are effective at improving parent and child outcomes. Vismara and colleagues [2012, 2013] conducted pilot studies ( n = 8 and n = 9) using a hybrid approach, which included an interactive DVD for didactic instruction on the Early Start Denver Model [ Rogers & Dawson, 2010] that parents reviewed prior to 12 weekly videoconference sessions (web-based) for live parent coaching/feedback. Using a single-subject, multiple baseline design, they found improvements in parent engagement style, child social communication, and high levels of user satisfaction. Hamad et al. [2010] used a web-based course to teach behavioral intervention skills to both parents ( n = 15) and professionals/paraprofessionals ( n = 36), and found improvements in knowledge of these techniques for both cohorts. Using a waitlist control design with 28 parents, Jang and colleagues [2012] also found that a web-based course on applied behavior analysis improved participant knowledge and was well-received. Ingersoll and colleagues [2015, 2016] employed a RCT design to compare parents learning Project ImPACT online through a self-directed only approach ( n = 13) versus a therapist-assisted approach ( n = 15). While both groups demonstrated improvements in child language, parenting stress, parenting efficacy, parent perceptions of the child, and implementation fidelity, the therapist-assisted group exhibited gains in child social skills and had a higher program completion rate. While these studies provide evidence that web-based, self-directed training for parents can be effective, they used relatively small convenience samples.

Given the challenges that children with ASD can experience during daily routines, this study was designed to evaluate a web-based tutorial for parents that focuses specifically on the context of home routines. Our focus on routines is consistent with the principle that adults are motivated to learn to the extent that they perceive it will help them perform the tasks they confront in everyday life [ Knowles, 1990]. This study builds upon and extends the pioneering work that has been conducted with families of children with ASD using web-based technology by being the first study to employ a RCT design with a relatively large sample. The specific goals of the present study were to examine whether the parenting tutorial is effective for improving outcomes that are: (a) routine-specific and directly targeted by its content (i.e., proximal outcomes); and (b) related to child social communication and the parent-child relationship across broader contexts (i.e., broad outcomes). Proximal outcomes included parents' use of specific evidence-based strategies [ Odom, Collet-Klingenberg, Rogers, & Hatton, 2010] and children's engagement behaviors during routines. Broad outcomes included parenting stress, parenting efficacy, and child social communication. Outcomes were assessed using self/parent-report measures only because the study was conducted remotely.

Methods

Participants

This RCT comprised 104 parents of children with ASD (mothers = 94; fathers = 10), who were recruited from Vanderbilt University and the University of Washington using research databases, websites, and flyers. To be eligible to participate, families needed to: (a) have a child between 18 and 60 months with a diagnosis of ASD and no severe auditory, visual, or motor impairments; (b) provide a copy of child's diagnostic report confirming an ASD diagnosis; (c) have access to the internet; and (d) be proficient in English and speak to the child in English at least 90% of the time. The Tutorial group and Control group were comparable on child age, parental age, and parental education, ps = 0.45-0.93, and the two study sites were also comparable on these demographics, ps = 0.07-0.37 ( Table 1). The study was reviewed and approved by the Institutional Review Board (IRB) at each university and all participants provided informed consent.

Table 1.

Tutorial group (n = 52)

Control group (n = 52)

Child age (in months) at entry M ( SD)

42.83 (13.39)

44.77 (12.50)

Parent age (in years) at entry M ( SD)

34.71 (6.24)

34.61 (6.22)

Procedure

Parents completed online surveys describing their own behavior and their child's behavior during everyday home routines at three time points: baseline (T1), post-tutorial completion (T2; 1 month after T1), and 1-month follow-up (T3; 2 months after T1). One-month measurement intervals were used to allow families in the Tutorial group sufficient time to review the tutorial and to examine short-term follow-up use. After completing T1 surveys, parents were randomized to the Tutorial group ( n = 52) or the Control group ( n = 52) using a random number sequence generator. Parents assigned to the tutorial condition were immediately provided with access to the web-based tutorial, which they were asked to go through at their own pace over the following month. All parents received the same online surveys at T2 and T3 regardless of whether or not the tutorial had been completed. At T2, parents in the Tutorial group also completed user satisfaction questionnaires regarding their experience with the tutorial. See Fig. 1 for recruitment, eligibility, and measure completion flow. The Control group received free access to the tutorial after completing T3 surveys; no additional data was collected from these families and their utilization of the tutorial was not tracked.

Figure 1.

Participant recruitment, enrollment, randomization, and retention.

The Enhancing Interactions tutorial was developed using adult learning principles designed to foster engagement, participation, and interest ( Vincent & Ross, 2001). The tutorial is highly interactive, making full use of the technology and principles of instructional design to enhance the learning experience. Interactive learning activities were incorporated to present new information as well as to test parents' comprehension of the material and reinforce learning. The tutorial content emphasizes the importance of everyday routines as opportunities for learning, and focuses on teaching parents how to use evidence-based strategies (e.g., using simple instructions, using visual supports) and avoid less than optimal strategies (e.g., repeating verbal directions if the child fails to comply) to improve their child's behavior and increase their child's participation in daily home routines. Four levels of engagement/participation during the routines are defined (i.e., not tolerating, tolerating, cooperating, and engaging socially), and parents learn how to systematically move their child's behavior from one level to the next. Videos of parents demonstrating the techniques with their children in actual home settings are incorporated to illustrate the material.

The tutorial comprises three main sections: (a) introductory material (e.g., definition of home routines; tips for establishing routines); (b) description and illustration of four daily routines-bath time, snack time, play time, and bed time-which includes both general information and individualized content; and (c) "toolbox" modules describing specific, evidence-based behavioral strategies for enhancing children's cooperation and participation with routines ( Table 2). It is structured so that parents are presented with a 'menu' of the four daily routines and are able to choose a specific activity within that routine that they would like to improve. For each routine, individualized content enables parents to: (a) identify the sequence of steps in their routine; (b) identify a specific step within the routine that they would like to improve (e.g., getting undressed for "bed time"); (c) identify the child's current level of participation in that step of the routine (e.g., tolerates); and (d) learn behavioral strategies for improving the child's participation during the selected step of the routine. Allowing parents to set individual goals for their child and then teaching them strategies to use during everyday situations has been found to be an effective way to train parents. This approach is consistent with Knowles' principles of andragogy (adult learning)-that adults are motivated to learn to the extent that they perceive it will help them perform tasks they confront in their life situations [ Knowles, 1990]. Select interactive sections from the tutorial can be viewed and tried out firsthand at: http://telepsychology.net/OnlineAssessmentTools/Resources/Autism2Demo/Story.html.

Table 2.

Section

Content

Introduction to home routines

Definition and examples of home routines

Importance of home routines for children with ASD

Tips for starting and ending home routines

Individual routines:
Bath time
Snack time
Play time
Bed time

Description of routine

Potential challenges for children with ASD

Strategies for increasing the child's ability to tolerate, participate, and interact in each routine

Identifying the child's current level of participation (i.e., tolerating, participating, or interacting)

Identifying the best next step (i.e., goal) for increasing the child's engagement in the routine

Tips for helping the child achieve the goal

Tool box modules

Using choice boards, first-then boards, visual schedules, and timers

Using prompting and reinforcement

Teaching imitation

Improving language understanding

Parents in the Tutorial group were instructed to review the general modules (i.e., the overview and "toolbox" modules), and to choose at least one specific daily routine to focus on. They were also encouraged to review the tutorial across at least 4 or 5 sessions, as the time to complete the entire tutorial is approximately 6 hours; parents did retain access to the tutorial after their one-month interval elapsed. Of the 52 parents in the Tutorial group, 46 (88.5%) viewed both the general modules and at least one specific daily routine.

