ProQuest Number: 13878081




All rights reserved

INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.

In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.






ProQuest 13878081

Published by ProQuest LLC (2019 ). Copyright of the Dissertation is held by the Author.


All rights reserved.
This work is protected against unauthorized copying under Title 17, United States Code
Microform Edition © ProQuest LLC.


ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, MI 48106 - 1346
ii
 ACKNOWLEDGEMENT

I would first and foremost like to acknowledge my late and beloved advisor Dr.

Robert (Bob) Schleser. I know that if he were here today he would say, “Good job kid”.

He believed in me in a way I did not even understand. I would also like to thank my lab

members (Lab 277) for their wisdom, practical help, and unconditional support. For the

all- nighters and Indian food runs, that made this possible. I would also very much like to

give my great appreciation to Dr. Michael Young who although was my surrogate

advisor, provided no less time support, knowledge, and guidance. He encouraged me to

reach my potential and helped me achieve number of other goals, including the

completion of this project, along the way. I would like to thank the faculty and staff at the

Illinois Institute of Technology for their dedication to the training of future psychologist

and the excellent education I received while under their tutelage. As an undergraduate

student at IIT I knew that I wanted to return to complete my graduate degree because of

the impact the school had on my understanding of psychology. To CeCe, I thank you for

helping me to become the clinician I am today. Thank you, Jessica and Alex, for all your

hard work! Last but certainly not least, I thank God, my family, and my friends for their

irrational belief in me. Dino, my love WE did it! I say we because without you I would

not be here. Hailey let us dance like none one is watching.

To my angels with Autism. You are truly the reason I exist. I pledge to fight for

you every day. I will use my platform for purpose, and truth, and justice. Thank you for

being my biggest inspiration.

Thank you all.

iii
 TABLE OF CONTENTS

Page

ACKNOWLEDGEMENT ....................................................................................... iii

LIST OF TABLES ................................................................................................... vi

LIST OF FIGURES ................................................................................................. vii

LIST OF SYMBOLS ............................................................................................... viii

ABSTRACT ............................................................................................................. ix

CHAPTER
1. INTRODUCTION ............................................................................... 1

1.1 Parent Engagement ................................................................. 2

1.2 Parent Expectations ................................................................. 4
1.3 The Present Study ................................................................... 15

2. METHODS .......................................................................................... 18

2.1 Participant Recruitment .......................................................... 18

2.2 Measures ................................................................................. 24
2.3 Procedures ............................................................................... 28

3. RESULTS ............................................................................................ 29

3.1 Preliminary Analysis ............................................................... 29

3.2 Hypothesis Testing ................................................................. 33
3.3 Additional Analyses ................................................................ 36

4. DISCUSSION ...................................................................................... 38

4.1 Findings ................................................................................... 38

4.2 Limitations and Future Directions .......................................... 41
4.3 Implications and Conclusions ................................................. 46

APPENDIX
A. PARENTAL INFORMED CONSENT ............................................... 49

B. DEMOGRAPHIC QUESTIONAIRE .................................................. 52

iv
 C. PARENT EXPECTATIONS MEASURE ........................................... 54

D. PARENTS EXPECTATIONS QUESTIONNAIRE FOR SHORT

TERM OUTCOMES ........................................................................... 60

E. SCREENING QUESTIONS ................................................................ 61

BIBLIOGRAPHY .................................................................................................... 65

v
 LIST OF TABLES

Table Page
1. Participant Characteristics (continuous variables) by Group ...................... 21

2. Participant Characteristics (categorical variables) by Group ...................... 31

3. Participant Characteristics (continuous variables) by Group ...................... 32

vi
 LIST OF FIGURES

Figure Page
1. Mean Long Term Expectation Scores by Group ......................................... 36

2. Mean Short Term Expectation Scores by Group ........................................ 36

vii
 LIST OF SYMBOLS

Symbol Definition

α Cronbach’s alpha

d Cohen’s d effect size measure

F The ratio of the difference between the variance of

group means by the variance within the groups

n Subset sample size

r Pearson product-moment correlation

P Probability that the results of analysis are by chance

SD Standard Deviation

SE Standard Error

ꭓ2 A measure of the association between categorical

variables

t A ratio of the difference between an estimated value of

a parameter from its hypothesized value to its standard
error

V Cramer’s V: Posttest measure of strength of association

between variables assessed in Chi Square analysis

% Percent

R2 Coefficient of determination

viii
 ABSTRACT

The purpose of this study was to determine if parent psychoeducation about

Autism Spectrum Disorder (ASD) impacts parents’ short-term and/or long-term

expectations for their children with ASD. The impact of parent psychoeducation on

