Implementation and evaluation of the parenting program Stepping Stones Triple P for children with autism spectrum disorders

Abstract

This research project consisted of an evaluation of the parenting program Stepping Stones Triple P for the Autism Spectrum Disorders population as well as an investigation of the role that parental attributions play in determining treatment outcome. Whilst the Triple P Positive Parenting Program has a large evidence base (Sanders, 1999; Sanders, Markie-Dadds, Tully & Bor, 2000) and preliminary evidence indicates that Stepping Stones is also efficacious (Roberts, Mazzucchelli, Studman & Sanders, 2006), to date neither Stepping Stones nor Triple P have been evaluated with the ASD population. Although specific parenting programs have been used with the ASD population for a number of years (Koegel, Schreibman, Britten, Burke, & O'Neill, 1982) the experience of parents of children with ASD in standard Parenting Programs that are more widely disseminated has not been researched. Parental attributions refer to a parent's search for the meaning of their child's behaviour and the parent's use of attributed causal factors in framing their response to their child's behaviour (Bugental, New, Johnston, & Silvester, 1998). There is some evidence that parental attributions are associated with parenting styles (Dix, Ruble, Grusec, & Nixon, 1986; Smith & O'Leary, 1995), child behaviour (Roberts, & Hallbert-Rowe, 1992) and outcomes in child mental health treatment (Watson, 1986). Morrissey-Kane and Prinz (1999) developed the beginnings of a model of the relationship between parental attributions and parental engagement in child mental health treatment. They focus on three of the four dimensions of Weiner (1980), namely locus, stability and controllability. Initially, a pilot study was conducted that involved forty-two parents of children with ASD viewing a DVD showing Stepping Stones parenting strategies. Parents were asked to rate each strategy for acceptability, usability and their intention to try the strategy. Additionally, parental attributions and parental perceived control were explored as possible barriers to positive evaluations of the strategies. A focus group of parents was used to gather qualitative information. The results from the pilot study indicated that parent response to Stepping Stones was generally positive. In addition, it was found that parental attributions of child behaviour to uncontrollable factors predicted higher ratings of usability. The second study was a randomised controlled trial of Stepping Stones for the ASD population. Fifty-nine families participated in this trial and were randomly allocated to treatment and wait-list control groups. The results demonstrate significant improvements in child behaviour, parenting styles, parental satisfaction and conflict about parenting as well as a sleeper effect for parental efficacy. The treatment effect was maintained at follow-up six months later and for a third of participants the change in child behaviour or parenting styles was clinically significant. The third study focused on the role of parental attributions in determining treatment outcome. The fifty-nine families that participated in the trial also completed measures of parental attributions before and after completing Stepping Stones. A tendency for parents to generalise from ASD-related behaviour to misbehaviour was identified as well as the presence of the positivity effect for stability and controllability attributions but not for locus attributions. A relationship between parental autistic traits and internal parent-referent attributions for ASD-related behaviour and misbehaviour was demonstrated. Following participation in Stepping Stones parents were significantly less likely to believe that their child's misbehaviour was caused by factors intrinsic to their child and significantly more likely to believe that their child's ASD-related behaviour may change with time. Thus, Stepping Stones was found to alter parental attributions in a way that promotes parental engagement according to the model of Morrissey-Kane and Prinz (1999). Parental attributions before the intervention significantly predicted decreases in parental overreactivity and parental verbosity during treatment. The changes in parental overreactivity are consistent with the model of Morrissey-Kane and Prinz (1999), however, the changes in parental verbosity are not. It is suggested that the model needs to be expanded to include a greater variety of dysfunctional parenting styles, not merely over-reactivity. Overall, this research project has demonstrated that Stepping Stones Triple P is an effective intervention for behavioural problems and dysfunctional parenting within the ASD population. In addition, the evidence suggests that Stepping Stones Triple P can alter parental attributions such that the program is more likely to promote parental engagement.