Proximal Outcome Measures

At each of the three-time points, parents completed two routine-specific surveys that were developed specifically for this study: one describing the behavioral strategies they used, and the other describing the child's engagement (or participation) behaviors. The items on these measures were selected to map onto the specific strategies taught in the tutorial. Parents rated each item on a four-point Likert scale indicating the frequency with which it occurred (ranging from "almost never [ 1]" to "almost always [ 4]") during home routines over the previous 2 weeks.

Parent Behavior Survey

This survey comprised 15 specific parent behaviors that examined parents verbal instructions/directions (e.g., using simple instructions, repeating verbal directions if the child fails to comply [reverse coded], praising the child for completing all or part of a routine), use of visual supports (e.g., use of pictures and timer), and their approach to structuring the routine steps. After reverse coding the one undesired behavior, higher scores on each item indicated more optimal use of evidence-based strategies. The items demonstrated acceptable internal consistency reliability, α = 0.79. Items are averaged to obtain a mean total score that ranges from 1 to 4, with higher scores indicating increased use of desired strategies.

Child behavior survey

This survey focused on five specific child behaviors, reflecting child engagement during routines (i.e., actively participating, interacting and communicating while participating, difficulty transitioning when getting started with a routine and/or after completing routine, and resisting participation). After reverse coding the negative behaviors (i.e., difficulty transitioning when getting started with a routine and/or after completing routine, and resisting participation), higher scores on each item indicated more optimal child engagement. The items demonstrated acceptable internal consistency reliability, α = 0.71. A mean total score was derived as above, so that the score ranged from 1 to 4, with higher scores indicating higher levels of child engagement.

Broad Outcome Measures

Parent interview for autism-clinical version (PIA-CV)

Children's social communication skills were assessed using the PIA-CV [ Stone et al., 2003], a parent-report measure of autism symptom severity designed for young children. The PIA-CV was adapted from the original version (PIA), which has strong psychometric properties, including construct validity and discriminant validity for children between 20 months and 6 years [ Stone & Hogan, 1993]. The PIA-CV consists of 41 behavioral items presented in questionnaire format that are rated on a 5-point Likert scale ranging from "almost never (1)" to "almost always (5)". PIA-CV domain scores have demonstrated sensitivity to diagnostic changes (measured independently) between the ages of 2- and 4-years old [ Stone et al., 2003] and has also been used with children under 24 months [ Carter et al., 2011]. Given the strategies and goals of the tutorial, two PIA-CV domains were used: Social Relating (17 items) and Nonverbal Communication (13 items); the two domains demonstrated good internal consistency reliability ( α = 0.85-0.88) with the current sample. Mean scores for each domain are calculated after reverse-coding negatively-worded items, such that scores range from 1 to 5, with higher scores reflecting more optimal levels of social communication.

Parental efficacy scale (PES)

Parenting efficacy was assessed through self-report using the PES [ Teti & Gelfand, 1991]. Ten items measuring parenting-related efficacy (e.g., understanding what the child wants, knowing what the child enjoys) are rated on a four-point Likert scale ranging from "not good at all (1)" to "very good (4)". The PES has strong psychometric properties and has been used in many studies involving children with ASD [ Carter, Martinez-Pedraza, & Gray, 2009]; it demonstrated acceptable internal consistency reliability ( α = 0.78) with the current sample. Items are summed to obtain a total score that ranges from 10 to 40, with higher scores reflecting higher levels of perceived parenting efficacy.

Parenting stress index/short form (PSI/SF)

The PSI/SF ( Abidin, 1995) consists of 36 items measuring three domains of parental stress: (a) Parental Distress (PD); (b) Parent-Child Dysfunctional Interaction (PCDI); and (c) Difficult Child (DC). The PSI/SF has strong psychometric properties and has been used extensively with families of children with disabilities, including ASD [ Tomanik, Harris, & Hawkins, 2004]; the three domains demonstrated good internal consistency reliability ( α = 0.84-0.91) with the current sample. Each domain contains 12 items that are scored on a five-point Likert scale ranging from "strongly disagree (1)" to "strongly agree (5)". Scores for each domain range from 12 to 60, with higher scores indicating higher levels of parenting-related stress.

Usability and Satisfaction Measures

System usability scale (SUS)

User satisfaction with the technical aspects of the web-based tutorial was assessed using the System Usability Scale [SUS; Bangor, Kortum, & Miller, 2008; Brooke, 1996]. The SUS is a reliable, well-validated 10-item scale designed to evaluate the usability and user satisfaction with web-based applications and other technologies. Each item is rated on a five-point Likert scale ranging from "strongly disagree (1)" to "strongly agree (5)". An example item is: "I thought the tutorial was easy to use". The SUS has good internal consistency reliability (coefficient α = 0.91) in assessing usability across diverse types of user interfaces [ Bangor et al., 2008]; it demonstrated similar internal consistency reliability ( α = 0.88) with the current sample. Due to experimenter error, item 9 of the scale (i.e., "I felt very confident using the tutorial") was accidently omitted from the survey for all participants. The "person mean substitution" approach was used to replace the missing item score for each participant by averaging their values from the nine available items [ Downey & King, 1998]. Satisfaction with technical usability was examined using a total score that ranges from 10 to 100 (total scores are multiplied by 2), with higher scores reflecting greater satisfaction with the usability of the tutorial.

User satisfaction questionnaire (USQ)

Satisfaction with the clinical content of the tutorial was evaluated using the User Satisfaction Questionnaire [ Kobak, 2004; Kobak, Craske, & Wolitsky-Taylor, 2013; Kobak, Reyn-olds, & Griest, 1994]. This measure has good internal consistency [Cronbach's alpha = 0.90; Kobak et al., 2013]; it demonstrated similar internal consistency reliability ( α = 0.93) with the current sample. It contains 15 statements covering different dimensions of the user experience (e.g., "There were sufficient examples and illustrations"). Items are rated on a four-point Likert scale ranging from "strongly disagree (1)" to "strongly agree (4)". Total scores range from 15 to 60, with higher scores reflecting greater satisfaction with the clinical content of the tutorial.

Results

Analytic Approach Overview

Intention-to-treat

The current study used the Intention-to-Treat model [ITT; Moher, Schulz, & Altman, 2001] in the analysis of the primary aims. The ITT approach requires that all participants who are randomly assigned be compared on outcomes regardless of their adherence to treatment, reasons for withdrawal, and the presence of missing responses. These guidelines (a) preserve the group comparability established by the randomization process at baseline; (b) reduce the bias introduced by participants dropping out of treatment; and (c) reflect how treatments will perform at the population level by ignoring degree of adherence to treatments when data are examined.