parent’s expectations for their children with ASD was assessed. Research has

demonstrated that a parent’s engagement in their child’s therapy impacts the

effectiveness of that intervention. Given the importance of parents’ engagement in

therapy, it is clinically relevant to identify the variables that may influence a parent’s

level of engagement. Working from the framework of Bandura’s expectation theory, the

ability to assess and intervene on expectations would likely have a positive influence on

parental engagement. Participants attending parent psychoeducation and parents on a

waitlist for parent psychoeducation completed expectations questionnaires before and

after parent psychoeducation. Results of a 2x2 (group x time) mixed factorial ANOVA

did not support the hypotheses that expectations changed over time as a function of

completing parent psychoeducation. These results are discussed in terms of potential

adjustments to current parent psychoeducation curriculum or additional variables that

may be of interest to better improve (i.e. increase) parent expectations.

ix
 1

CHAPTER 1

INTRODUCTION

The prevalence rate of Autism Spectrum Disorders (ASD) has increased from 1 in

150 in 2000 to 1 in 59 in 2018 according to the Center for Disease Control and

Prevention (Baio et al., 2018). The reasons for this rise have been debated by

professionals and some have attributed the increased prevalence to better screening and

diagnostic procedures and/or reclassification of other similar disorders as ASD (Nevison

& Blaxill, 2017). Given the reported rise in the prevalence of ASD, the need for effective

interventions is crucial. Additionally, the exorbitant cost of ASD in the United States,

which is estimated to reach 461 billion in 2025 (Leigh & Du, 2015), highlights the

necessity to identify the most effective interventions in order to maximize the use of these

funds.

Evidence-based interventions have been established for improving the symptoms

and behavior challenges associated with ASD (Eldevik et al., 2009; Howard et al., 2005;

Lovaas, 1987). These interventions are based on Applied Behavior Analysis (ABA) and

may be packaged and/or delivered under different names such as Early Intensive

Behavioral Interventions (EIBI) or Intensive Behavioral Therapy (IBT) (Eikeseth et al.,

2002; Eldevik et al., 2009; Ortega, 2010). Despite the effectiveness of these

interventions, child outcomes are impacted by parent involvement in the intervention

(Matson, Mahan, & Matson, 2009). The National Research Council determined that

parent training is a necessary component of these types of interventions given that a

parent’s role is to guide their child’s development and maintain intervention gains (Tonge

et al., 2014). Therefore, understanding the impact of parent engagement, and variables
 2

that influence engagement, is important for determining how to optimize ASD

intervention effectiveness.

1.1 Parent Engagement

Client engagement in intervention is essential for optimal effectiveness of any

intervention. This is particularly true for parent engagement in their child’s therapy

(Nock & Kazdin, 2005). Engagement has been defined as the extent to which a client

actively participates in the intervention offered (Tetly et al., 2011). Participation in

intervention includes attendance, completion of the specified course of treatment,

homework completion, and in-session contribution (e.g. disclosure) (Lebeau et al., 2013;

Macgowan et al., 2005; McMurran et al., 2010; Tetley et al., 2011).

Parents play a role in their child’s therapy in a number of ways, including acting

as a direct interventionist, collaborating with therapists, and advocating for their child’s

therapy (Jellet, Wood, Giallo, & Seymour, 2015). Numerous studies have reported on the

impact of parent involvement in their child’s therapy. In general, the consensus is that

parent involvement in therapy is more beneficial than individual therapy regardless of

therapeutic orientation (Dowell, 2011). A moderate effect size for adding a parent

component to child therapy has consistently been observed (Dowell, 2011). Parent

engagement in intervention is beneficial across populations and child outcomes including

adolescent HIV prevention behaviors, child internalizing and externalizing symptoms,

and overall family functioning (Adams, 2001; Dowell, 2011; Wang et al., 2014).

For individuals with ASD, child outcomes are related to parent engagement in

ASD-related interventions. More specifically, parent involvement in therapy has been

 3

observed to increase the rate of skill acquisition for children with ASD. A meta-analysis

conducted by Strauss, Manicin, and Fava (2013) observed significant increases in

adaptive functioning and IQ following completion of behavioral intervention that

included a parent component. Lafaskis and Sturney (2007) effectively trained parents to

use discrete trial teaching (DTT), a behavior analytic technology, to teach their child with

ASD new motor skills. In a subsequent generalization phase, all three parents exhibited

the ability teach their child vocal imitations without further specific training. The children

with ASD were able to acquire skills outside of therapy when their parents were included

in the intervention process. These studies illustrate the added benefits of parent

engagement in evidenced based interventions for individuals with ASD.