Data screening and attrition

All outcome variables at T1-T3 demonstrated acceptable levels of skewness and kurtosis and did not contain outliers as measured through leverage and Cohen's distance [ Tabachnick, Fidell, & Osterlind, 2001]. There were no site differences on the percent of participants with missing data, χ ² = 3.03, P < 0.08. There were significantly more participants missing post-treatment data (i.e., T2 and T3) in the Tutorial group (21%, n = 11) than the Control group (2%, n = 1), χ ² = 9.42, P < 0.01; of the 11 participants in the tutorial group with missing post-treatment data, 55% ( n = 6) did not complete the tutorial. In addition, at T1 there were no significant differences between the participants in Tutorial group without post-treatment data and those in the Tutorial and Control groups with post-treatment data on the outcome variables, ps = 0.09-1.00, or other key demographics including child's age, ps = 1.0, parental age, P = 0.58-1.00, and parental education, P = 0.88; the subgroup of the Control group without post-treatment data was not included in the analyses since it comprised only 1 participant. Overall, these attrition analyses appeared to indicate that the post-treatment data were missing at random and that it was appropriate to apply the ITT approach using an estimation method and avoid list-wise deletion [ Bell, Kenward, Fairclough, & Horton, 2013].

Analyses and handling missing data

Hierarchical Linear Models [HLM; Singer & Willett, 2003] with Maximum Likelihood estimation were conducted using the HLM7 program [ Raudenbush, Bryk, & Congdon, 2011] to apply the ITT approach and avoid list-wise deletion of participants with missing responses. Bayesian estimates of the intercept and slopes (i.e., time vectors) were derived from the final models for each participant using the Level-2 residual file from HLM7 in order to provide estimated means and standard deviations in Table 3, which also includes effect sizes (i.e., Cohen's d).

Analyses

HLM overview

Two-level HLMs were used to determine whether there were differences between the Tutorial and Control groups at pre- and post-treatment. At Level-1, time effects were modeled through two dummy vectors coding for T1 (i.e., vector 1 = 0 and vector 2 = 0), T2 (i.e., vector 1 = 1 and vector 2 = 0), and T3 (i.e., vector 1 = 0 and vector 2 = 1) to allow for direct comparisons between the groups at each time point at Level-2; these predictors were modeled as random effects. Age was examined as a covariate at Level-2, but it was not significantly associated with the outcomes at any of the three-time points, ps = 0.08-0.99, and as a result, was not retained in the final models. Tutorial group assignment was examined as a Level-2 predictor of random effects, including as a predictor at T1 to assess whether the groups were comparable at baseline.

Proximal outcomes

Broad outcomes

Parent satisfaction with tutorial

Parents in the Tutorial group indicated high levels of satisfaction with the: (a) technical aspects ( M = 91.00, SD = 10.32) as the overall mean score reflected an average score of at least "4" (or "agree") on all SUS items; and (b) clinical content ( M = 53.90, SD = 5.65) as the overall mean score reflected an average score of at least "3" (or "agree") on all USQ items.

Discussion

The current study is the first to employ a RCT design with a large sample to evaluate the effectiveness of a self-directed, web-based training aimed at improving parent-child interactions during daily routines. The parenting tutorial was effective in improving key parent and child outcomes immediately (T2) and one month after its completion (T3). Specifically, the Tutorial group exhibited: (a) increased parental use of evidence-based strategies at T2 and T3 (large effect sizes); (b) decreased parenting stress and increased parenting efficacy at T3 (medium effect sizes); and (c) improved child engagement during routines and broader social communication at T2 and T3 (medium to large effect sizes). The Control group did not exhibit any such gains. The parents in the Tutorial group also rated the tutorial highly on usability and were highly satisfied with content. Overall, the tutorial appears to be a promising and accessible way for empowering parents and improving parent-child interactions.

The tutorial had a direct effect on the immediate dynamics of the interactions during routines as it led to changes in the routine-specific strategies parents used and improvements in the behaviors exhibited by children. Parents in the Tutorial group, but not the Control group, reported a significant increase in the evidence-based strategies they were implementing during routines with their children at T2 and T3. These strategies incorporated a variety of evidence-based techniques, including providing simple verbal instructions, using visual schedules, and appropriately modifying routine steps. These strategies were heavily emphasized throughout the tutorial, as parents learned about their general use as well as specific ways to adapt them to meet the unique demands of a given routine. This study, along with a case study [ Kashinath, 2006], indicates that after receiving training, parents increase their use of evidence-based teaching strategies during daily routines with their children. Children in the Tutorial group exhibited increased engagement during routines at T2, which was sustained at T3. This finding indicates that children improved in their ability to tolerate and transition during routines, which may include exhibiting fewer externalizing behaviors (e.g., physically struggling, leaving the area, fussing). Overall, it appears that children and their parents were able to advance through the lower levels of participation (i.e., tolerating) and reached the higher levels of participation (i.e., engaging socially).

In addition to changing routine-related behaviors, the tutorial led to improvements in broad outcomes for children and parents. Despite having lower levels on social communication than the Control group at T1, the children in the Tutorial group surpassed the Control group at T2 and T3. These social-communication improvements coincided temporally with children's increased ability to engage during routines and may suggest that improvements in routine-specific behaviors generalized to broader contexts and interactions. These findings continue to highlight the potential benefits of implementing interventions that focus on routines, as routines can frequently provide opportunities for positive and frequent social interactions that can support early social-communication development [ Spagnola & Fiese, 2007].

Furthermore, parenting stress related to challenges in the parent-child relationship (i.e., PSI/SF PCDI scale) declined significantly for parents in the Tutorial group, but not until T3; in contrast, there were no significant declines in stress as measured by the other two PSI/SF scales, which assess parental distress and how difficult the parent perceives the child to be. This pattern of findings suggests that parents' stress was ameliorated because they, specifically, perceived that the quality of their relationship and interactions with their children improved. Parents in the Tutorial group also exhibited significant gains in parenting efficacy by T3. Along with learning new strategies to use during routines, parents received education on how to perceive and interpret some their children's challenging behaviors and deconstruct routines into key stages. This new knowledge may have made parents feel that they were more effective managers of their children's behaviors [ Spagnola & Fiese, 2007]. These findings parallel those of other RCTs examining parent-mediated ASD interventions, which have also found declines in parental stress and increases in parenting efficacy/empowerment [ Ingersoll et al., 2016; Kasari et al., 2015; Minjarez et al., 2013]. The present study suggests that teaching parents specific and contextualized behavioral strategies may be effective even when they are not part of a specific and comprehensive intervention program.

Given that daily routines represent a transactional pattern of parent-child behaviors, it is possible that parent strategies may have positively affected child behavior, which in turn influenced parents' sense of efficacy and stress [ Spagnola & Fiese, 2007]. There is evidence indicating that lower levels of social relating and higher levels of externalizing behaviors in children with ASD are associated concurrently with higher levels of parenting stress [ Davis & Carter, 2008]. Within the current study, for example, it is possible that improvements in children's participatory behaviors during routines and increases in social relatedness facilitated the later improvements seen in parenting stress for the Tutorial group.

While this study applied an innovative approach (i.e., self-directed, web-based learning) and had notable strengths, including a RCT design and relatively large sample, there are significant limitations that need to be considered carefully. First, there was no direct observation of the parent and child outcomes since the study was conducted remotely; all outcomes were based on parental reports from a single respondent for each parent-child dyad. This significant limitation introduced the possibility that improvements in outcomes may have reflected a social desirability response bias and/or a placebo effect. However, it is unlikely that the social desirability or placebo effect account for the entire pattern of results, given that not all outcomes (i.e., parenting efficacy and parenting stress) demonstrated immediate improvement at T2. Furthermore, the lack of direct observation measures is magnified for the proximal outcomes given that those routine-specific surveys were developed and used for the first time as part of this study. It will be imperative for future studies to examine child outcomes and the fidelity with which parents' implement strategies with objective measures. Second, because there were no in-person visits, we were not able to confirm participants' ASD diagnosis through a gold-standard evaluation conducted by the research team and, instead, had to rely on reviewing diagnostic reports from community-based diagnosticians. Third, the current sample was homogeneous with respect to key socioeconomic factors, as the majority of participants were White, Non-Hispanic mothers with a college education. As a consequence, we were not able to examine the extent to which SES factors: (a) functioned as moderators of the treatment effect; and/or (b) impacted parents' preferential and optimal learning style. Relatedly, because 90% of the parents in the sample were mothers, we were unable to compare whether outcomes differed for families based on whether it was the father or mother who was learning and completing the tutorial. Fourth, we cannot speak to the long-term sustainability of the gains demonstrated by parents and children because the study employed a relatively short follow-up window (i.e., T1-T3 occurred during two-month period). Finally, participants were also receiving other community intervention services, which we were unable to quantify and examine in the current analyses.

In addition to using direct observation for measuring key outcomes, including a more diverse population, and applying a longer follow-up period, future studies should investigate: (a) whether gains in child behaviors generalize to different situations/contexts; and (b) the potential mechanisms by which the tutorial had an effect on broad outcomes. Furthermore, there needs to be additional empirical investigation into the extent to which the behaviors targeted and improved during routines generalize to other settings and contexts.

Overall, the parenting tutorial provides an effective, low-cost way for improving parent-child interactions during daily routines, which may improve children's broader social communication and augment other types of treatment services. Because the tutorial employs self-directed, web-based training that can be completed in the home, it has the potential to circumvent prominent barriers to obtaining services such as shortages of service providers and logistical constraints. Empowering parents with knowledge and skills for teaching their young child with ASD provides resources to the people with the most vested interest and longest lasting influence on a child's long-term growth and development.

Lay Summary.

This web-based tutorial helped parents of children with ASD use proven strategies to improve their child's participation in daily routines at home. Parents who used the tutorial reported less parenting stress, felt better about their parenting skills, and reported better child social interactions compared to parents who did not use the tutorial. This tutorial may be especially helpful for families who have limited access to services, as it can be completed at home.

Acknowledgments

This study was funded by the National Institute of Mental Health, National Institutes of Health, and the Department of Health and Human Services, under Small Business Innovation Research (SBIR) Grant No. R44MH086936, which was awarded to the Center for Psychological Consultation (Kenneth Kobak, PI). The authors acknowledge the contributions of Shanni Geller, the primary research assistant, who managed recruitment, enrollment, and data collection at the University of Washington. We are grateful for the families who gave their valuable time to participate in this study. While the lead author (LVI) does not have a financial conflict of interest (FCOI), the supporting authors (KK, AS, LW, ZW, and WLS) have a FCOI to declare as they receive profits from the sales of the tutorial.

Contributor Information

Lisa V. Ibañez, From the Department of Psychology, University of Washington, Seattle, Washington

Kenneth Kobak, Center for Psychological Consultation, Madison, Wisconsin.

Amy Swanson, Vanderbilt Kennedy Center Treatment and Research Institute for Autism Spectrum Disorders, (TRIAD), Vanderbilt University Medical Center, Nashville, Tennessee.

Lisa Wallace, Vanderbilt Kennedy Center Treatment and Research Institute for Autism Spectrum Disorders, (TRIAD), Vanderbilt University Medical Center, Nashville, Tennessee.

Zachary Warren, Department of Pediatrics, Vanderbilt Kennedy Center Treatment and Research Institute for Autism Spectrum Disorders, (TRIAD), Vanderbilt University Medical Center, Nashville, Tennessee.

Wendy L. Stone, Department of Psychology, University of Washington, Seattle, Washington

References

1. Abidin RR. Parenting stress index professional manual. 3rd. Odessa, FL: Psychological Assessment Resources, Inc; 1995. [Google Scholar]

2. Bailey K. Supporting families. In: Chawarska K, Klin A, Volkmar FR, editors. Autism spectrum disorders in infants and toddlers: Diagnosis, assessment, and treatment. New York: Guilford; 2008. pp. 300-326. [Google Scholar]

3. Bangor A, Kortum P, Miller JA. The system usability scale (SUS): An empirical evaluation. International Journal of Human-Computer Interaction. 2008;24:574-594. [Google Scholar]

4. Brooke J. SUS: A quick and dirty usability scale. In: Jordan PW, Thomas B, Weerdmeester BA, McClelland IL, editors. Usability evaluation in industry. London: Taylor and Francis; 1996. pp. 189-194. [Google Scholar]

5. Jang J, Dixon DR, Tarbox J, Granpeesheh D, Kornack J, de Nocker Y. Randomized trial of an eLearning program for training family members of children with autism in the principles and procedures of applied behavior analysis. Research in Autism Spectrum Disorders. 2012;6:852-856. [Google Scholar]

6. Knowles MS. The adult learner: A neglected species. 4th. Houston: Gulf Publishing; 1990. [Google Scholar]

7. Minjarez MB, Mercier EM, Williams SE, Hardan AY. Impact of pivotal response training group therapy on stress and empowerment in parents of children with autism. Journal of Positive Behavior Interventions. 2013;15:71-78. [Google Scholar]

8. Nieuwboer CC, Fukkink RG, Hermanns JM. Online programs as tools to improve parenting: A meta-analytic review. Children and Youth Services Review. 2013;35:1823-1829. [Google Scholar]

9. Odom SL, Collet-Klingenberg L, Rogers SJ, Hatton DD. Evidence-based practices in interventions for children and youth with autism spectrum disorders. Preventing School Failure: Alternative Education for Children and Youth. 2010;54:275-282. [Google Scholar]

10. Raudenbush SW, Bryk AS, Congdon R. HLM 7.00 for Windows [Computer software] Lincolnwood, IL: Scientific Software International, Inc; 2011. [Google Scholar]

11. Rogers SJ, Dawson G. The early start Denver model for young children with autism: Promoting language, learning, and engagement. New York: Guilford Press; 2010. [Google Scholar]

12. Singer JD, Willett JB. Applied longitudinal data analysis: Modeling change and event occurrence. Oxford University Press; 2003. [Google Scholar]

13. Spagnola M, Fiese BH. Family routines and rituals: A context for development in the lives of. Young Children. Infants & Young Children. 2007;20:284-299. [Google Scholar]

14. Tabachnick BG, Fidell LS, Osterlind SJ. Using multivariate statistics. 5th. Boston, MA: Allyn and Bacon; 2001. [Google Scholar]

15. Tomanik S, Harris GE, Hawkins J. The relationship between behaviors exhibited by children with autism and maternal stress. Journal of Intellectual and Developmental Disability. 2004;29:16-26. [Google Scholar]

16. Vincent A, Ross D. Personalize training: determine learning styles, personality types and multiple intelligences online. The Learning Organization. 2001;8:36-43. [Google Scholar]

# data[].attributes.attachment_link.title
Enhancing Interactions during Daily Routines: A Randomized Controlled Trial of a Web-Based Tutorial for Parents of Young Children with ASD

# data[].attributes.attachment_link.description
Children with Autism Spectrum Disorder (ASD) often experience difficulty participating in everyday home routines, such as bed time or bath time. This randomized controlled trial examined the efficacy of an interactive, web-based parenting tutorial ...