According to the national certifying board for individuals that practice ABA

(Behavior Analyst Certifying Board), best practices for treating individuals with ASD

includes involving the parent in every aspect of the therapy process (goal setting,

generalizing skills, etc.) (BACB, 2015). Given that parent engagement is related to child

outcomes, there is a need to identify ways to improve parent engagement. Although it has

been indicated that clinician coaching for parents significantly improves parent

engagement in ASD intervention; additional ongoing clinician coaching requires more

time, money, and resources (Ingersoll & Berger, 2015). Therefore, identifying individual

parent variables that influence engagement may provide insight into other avenues for

increasing parent engagement. Ideally, targeting individual parent variables would

increase parent engagement without the need for ongoing clinician involvement.
 4

1.2 Parent Expectations

1.2.1 Expectancy Theory. One variable that has been proposed to explain why and to

what extent parents engage in their child’s therapy is the parent’s expectation for their

child based on the perception of their child’s abilities. Research on parent expectations is

largely based on Bandura’s (1977; 1995) Expectancy Theory. Expectancy Theory posits

to explain how a person’s expectation of an outcome impacts their motivation and related

behavior. Per Expectancy Theory, an individual predicts the outcome of a situation based

on 1) the behavior required to achieve the outcome, and 2) their ability to engage in the

behavior. These variables were termed outcome expectancy and efficacy expectancy,

respectively (Bandura, 1977, 1992). The individual’s behavior related to that outcome is

then based on the estimation of their ability achieve that outcome. Bandura termed this

estimation of one’s own ability “self-efficacy.” Self-efficacy is the result of one’s prior

knowledge based on experience or observing others. An individual’s self-efficacy is not

stagnant and can vary based on new knowledge. The pliability of one’s self efficacy is

based on the magnitude, generality, and strength of the belief. The magnitude of efficacy

expectations may differ within an individual based on the perceived difficulty of a task.

This indicates that a person may have different levels of self-efficacy for different tasks.

The generality of self-efficacy refers to how much an individual’s self-efficacy is

constrained to a single task or applies to different, but similar, tasks. The strength of

one’s efficacy expectation denotes how easily an expectation is altered based on a

disconfirming experience. A weak efficacy expectation may be further diminished when

the individual experiences a situation in which they are not successful in achieving an
 5

outcome. If one has a strong efficacy expectation it is not easily changed, even with

negative experiences (Bandura, 1977).

In the literature, self-efficacy has been observed to relate to a variety of behaviors,

including athletic performance, academic performance, and substance use (Barros, 2004;

Levi et al., 2014; Weinberg, Gould, & Jackson, 1979). Feather (1982) used this theory to

explain why people in need of treatment do not often seek out treatment or services. It

was proposed that because they lack confidence in their efficacy to help themselves, they

do not engage in the behavior of treatment seeking. In summary, Bandura’s Expectancy

theory has been applied to understanding human performance in a variety of contexts. In

addition to using Bandura’s theory to understand motivation for an individual’s behavior

based on self-efficacy, it has also been applied to understanding motivation of behavior

based on the expectations of others’ capabilities. This application of expectancy theory

asserts to explain a person’s behavior as a result of predicting an outcome that requires

the action of another individual.

1.2.2 Expectancy Theory Applied to Parents Expectations. Bandura’s theory of

expectations may apply not only to oneself, but also to the judgment of others’

capabilities, known as “other-efficacy” (Dunlop, Beatty, & Beauchamp, 2011; Lopez &

Lent, 1991). Expectations about another individual’s ability to achieve an outcome are

based on the same constructs of self-efficacy. However, in other-efficacy, an individual

evaluates another individual’s ability to engage in a behavior and achieve an outcome. As

a result of other-efficacy judgment, an individual adjusts their own behavior. This

concept (other-efficacy) has been observed to impact the behavior of school-aged

 6

children when deciding peer group preferences (Andrews et al., 2016). Similarly, the

behavior of individuals in romantic relationships has been indicated as significantly

related to their assessment of their partner’s other-efficacy (Lopez & Lent, 1991). Other-

efficacy has also been demonstrated to influence an individual’s behavior more than self-

efficacy (Dunlop, Beatty, & Beauchamp, 2011). Individual college student’s performance

on a dance task with a partner was significantly related to self-reported other-efficacy

beliefs about their dance partner’s abilities. Even when the results of practice dance

sessions were manipulated to result in enhanced self-efficacy, performance was more

closely related to other-efficacy.