# data[].attributes.headline
Speech, Hearing, or Cognitive Rehabilitation and how it can help individuals with Autism

# data[].attributes.subject
Speech, Hearing, or Cognitive Rehabilitation and how it can help individuals with Autism

# data[].attributes.body
Speech-Language Therapy: This therapy supports hearing and communication indirectly in individuals with autism who have hearing differences or sound sensitivities. These sensitivities can make it harder to process spoken language, which may affect language development and social communication. This therapy is important for individuals that are nonverbal. Speech-language pathologists use evidence-based strategies to help improve communication skills. Speech-Language therapy is highly recommended when language comprehension is impacted by auditory processing issues. More professionals that can perform speech-language therapy include speech-language pathology assistants and audiologists.

# data[].attributes.attachment_link.title
Engaging Speech Therapy Games and Activities for Children with Autism | Speech Development

# data[].attributes.body
Gait training is a series of exercises and training that focus on how to improve an individual walk. They also focus on strength, balance, and coordination. In the short term, gait training improves walking patterns and foundational motor skills using exercises and sensory cues. Over the long term, it enhances balance, prevents physical issues, and promotes greater independence in daily life. Professionals such as physical therapists, occupational therapists, and gait and clinical movement specialists can perform.

# data[].attributes.body
Balance and Coordination Training: These trainings are types of exercises that improve balance and coordination. These include yoga exercise, core stability exercises, beam walking, one leg standing. In the short term, this training helps improve motor skills and encourages safer movement during physical tasks. Over the long term, it enhances body awareness and coordination, helping to prevent injuries related to poor balance in individuals with autism. Professionals such as occupational therapists, physical therapists, certified strength and conditioning specialists, personal trainers, and chiropractic neurologists.

# data[].attributes.body
1. Adaptive Equipment Training: Adaptive equipment training helps individuals learn to use special tools and devices to manage physical challenges and become more independent in everyday activities. Professionals such as occupational therapists, occupational therapy assistants, physical therapists and physical therapist assistants. While this short term will help them use tools it in the long term will support with daily tasks or progressive skill development, especially in cases of significant motor or sensory challenges.

1. Using specialized tools that assist

1. Dressing

2. Eating

3. Grooming

# data[].attributes.headline
Physical and Occupational Rehabilitation Options

# data[].attributes.subject
Physical and Occupational Rehabilitation Options

# data[].attributes.body
Physical and occupational therapy are important for helping people with autism improve their movement, sensory processing, and everyday life skills. Some rehabilitation options are:

-Adaptive Equipment Training

-Balance and Coordination Training

-Gait Training

# data[].attributes.body
Exposure therapy can help people with autism by slowly helping them feel less anxious about things that bother them, like social situations or certain sounds or feelings. By facing these triggers step by step in a safe way, they can learn to handle their anxiety, build coping skills, and avoid these situations less over time. Exposure therapy can help people with autism by slowly helping them feel less anxious about things that bother them, like social situations or certain sounds or feelings. By facing these triggers step by step in a safe way, they can learn to handle their anxiety, build coping skills, and avoid these situations less over time

# data[].attributes.attachment_link.title
Mayo Clinic Minute: Helping kids with anxiety through exposure therapy

# data[].attributes.headline
Psychosocial Rehabilitation Treatments: RDI and ERP. What are They?

# data[].attributes.subject
Psychosocial Rehabilitation Treatments: RDI and ERP. What are They?

# data[].attributes.body
RDI stands for relationship development intervention and it is a therapy that helps people with autism and other developmental challenges build social and emotional skills through everyday interactions. It focuses on strengthening relationships, with parents being trained to guide their child’s growth step by step.

ERP stands for Exposure and Response Prevention and this helps a person slowly face their fears. This one helps individuals help their OCD.

# data[].attributes.body
RDI is a child-centered, play-based therapeutic model that focuses on reaching functional emotional developmental milestones to create a foundation for learning and development.

# data[].attributes.attachment_link.description
When exploring therapeutic interventions for your child, there are many options to consider. Therefore, you will want to make a prioritized list of your child’s needs…

# data[].attributes.headline
Psychological /social issues caused by Autism

# data[].attributes.subject
Psychological /social issues caused by Autism

# data[].attributes.body
1) Anxiety: caused by social situations or being overstimulated

2) Depression: caused by feeling alone, socially isolating to avoid conflict

3) ADHD/ ADD: can lead to difficulties with attention, hyperactivity, and impulsion

4) Eating Disorders- use food as a way to cope with emotions or self-worth

5)S.U.D(substance use disorder): can lead to possible addiction, caused by a coping mechanism to overstimulation of emotions

6) O.C.D( obbessive compulsive disorder) :

excessive thoughts about actions or emotions

There are lots of resources and support groups to help those with A.S.D

https://behavioral-innovations.com/blog/autism-and-impact-on-mental-health/

# data[].attributes.attachment_link.title
Autism and Impact on Mental Health | Behavioral Innovations

# data[].attributes.attachment_link.description
Discover the impact of autism on mental health, including co-occurring conditions, support strategies, and resources for children and adults on the spectrum.

# data[].attributes.body
ABA therapy is a common treatment for individuals who need help with behavior. Treatment will most likely be covered by insurance if individual has been diagnosed with ASD. If people avoid treatment long term affects can include negative hurtful behavior towards them self and others.

# data[].attributes.attachment_link.title
Understanding the High Costs of Autism Care | Hope For Three

# data[].attributes.attachment_link.description
Explore the significant financial challenges faced by families of children with autism. Learn about the costs of therapies, treatments, and support services, and discover how Hope For Three is helping bridge the financial gap.

# data[].attributes.headline
Treatment 2: Speech and Language Therapy (SLT)

# data[].attributes.subject
Treatment 2: Speech and Language Therapy (SLT)

# data[].attributes.body
SLT helps autistic individuals improve verbal and non-verbal communication. It addresses issues like delayed speech, difficulty with gestures, or using communication devices.

Estimated Cost:

Average: $100 – $250 per session

Yearly total: $3,000 – $15,000+

# data[].attributes.attachment_link.title
How Speech Therapy Boosts Communication for Children with Autism | Arizona Autism United (AZA United)

# data[].attributes.attachment_link.description
This blog explains the various benefits of Speech and Language Therapy for individuals with autism spectrum disorders.

# data[].attributes.body
OT teaches children practical daily living skills — dressing, feeding, hygiene, and motor coordination. It often includes sensory integration strategies.

Estimated Cost:

Average: $100 – $200 per session

Yearly total: $4,000 – $6,000+

# data[].attributes.headline
Treatment 1: Applied Behavior Analysis (ABA)

# data[].attributes.subject
Treatment 1: Applied Behavior Analysis (ABA)

# data[].attributes.body
ABA focuses on improving specific behaviors (like communication, social skills, and academics) by reinforcing positive actions and reducing problematic ones. It is the most researched and widely used therapy for children with autism.

Estimated Cost:

Average: $120 – $150 per hour

Yearly total: $45,000 – $75,000 (for full-time therapy)

Insurance Coverage:

Often covered partially or fully by private insurance and Medicaid (depending on state).