In specifically looking at other-efficacy applied to parents’ expectations for their

child, the literature has yielded similar results. Research has consistently shown that a

parent’s expectations of their child’s ability to achieve outcomes are positively linked

with actual future outcomes for their child (Field & Hoffman, 1999; Mutua, 2001). This

is most often modulated by the parent’s behavior as a result of other-efficacy in relation

to their child’s abilities. Mutua and Dimitrov (2001) assessed parents’ expectations of

their child’s ability to achieve outcomes in a number of areas (Adult Responsibilities,

Civil Rights, and Social Acceptance) in the future. The children being rated were all

previously identified as intellectually impaired. Parent responding about their child’s

ability to achieve outcomes (other-efficacy) was significantly related to parent enrollment

of that child in special education services. Given that special education is an intervention

for improving skills in individuals with intellectual impairment, these findings are

concerning and further support the need to better understand parent expectations for their

child and their help-seeking behavior for their child.

 7

1.2.3 Parent Expectations and Child Outcomes. Other-efficacy of parents for their

child has also been evaluated in the context of understanding the direct relationship

between parent expectations and child outcomes. Abraham and colleagues (2009)

explored the impact of parents’ expectations on child academic outcomes. Parents of

school-aged children, up to 13 years old, were asked to report educational attainment

expectations for their child. At 5 year follow up, standardized child achievement scores

were significantly related to parent expectations of their child at time 1. This relationship

was significant even when controlling for child achievement at time 1 and parent

demographic variables. Other longitudinal studies looking at parent expectations and

child academic outcomes have supported these findings (Englund et al., 2004). The

relationship between parent expectations and child outcomes appears to apply across

cultures (Areepattamannil & Lee, 2014). Parents with immigrant status in Canada

reported expected child achievement outcomes for children ages 5 to 18 years old

(Areepattamannil & Lee, 2014). Parent reported expectations significantly correlated

with child school achievement, when controlling for child and family demographic

variables.

Additionally, parent expectations relate to outcomes in individuals with ASD. In a

longitudinal study conducted by Kirby (2016), actual outcomes were compared to parent-

reported future expectations for their child with ASD. Child ages ranged from 13-16

years old at time 1 and 21-25 years old at 8-year follow-up. At time 1, parents rated their

child’s ability to achieve outcomes (paid work, live independently, social participation) in

the future. At follow-up, the status of paid work and living arrangements were assessed,

as well as the frequency of social interactions with friends (i.e. ‘never’, ‘once a week’, ‘2
 8

or more times per week’). Parent expectations of child outcomes (work, living, social)

significantly predicted actual child outcomes at 8-year follow-up.

In summary, parent expectations relate to child outcomes across populations and

type of outcome (e.g., academic, adaptive skills, independent living). Evaluating the

expectations of parents of children with ASD is of importance, given the profound needs

of these individuals and the pronounced role of parents in their lives.

1.2.4 Parent Expectations for Children with Autism Spectrum Disorder. Given that

prognosis for individuals varies greatly, there is no standard for which to compare ‘low’,

‘high’, or ‘realistic’ expectations (Reif et al., 20107). Therefore, the majority of literature

compares the expectations for individuals with ASD against other populations or other

variables. A study by Ivey (2004) compared parent expectations for child outcomes to

how important these outcomes were to the parent. In this study, parents of children with

ASD (n = 25) ages 6-10 years old, reported how likely it was that their child would

achieve outcomes presented on a 20-item expectation assessment (Mutua, 2001). Parents

responded on how important an outcome was for their child (Importance Subscale) (1 =

highly unimportant, 5 = very important) and how likely it was for their child to achieve

that outcome (Likelihood Subscale) (1= highly unlikely, 5 = very likely). The authors

compared parent reported scores for how important an item was versus how likely the

child would achieve the outcome. For both subscales, “take care of parent in old age” was

the lowest rated item and “attend school’’ was the highest rated item. Subjectively,

parents did not have high expectations for their child with ASD (M = 73.83, SD = 14.12)

given that items scores ranged from 1.96 - 4.86. No items were consistently rated as
 9

highly likely by parents. At the item level, there were five items in which importance

ratings were significantly higher than likelihood: support network of friends, secure

financial futures, safe from physical harm, highest education possible, and have own

children. These results indicated that parents found these variables important for their

child but that their child was unlikely to achieve the outcome.

In a qualitative study, Poon (2013) evaluated parent expectations for their child

with ASD, post-school years. None of the parents reported expecting their child to

independently access the community. More specifically, parents reported that they

expected their child to be either unemployed or working in low positions specifically

modified for individuals with ASD, such as employment workshops.

The expectations for young adults to work in the community or maintain a

private residence are lower for parents of individuals with ASD than parents of those with

Down syndrome (Blacher et al., 2010; Ogston, Mackintosh, & Myers, 2011). In a study

conducted by Ogston, Mackintosh, and Myers (2011), mothers of individuals with ASD

(n = 199) and mothers of individuals with Down syndrome (n = 60) reported their

concerns about their child’s ability to achieve and cope in the future. Parent report was

significantly related to child diagnosis and level of symptom severity. Parents of

individuals with ASD indicated significantly more concern for their child’s future and

their ability to achieve certain outcomes. Blacher, Kraemer, and Howell (2010) reported

seemingly conflicting results in that they observed that parents of individuals with ASD

and Down syndrome (ages 18-26 years old) had high expectations for their child

obtaining employment in the future. However, the expectations questions asked parents

to rate if they would ‘like’ their child to obtain employment and not if they believed their
 10

child would obtain employment. In comparing parent responding across diagnoses (ASD,

Down syndrome, cerebral palsy, and unspecified learning disorder), parents of young

adults with ASD rated more concern across post-school attainment variables (residential,

vocational, daily activities, recreation, health, and financial) even when controlling for

maladaptive behavior (Blacher, Kraemer, & Howell, 2010). In summary, parents of

children with ASD have lower expectations for their child across outcomes. Some

possible reasons for this discrepancy are the heterogeneity of ASD symptoms and

severity level in the population. The variability of symptomology has made it difficult for

professionals to establish a clear prognosis for the disorder. Furthermore, individual’s

with Down syndrome can be diagnosed as early as, and even prior to, birth allowing for

early intervention and planning (Ogston, Mackintosh, & Myers, 2011). In addition,

similar to participants in the Ivey (2004) study, there is a discrepancy between what

parents would like or think is important, and their actual beliefs about the future.

Results of these studies suggest that parents of individuals with ASD have

relatively low expectations for their children in the areas of work, independent living, and

social participation. Additionally, parents of individuals with ASD have more concern

about their child’s future than do parents of children with similar conditions. These

results indicate the need to identify the variables that impact parent expectations to

expand our understanding of how parent expectations develop and possibly inform areas

for intervening and improving expectations.

1.2.5 Variables that Impact Parent Expectations. Given the relationship between

child outcomes and parent expectations for their child (other-efficacy), it is vital to
 11

determine the variables that impact parent expectations for individuals with ASD.

Identifying these variables may help target areas for intervening to improve parent

expectations. Within the literature, ASD symptom severity, child age, and access to

resources have been identified as possibly contributing to the development of parent

expectations for their child with ASD (Poon, Koh, & Magiati, 2013; Poon, 2013).

ASD Severity. Research has indicated that a child’s ASD symptom severity is

related to parent expectations for their child (Holmes, Himi, & Strassberg, 2016; Poon,

Koh, & Magiati, 2013). In a study by Poon and colleagues (2013), 105 parents of

children aged 6-18 years old with a diagnosis of ASD, intellectual impairment, or

medical disability were administered the Autism Treatment Evaluation Checklist (ATEC;

Rimland & Edelson, 2005) to measure ASD symptom severity and the Likelihood

subscale of an expectations questionnaire to assess parent expectations for their child’s

future outcomes. ASD severity reliably predicted parent reports of expectations for their

child. Similarly, Holmes and colleagues (2016) observed that for parents of children with

ASD, parent report of expectations for their child’s sexual and romantic relationships was

predicted by their child’s ASD symptom severity. Parents of individuals with ASD aged

12 to 18 years old completed a sexuality survey rating the likelihood of their child

achieving outcomes related to their romantic relationships (Mutua & Dimitrov, 2001).

ASD symptom severity measures were also completed (Constantino & Gruber, 2012).

After controlling for child age, ASD symptom severity significantly predicted parent

ratings of child expectations.

Child Age. The relationship between child age and parent expectations is

inconclusive in the literature. Ogston and colleagues (2011) found that child age
 12

correlated with parent future concerns for individuals with ASD. More specifically,

concern was positively correlated with child age. Conversely, Poon, Koh, and Magiati

(2013) observed that ASD symptom severity was the only variable that significantly

predicted parent ratings of future outcomes when age and severity were entered as

predictors into a multiple regression. Holmes, Himi, and Strassberg (2016) reported

similar results.

Access to Resources. Poon (2013) conducted a qualitative study assessing parent

expectations of their child with ASD. Participants included parents of individuals with

ASD (ages 12-19 years old). During a semi-structured interview, parents indicated their

expectations for their child’s employment, living arrangements (short-term and long-

term), and community participation in the future. Additionally, parent responses were

coded for variables related to their expectations. An emerging theme was limited access

to resources. Consequently, Poon (2013) proposed that a possible explanation for the low

expectations of parents of children with ASD is limited access to resources for their child.