Coverage more likely if a diagnosis and treatment plan are provided by a certified professional.

Consequences If Avoided:

Child may experience worsening behavioral challenges, limited independence, and poor social development.

Early intervention with ABA has proven long-term benefits; skipping it may reduce quality of life and educational outcomes.

# data[].attributes.attachment_link.readable_text
What is Applied Behavior Analysis?

Applied Behavior Analysis (ABA) is a therapy based on the science of learning and behavior.

Behavior analysis helps us to understand:

How behavior works

How behavior is affected by the environment

How learning takes place

ABA therapy applies our understanding of how behavior works to real situations. The goal is to increase behaviors that are helpful and decrease behaviors that are harmful or affect learning.

ABA therapy programs can help:

Increase language and communication skills

Improve attention, focus, social skills, memory, and academics

Decrease problem behaviors

The methods of behavior analysis have been used and studied for decades. They have helped many kinds of learners gain different skills - from healthier lifestyles to learning a new language. Therapists have used ABA to help children with autism and related developmental disorders since the 1960s.

How does ABA therapy work?

Applied Behavior Analysis involves many techniques for understanding and changing behavior. ABA is a flexible treatment:

Can be adapted to meet the needs of each unique person

Provided in many different locations - at home, at school, and in the community

Teaches skills that are useful in everyday life

Can involve one-to-one teaching or group instruction

Positive Reinforcement

Positive reinforcement is one of the main strategies used in ABA.

When a behavior is followed by something that is valued (a reward), a person is more likely to repeat that behavior. Over time, this encourages positive behavior change.

First, the therapist identifies a goal behavior. Each time the person uses the behavior or skill successfully, they get a reward. The reward is meaningful to the individual - examples include praise, a toy or book, watching a video, access to playground or other location, and more.

Positive rewards encourage the person to continue using the skill. Over time this leads to meaningful behavior change.

Antecedent, Behavior, Consequence

Understanding antecedents (what happens before a behavior occurs) and consequences (what happens after the behavior) is another important part of any ABA program.

The following three steps - the " A-B-Cs " - help us teach and understand behavior:

1. An antecedent: this is what occurs right before the target behavior. It can be verbal, such as a command or request. It can also be physical, such a toy or object, or a light, sound, or something else in the environment. An antecedent may come from the environment, from another person, or be internal (such as a thought or feeling).

2. A resulting behavior: this is the person's response or lack of response to the antecedent. It can be an action, a verbal response, or something else.

3. A consequence: this is what comes directly after the behavior. It can include positive reinforcement of the desired behavior, or no reaction for incorrect/inappropriate responses.

Looking at A-B-Cs helps us understand:

1. Why a behavior may be happening

2. How different consequences could affect whether the behavior is likely to happen again

EXAMPLE:

Antecedent: The teacher says "It's time to clean up your toys" at the end of the day.

Behavior: The student yells "no!"

Consequence: The teacher removes the toys and says "Okay, toys are all done."

How could ABA help the student learn a more appropriate behavior in this situation?

Antecedent: The teacher says "time to clean up" at the end of the day.

Behavior: The student is reminded to ask, "Can I have 5 more minutes?"

Consequence: The teacher says, "Of course you can have 5 more minutes!"

With continued practice, the student will be able to replace the inappropriate behavior with one that is more helpful. This is an easier way for the student to satisfy the child's needs!

What Does an ABA Program Involve?

Good ABA programs for autism are not "one size fits all." ABA should not be viewed as a canned set of drills. Rather, each program is written to meet the needs of the individual learner.

The goal of any ABA program is to help each person work on skills that will help them become more independent and successful in the short term as well as in the future.

Planning and Ongoing Assessment

A qualified and trained behavior analyst (BCBA) designs and directly oversees the program. They customize the ABA program to each learner's skills, needs, interests, preferences and family situation.

The BCBA will start by doing a detailed assessment of each person's skills and preferences. They will use this to write specific treatment goals. Family goals and preferences may be included, too.

Treatment goals are written based on the age and ability level of the person with ASD. Goals can include many different skill areas, such as:

Communication and language

Social skills

Self-care (such as showering and toileting)

Play and leisure

Motor skills

Learning and academic skills

The instruction plan breaks down each of these skills into small, concrete steps. The therapist teaches each step one by one, from simple (e.g. imitating single sounds) to more complex (e.g. carrying on a conversation).

The BCBA and therapists measure progress by collecting data in each therapy session. Data helps them to monitor the person's progress toward goals on an ongoing basis.

The behavior analyst regularly meets with family members and program staff to review information about progress. They can then plan ahead and adjust teaching plans and goals as needed.

ABA Techniques and Philosophy

The instructor uses a variety of ABA procedures. Some are directed by the instructor and others are directed by the person with autism.

Parents, family members and caregivers receive training so they can support learning and skill practice throughout the day.

The person with autism will have many opportunities to learn and practice skills each day. This can happen in both planned and naturally occurring situations. For instance, someone learning to greet others by saying "hello" may get the chance to practice this skill in the classroom with their teacher (planned) and on the playground at recess (naturally occurring).

The learner receives an abundance of positive reinforcement for demonstrating useful skills and socially appropriate behaviors. The emphasis is on positive social interactions and enjoyable learning.

The learner receives no reinforcement for behaviors that pose harm or prevent learning.
ABA is effective for people of all ages. It can be used from early childhood through adulthood!
Who provides ABA services?

A board-certified behavior analyst (BCBA)provides ABA therapy services. To become a BCBA, the following is needed:

Earn a master's degree or PhD in psychology or behavior analysis

Pass a national certification exam

Seek a state license to practice (in some states)

ABA therapy programs also involve therapists, or registered behavior technicians (RBTs). These therapists are trained and supervised by the BCBA. They work directly with children and adults with autism to practice skills and work toward the individual goals written by the BCBA. You may hear them referred to by a few different names: behavioral therapists, line therapists, behavior tech, etc.

To learn more, see the Behavior Analyst Certification Board website.

What is the evidence that ABA works?

ABA is considered an evidence-based best practice treatment by the US Surgeon General and by the American Psychological Association.

"Evidence based" means that ABA has passed scientific tests of its usefulness, quality, and effectiveness. ABA therapy includes many different techniques. All of these techniques focus on antecedents (what happens before a behavior occurs) and on consequences (what happens after the behavior).

More than 20 studies have established that intensive and long-term therapy using ABA principles improves outcomes for many but not all children with autism. "Intensive" and "long term" refer to programs that provide 25 to 40 hours a week of therapy for 1 to 3 years. These studies show gains in intellectual functioning, language development, daily living skills and social functioning. Studies with adults using ABA principles, though fewer in number, show similar benefits.

Is ABA covered by insurance?

Sometimes. Many types of private health insurance are required to cover ABA services. This depends on what kind of insurance you have, and what state you live in.

All Medicaid plans must cover treatments that are medically necessary for children under the age of 21. If a doctor prescribes ABA and says it is medically necessary for your child, Medicaid must cover the cost.

Please see our insurance resources for more information about insurance and coverage for autism services.

You can also contact the Autism Response Team if you have difficulty obtaining coverage, or need additional help.

Where do I find ABA services?

To get started, follow these steps:

1. Speak with your pediatrician or other medical provider about ABA. They can discuss whether ABA is right for your child. They can write a prescriptionfor ABA if it is necessary for your insurance.