Similar themes have emerged from qualitive studies for children without ASD (Irwin &

Elley, 2012). Parents of neurotypical school-aged children were asked about their

expectations for their child’s academic and employment prospects in the future. The

theme of limited opportunities and resources was indicated as a common reason for lower

parent-reported expectations. Although parent education and background often determine

actual and perceived resources, multiple studies controlling for these variables suggest

that parent background does not account for parent expectations alone (Abraham et al.,

2009; Areepattamannil & Lee, 2014). Therefore, it appears that regardless of parent

background, environmental and child variables impact parent expectations for their child.
 13

This is particularly relevant for parents of individuals with ASD, given that parents of

individuals with ASD have been documented to lack resources regardless of race or

socioeconomic status (Farmer et al., 2014).

1.2.6 Limitations in Access to ASD Resources. Investigators have demonstrated a

lack of access for parents of children with ASD in a number or areas, including diagnosis,

comprehensive care, and information about ASD. Limited access to resources is

particularly prevalent for children receiving public health insurance. Medicaid managed

care databases have revealed that children with ASD are under-identified and fail to

access behavioral health services (Ruble et al., 2005). On average, time from parent

concern to actual ASD diagnosis by a professional is 2 years (Sansosti, Lavik, & Sansoti,

2012). This wait time is even longer for children in minority groups, regardless of English

fluency level (Magana & Lopez, 2013). Magana and Lopez (2013) compared time from

concern to diagnosis for 48 Latino and 56 Caucasian children. Latino children (Mage = 3.9,

SD = 1.7) were diagnosed significantly later (8 months) than Caucasian children (Mage =

3.1, SD = 1.5). It was also indicated that in general, Latino children received fewer ASD

related services and reported more unmet needs. In terms of comprehensive care, parents

reported concerns that they did not have access to a comprehensive primary care facility,

the professionals they saw did not spend enough time with them, and they did not receive

adequate information about ASD and related resources (Farmer et al., 2004). Across

ethnicities (e.g. Asian and Latino) and country of origin parents of children with ASD

indicated a lack of ASD-related information (Chlewbowski et. al., 2018; Poon, 2013).

This sentiment was also observed in qualified professionals (i.e., pediatricians) whom
 14

self- reported they lacked information about ASD and related services to share with their

patients (Carbone et al., 2009; Hyman & Johnson, 2012). Reasons for the lack of services

in the ASD population include a lack of qualified providers, poor coordination between

service providers, high out-of-pocket costs, and lack of health insurance coverage.

In summary, access to information, providers, healthcare, and services for

children with ASD is limited, inadequate, uncoordinated, and costly. The majority of

children with ASD have service needs unmet regardless of related demographics such as

education and income (Farmer, 2004). However, being low-income and having less

education may further delay access to services. These findings provide support for the

theory asserted by Poon (2013) that low expectations for child outcomes in parents of

children with ASD may be due to a lack of access to education, services, etc. This lack of

access is possibly negatively influencing parent’s beliefs about their child’s ability to

achieve outcomes.

Parents of children with ASD may have low expectations of their child due to a

lack of knowledge about what and/or how resources and intervention for ASD will help

their child achieve the outcome. That is, if parents do not have information about what is

available for their child, they do not have all the information about what is possible for

their child with ASD, leading to low expectations. Poon’s (2013) theory that expectations

may be influenced by access to information and resources fits in the framework of

Bandura’s theory given that other efficacy (expectations) is impacted by new experiences

and knowledge (Bandura, 1992). Therefore, it can be predicted that parent expectations

will increase if new information is provided to the parents that directly relates to their

child’s ability to achieve an outcome.

 15

1.3 The Present Study

1.3.1 Rationale. The impact of ASD on the child and family is well documented

(Koydemira & Tosuna, 2009; Matthews et al., 2011). The challenges of raising a child

with ASD often results in a lack of family cohesion, low marital satisfaction, and parental

psychopathology. With proper evidence-based interventions and parent involvement in

these interventions, improvements may be expected in the child’s skills and behavior. In

addition, there may be reductions in parental stress and psychopathology. With adequate

parent training, parents learn the skills to teach their children and help generalize and

maintain skills. This is possible even when training programs are not standardized or

manualized (Kaminski et al., 2008). One of the variables that may impact optimal parent

engagement in ASD interventions is parent expectations for their child. Bandura (1977)

purported that expectations are analogous to cognitive motivation. That is, expectations

are a proxy of what parents think is possible and therefore worth working towards. When

individuals have low expectations, they are aware of the required behaviors to achieve a

goal but do not perceive that engaging in the required behavior to achieve a goal is

possible. In a study looking at parent expectations of their child’s development, parents

of children with developmental and/or cognitive impairment reported stable expectations

over time (Matsumara et al., 1998). Furthermore, parent expectations were observed to

decrease as children matured, and were predicted by childrens’ functioning at 3 years old.

These findings support the need for intervening in parent expectations, given that parent

expectations have been observed to be stable without intervention. Given the dearth of

information on acceptable targeted ‘levels’ of expectations, and no aversive results

reported for higher expectations in the aforementioned cited literature, it could be

 16

proposed that the current goal would simply be to ‘increase’ expectations until ideal

levels of parent expectations are identified.

One factor that has been identified as a possible source of the lower expectations

of parents of children with ASD is access to information about ASD (Poon et al., 2013).

Given that research has identified that access to psychoeducation, and other resources, is

limited for parents of children with ASD, it is very possible that access to resources is at

least one of the factors that impacts parental expectations. To fill gaps in the literature,

this study assessed if psychoeducation about ASD and/or techniques for ASD, in the form

of parent psychoeducation, changes parents’ expectations. Parent psychoeducation about

ASD was chosen because 1) it falls within the proposed theories cited (Bandura, 1977,

1992; Poon 2013) and 2) feasibility, as psychoeducation is the primary focus of most

group-based parent training courses for ASD (Tongue et. al., 2006). Consistent with

Bandura’s Expectancy Theory, psychoeducation may improve expectations, in that new

experiences and knowledge are believed to alter efficacy expectations. Additionally,

psychoeducation was targeted given that it is funded by private and public insurance. As

clinicians, it is important to identify ways optimize the effectiveness, and subsequent cost

efficiency, of interventions to justify continued funding. Both long-term and short-term

expectations were assessed. In addition, this study assessed if symptom severity and/or

child age impacted a parent’s expectations, consistent with previously completed studies.

1.3.2 Hypotheses. The goal of the present study was to assess whether parents

receiving psychoeducation about ASD changes parents’ expectations about their child’s

future. In a 2 (psychoeducation vs. waitlist control) by 2 (pre vs post) design, the

 17

interaction effect was examined to determine if parent expectations change over time as a

function of parent psychoeducation attendance compared to a waitlist control group.

More specifically we hypothesized

A. Time: Parents attending parent education group have higher scores on

the expectation measure after attending a parent-training program for ASD

psychoeducation in relation to their baseline score.

B. Group: Parents attending parent psychoeducation have higher scores on

the expectation measure than the control group after attending a parent

education program.

In addition, the study assessed the degree to which child ASD symptom severity

is associated with parental expectations for the child.

 18

CHAPTER 2

METHODS

2.1 Participant Recruitment

Participant recruitment began at the Pediatric Developmental Center (PDC) at

Advocate Illinois Masonic Medical Center. Due to issues with the feasibility of

recruitment in a timely manner, recruitment was also initiated via Qualtrics Panels. A

total of 276 participants, from both recruitment sources, completed all measures at Time

1 (T1). Participants were parents or legal guardians of children with ASD. Inclusion

criteria required participants to be a legal guardian of a child with ASD. Exclusion

criteria required that parents did not previously complete parent psychoeducation for

ASD.

2.1.1 The Pediatric Developmental Center (PDC). The PDC is a comprehensive

outpatient diagnosis and treatment center that serves children with special needs in the

Chicagoland area. The PDC runs an Autism Treatment Program which serves families

with children with Autism Spectrum Disorder. Parents/guardians of children ages 2 to 18

years were recruited after signing up for the parent psychoeducation component of the

Autism Treatment Program. Recruitment occurred both over the phone and on site.

2.1.2 Qualtrics. Qualtrics identified participants from existing participant panels with

their subcontractors. Screening criteria were provided to Qualtrics and used to target

participants via their standard methods. For the parent psychoeducation group,

participants were required to be initiating parent psychoeducation group for parents of

 19

children with ASD during their participation. For the wait list group, they were required

to be signed up for an ASD focused parent psychoeducation group but would not initiate

training prior to their participation in the study. These were assessed by asking

participants to identify their parent training status (Appendix E) as well as dates of

training. This information was asked again at T2 to assess consistency of reporting.

Potential participants completed profiles with demographic information and other

questions that Qualtrics used to target participants for specific studies. Individuals that

completed profiles on Qualtrics were verified by a third party for accurate profile

information when possible. If an individual’s profile contained information that matched

the study recruitment criteria, then the participant was invited to complete the study via a

private email link. Participants also were asked to verify their inclusion status prior to

starting the study by answering screening questions that either allowed them to continue

on to the study or were directed from the study if they did not qualify. Additional, quality

assurance procedures were in place including time exclusions for brief responding and

limits on participant invitations based on prior number of surveys completed.