2. Check whether your insurance company covers the cost of ABA therapy, and what your benefit is.

3. Search our resource directory for ABA providers near you. Or, ask your child's doctor and teachers for recommendations.

4. Call the ABA provider and request an intake evaluation. Have some questions ready (see below!)

What questions should I ask?

It's important to find an ABA provider and therapists who are a good fit for your family. The first step is for therapists to establish a good relationship with your child. If your child trusts his therapists and enjoys spending time with them, therapy will be more successful - and fun!

The following questions can help you evaluate whether a provider will be a good fit for your family. Remember to trust your instincts, as well!

1. How many BCBAs do you have on staff?

2. Are they licensed with the BACB and through the state?

3. How many behavioral therapists do you have?

4. How many therapists will be working with my child?

5. What sort of training do your therapists receive? How often?

6. How much direct supervision do therapists receive from BCBAs weekly?

7. How do you manage safety concerns?

8. What does a typical ABA session look like?

9. Do you offer home-based or clinic-based therapy?

10. How do you determine goals for my child? Do you consider input from parents?

11. How often do you re-evaluate goals?

12. How is progress evaluated?

13. How many hours per week can you provide?

14. Do you have a wait list?

15. What type of insurance do you accept?

For more information
ATN/AIR-P Parent's Guide to Applied Behavior Analysis ATN/AIR-P An Introduction to Behavioral Health Treatments Behavior Analyst Certification Board (BACB) Association for Behavior Analysis International (ABAI)

# data[].attributes.attachment_link.title
Applied Behavior Analysis (ABA) | Autism Speaks

# data[].attributes.attachment_link.description
What is aba therapy? Click here to learn about applied behavior analysis and how it works.

# data[].attributes.body
While daily tasks are difficult to many individuals on the spectrum, the concept of independent living can be different than a person without autism. Self-care tasks—such as maintaining personal hygiene and managing dressing routines—can be challenging. Similarly, home maintenance activities like cooking, cleaning, and handling household responsibilities may also present difficulties.

Development towards independence can be achieved by helping people with autism by breaking tasks into small steps, teach safety skills for the community, and create clear routines. Using pictures, showing how to do things, and giving praise can also build confidence and self-reliance.

Long-term management of these behaviors and tasks can assist people with autism live a better day to day life.

# data[].attributes.headline
Approaches for Long-term Autism Treatments

# data[].attributes.subject
Approaches for Long-term Autism Treatments

# data[].attributes.body
The one's we will be focusing on are Applied behavioral analysis, Speech-Language Therapy and Occupational therapy. They all intended to help children with autism develop functional communication, reduce problem behaviors, and become more independent in daily life.

# data[].attributes.attachment_link.readable_text
Types of Treatments

There are many types of treatments available. These treatments generally can be broken down into the following categories, although some treatments involve more than one approach:

Behavioral approaches

Behavioral approaches focus on changing behaviors by understanding what happens before and after the behavior. Behavioral approaches have the most evidence for treating symptoms of ASD. They have become widely accepted among educators and healthcare professionals and are used in many schools and treatment clinics. A notable behavioral treatment for people with ASD is called applied behavior analysis (ABA). ABA encourages desired behaviors and discourages undesired behaviors to improve a variety of skills. Progress is tracked and measured.

Two ABA teaching styles are discrete trial training (DTT) and pivotal response training (PRT).

DTT uses step-by-step instructions to teach a desired behavior or response. Lessons are broken down into their simplest parts, and desired answers and behaviors are rewarded. Undesired answers and behaviors are ignored.

PRT takes place in a natural setting rather than clinic setting. The goal of PRT is to improve a few "pivotal skills" that will help the person learn many other skills. One example of a pivotal skill is being able to initiate communication with others.

Developmental approaches

Developmental approaches focus on improving specific developmental skills, such as language skills or physical skills, or a broader range of interconnected developmental abilities. Developmental approaches are often combined with behavioral approaches.

The most common developmental therapy for people with ASD is speech and language therapy. Speech and language therapy helps to improve the person's understanding and use of speech and language. Some people with ASD communicate verbally. Others may communicate through the use of signs, gestures, pictures, or an electronic communication device.

Occupational therapy teaches skills that help the person live as independently as possible. Skills may include dressing, eating, bathing, and relating to people. Occupational therapy can also include

Sensory integration therapy to help improve responses to sensory input that may be restrictive or overwhelming.

Physical therapy can help improve physical skills, such as fine movements of the fingers or larger movements of the trunk and body.

The Early Start Denver Model (ESDM) is a broad developmental approach based on the principles of ABA. It is used with children 12-48 months of age. Parents and therapists use play, social exchanges, and shared attention in natural settings to improve language, social, and learning skills.

Educational approaches

Educational treatments are given in a classroom setting. One type of educational approach is the Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH) approach. TEACCH is based on the idea that people with autism thrive on consistency and visual learning. It provides teachers with ways to adjust the classroom structure and improve academic and other outcomes. For example, daily routines can be written or drawn and placed in clear sight. Boundaries can be set around learning stations. Verbal instructions can be complemented with visual instructions or physical demonstrations.

Social-relational approaches

Social-relational treatments focus on improving social skills and building emotional bonds. Some social-relational approaches involve parents or peer mentors.

The Developmental, Individual Differences, Relationship-Based model (also called DIR or "Floor Time") encourages parents and therapists to follow the interests of the individual to expand opportunities for communication.

The Relationship Development Intervention (RDI) model involves activities that increase motivation, interest, and abilities to participate in shared social interactions.

Social Stories provide simple descriptions of what to expect in a social situation.

Social skills groups provide opportunities for people with ASD to practice social skills in a structured environment.

Pharmacological approaches

Important to know‎

Some medications treat co-occurring symptoms (those that happen along with ASD) and can help people with ASD function better. For example, medication might help manage high energy levels, inability to focus, or self-harming behavior, such as head banging or hand biting. Medication can also help manage co-occurring psychological conditions, such as anxiety or depression, in addition to medical conditions such as seizures, sleep problems, or stomach or other gastrointestinal problems.

It is important to work with a doctor who has experience in treating people with ASD when considering the use of medication. This applies to both prescription medication and over-the-counter medication. Individuals, families, and doctors must work together to monitor progress and reactions to be sure any negative side effects of the medication do not outweigh the benefits.

Psychological approaches

Psychological approaches can help people with ASD cope with anxiety, depression, and other mental health issues. Cognitive-behavior therapy (CBT) is one psychological approach that focuses on learning the connections between thoughts, feelings, and behaviors. During CBT, a therapist and the individual work together to identify goals and then change how the person thinks about a situation to change how they react to the situation.

Complementary and alternative treatments

Some people with ASD and their families use treatments that do not fit into any of the other categories. These treatments are known as complementary and alternative treatments. Complementary and alternative treatments are often used to supplement more traditional approaches. They might include special diets, herbal supplements, chiropractic care, animal therapy, arts therapy, mindfulness, or relaxation therapies. Individuals and families should always talk to their doctor before starting a complementary and alternative treatment.

Additional ASD Treatment Options‎

# data[].attributes.attachment_link.title
Treatment and Intervention for Autism Spectrum Disorder

# data[].attributes.attachment_link.description
Treatment and intervention information for people with autism spectrum disorder (ASD).

# data[].attributes.headline
Increased Risk to Other Health Conditions

# data[].attributes.subject
Increased Risk to Other Health Conditions

# data[].attributes.body
People with autism have co-ocurring health issues such as  gastrointestinal disorders, anxiety, epilepsy, and depression. These elevated risks likely result from a combination of factors, such as shared genetic or environmental influences, sensory sensitivities, social difficulties, and challenges in communication and self-expression.

Development: Some medications address symptoms that often occur with ASD and can help individuals with ASD function more effectively.

Long-term management of these co-occurring complications is necessary to be able to regulate their symptoms of autism.

# data[].attributes.body
Here are a few complications involved when an individual is autistic.

1. Social interaction difficulties

2. Increased Risk of Other health Conditions

3. Difficulties with Independent Conditions

# data[].attributes.attachment_link.title
Autism Spectrum Disorder (ASD)- Causes, Symptoms, And Treatment In Hyderabad-

# data[].attributes.headline
How to Improve Social Interaction Difficulties

# data[].attributes.subject
How to Improve Social Interaction Difficulties

# data[].attributes.body
As we learned, individuals with autism have differentiated cerebellums which affect social interaction and cues.

Individuals that are autistic can help progress improvement on social skills with applied behavior analysis and through structured social skill training. Fostering community support and promoting social inclusion can play a vital role in enhancing outcomes for individuals with autism spectrum disorder. Long-term management of social interaction is necessary to be able to live a smoother life and build community.

# data[].attributes.body
Applied Behavior Analysis (ABA) is a way to understand and change behavior. It uses ideas from learning to help people improve important skills, like talking and getting along with others. ABA is often used to support people with autism. It works by watching behavior closely and using tools like rewards and changes in the environment to help people learn and grow.

# data[].attributes.attachment_link.title
What Is Applied Behavior Analysis (ABA)? | Child Mind Institute

# data[].attributes.headline
Professional’s Observation on the Child’s Behavior

# data[].attributes.subject
Professional’s Observation on the Child’s Behavior

# data[].attributes.body
Doctors use their own observations and assess them and view what criteria has been met.

# data[].attributes.body
Well, as a parent, you are the closest to the child. While there is no specific test there are descriptions or behavior observations that can be used to inform a doctor when seeing symptoms.

# data[].attributes.body
While there is not specific test for autism there are two main methods that contribute to a diagnosis.

1. Parents/ Caregivers Descriptions

2. Professional's Observations on the Child's Behavior

# data[].attributes.body
Individuals with autism won’t hit language milestones especially as children. The inability to develop language is one of the earliest signs of autism. But many parents don't know whether is is speech delay or autism. The chart above shows the differences, but as always parents or caregivers should also refer to their observations and contact their care providers.

# data[].attributes.body
An early sign is when children want to play alone and aren’t interacting with their peers. As we learned before, the parts of the brain that affect the social cues therefore lack social engagement or awareness.

# data[].attributes.headline
My Baby Isn't Recognizing Their Name: Delayed response to their names by 9 months

# data[].attributes.subject
My Baby Isn't Recognizing Their Name: Delayed response to their names by 9 months

# data[].attributes.body
While not every child who experiences this symptom has autism, it is known as an early marker or observation in those that have been diagnosed as a young child.

# data[].attributes.body
Individuals with autism demonstrate repetitive behaviors such as clapping hands, repeating words,  playing with toys the same way every time, hitting the same body part and a strong desire for routines and structure.

# data[].attributes.attachment_link.title
What to know about repetitive behaviors in autism

# data[].attributes.headline
What are common signs of autism in early childhood?

# data[].attributes.subject
What are common signs of autism in early childhood?

# data[].attributes.body
Restricted and Repetitive Behaviors

Delayed response to their names by 9 months

Lack of social engagement with others by 3 years of age

Delayed language skill

# data[].attributes.body
Individuals with autism spectrum disorder (ASD) often exhibit disruptions in synaptic plasticity, which affect neuronal communication and information processing, contributing to challenges in social interaction, communication, and cognition. Additionally, structural variations in the size and shape of various brain regions are associated with altered emotional processing, cognitive function, and motor skills. Other physiological abnormalities commonly observed in ASD include dysfunction in the gut-brain axis, neuroinflammation, immune sensitivity, mitochondrial energy production deficits, and hormonal imbalances.

# data[].attributes.body
The hippocampus is a region in the brain critical for learning and memory, often shows size differences in individuals with autism—sometimes appearing enlarged, which may be associated with enhanced short- and long-term memory, while in other cases, these structural variations are linked to impairments in learning and memory. Additionally, altered neurotransmitter connectivity within the hippocampus may contribute to these cognitive differences.

# data[].attributes.body
The frontal lobe of the brain is involved in decision making and social behavior—may differ in size or volume compared to neurotypical individuals and often exhibits weaker connectivity with other brain regions. These differences can lead to variability in abilities such as impulse control, following step-by-step instructions, and navigating social interactions, with outcomes differing widely across the autism spectrum.

# data[].attributes.body
In individuals with autism, the amygdala is often smaller and may exhibit altered connectivity with the brain’s cortex. These differences can contribute to challenges in processing fear and anxiety, as well as in interpreting emotions and social cues.

# data[].attributes.headline
What is the Cerebellum and how its affected by ASD?

# data[].attributes.subject
What is the Cerebellum and how its affected by ASD?

# data[].attributes.body
Watching this video explains the affects on the cerebellum and how Changes in the cerebellum cause diﬃculties on motor skills, social interaction and language processing.

# data[].attributes.headline
Want to know the Primary Anatomical Structures Affected by Autism?

# data[].attributes.subject
Want to know the Primary Anatomical Structures Affected by Autism?

# data[].attributes.body
Well when researching ASD affects cerebellum, Hippocampus, Amygdala, and Frontal Cortex

# data[].attributes.body
Autism (ASD) as a whole is not treatable. There are several different factors that diagnose autism and not everyone with autism is the same. For example some children with autism can be attracted to toys with unique shapes and feelings, however when met with another autistic child that child may not like the sensory input that unique toy gives off.

# data[].attributes.attachment_link.title
Every Autism Type Explained In 16 Minutes

# data[].attributes.headline
Why do children that have autism seek sensory input?

# data[].attributes.subject
Why do children that have autism seek sensory input?

# data[].attributes.body
Sensory input for autistic children means more than a tight squeeze! Our focus question is why do children seek sensory input and why do others have a hard time recognizing sensory input?

# data[].attributes.attachment_link.title
The Sensory Room: Helping Students With Autism Focus and Learn

# data[].attributes.headline
Primary Cause of Autism: Environmental Factors

# data[].attributes.subject
Primary Cause of Autism: Environmental Factors

# data[].attributes.body
Several causes of autism or advanced cases come from environmental factors such as parental age, exposure to substances, prenatal mental and physical health conditions.

# data[].attributes.body
Autism is a hereditary trait. Autism occurs during prenatal brain development. Autism is not caused by a single gene but by genetic and environmental factors. Several autism cases are linked to genetic mutations passed down from parents, however, some come from spontaneous gene variation even when parents do not have it.

# data[].attributes.body
People of all ages suffer from Autism. There is not a common Age, Ethnicity, Gender, etc because Autism is a hereditary trait meaning if someone has autism, then its in there genetic code.