2.1.3 Study Groups. The status of the participants recruited from the PDC was based

on the month the participant was registered for training and confirmed by contacting

participant about their attendance status for parent psychoeducation. Limited information

was available for the participants recruited from Qualtrics. Although the participants in

the psychoeducation group self-reported on the content of the psychoeducation groups,

this information could not be confirmed for accuracy with the actual group facilitator.

Topics reported by the participants included: symptoms of ASD/Asperger’s, information

 20

about medication management, and ASD/Asperger’s related interventions. Additionally,

no information was collected on the format of ASD psychoeducation received by

participants. However, given the literature on parent training outcomes, it has been

indicated that format (individual vs. group) and/or modality (video vs. in-person)

(Eyeberg & Matarazzo, 1980; Hutchings et al., 2002; Kaminski et al., 2008) does not

yield significant differences in parent or child outcomes. Therefore, participants from

PDC and Qualtrics were combined for the psychoeducation groups (PE). For the

Qualtrics recruited participants, group status was determined by their answer to screening

questions (I am enrolled or on wait-list for parent training/education but have not started

my training OR I am currently in parent training/education group). Participant status in

the group was verified by comparing their reported dates of parent psychoeducation

attendance with their actual participation in the study. A number of participants (n = 46)

who identified as ‘currently enrolled in parent psychoeducation’, but with dates of

training preceding the start of the study, were excluded. Additionally, 104 participants

were excluded because they indicated no intention to complete parent psychoeducation

and were not on a waitlist. Participants were excluded if dependents were over the age of

18 years (n = 34), dependents age at diagnosis was younger than 1 years old (n = 1), or

there were obvious data errors in the age of the child or guardian (n = 3). In total, 188 of

the 276 participants were excluded, leaving 88.

2.1.4 Retention. Of the remaining 88 participants (Table 1), 58 (65%) completed the

study in its entirety and were included in the final analyses. Participants that dropped out

(n = 30) did not differ from the analysis group on long term expectations at Time 1 (T1
 21

LE) (t (86) = -.18, p = .86), short term expectations at Time 1 (T1 SE) (t (86) = .26, p =

.79), age of participant (t (86) = -.34, p = .74), age of dependent (t (86) = 1.28, p = .20),

or age of dependent at diagnosis (t (86) = .52, p = .60). The ‘Drop Out’ group reported

significantly greater dependent ASD symptom severity (M (SD) = 82.30 (23.48)) than

participants that completed the study (M (SD) = 67.66 (31.59), (t (75.2) = 2.46, p = .016).

Within the group of participants that withdrew from the study (n = 30), study

groups (WL vs. PE) did not differ from the analysis group on long term expectations at

Time 1 (T1 LE) (t (9.1) = .11, p = .92), short term expectations at Time 1 (T1 SE) (t (28)

= 1.44 p = .16), age of participant (t (28) = 1.3, p = .31), age of dependent (t (28) = .90, p

= .38), age of dependent at diagnosis (t (25.80) = .1.57, p = .13), or dependent ASD

symptom severity (t (28) = -.08, p = .94).

 22

Table 1

Participant Characteristics (continuous variables) by Group

Drop Out Range Completed Range

(n = 30) (min-max) (n = 58) (min-max)
Mean (SD) Mean (SD)
Age 33.47 (8.29) 23-60 34.14 (9.03) 19-60
Age of Dependent 8.50 (4.56) 3-17 7.32 (3.85) 2-16
Age at Diagnosis 4.70 (3.66) 2-15 4.35 (2.65) 1-12
T1 LE 73.73 (14.73) 41-100 76.90 (14.45) 50-100
T1 SE 20.40 (3.90) 12-25 20.16 (4.30) 12-25
ATEC * 82.30 (23.48) 24-112 67.66 (31.59) 1-140

Note: T1 LE= long term expectations, T1 SE = short term expectations,

Age is reported in years

*Group difference significant, p < .05

For categorical variables (Table 2) groups with a small number of participants

were combined for analysis. For ethnicity a single ‘Other’ group consisted of participants

identified as ‘Asian’ (n = 3 (34%)) or ‘Other’ (n = 2 (2.3%)). For previous diagnosis an

“ADHD/Anxiety” group was created from the “Anxiety/OCD” (n = 9 (10.2)) and

“ADHD” (n = 36 (40.9%)) groups. For marital status a ‘Not Partnered’ group consisted

of individuals who identified as ‘Divorced’ (n = 5(5.7%)) or ‘Never Married’ group (n =

15 (17.0%)). One individual (1.1%) that identified as “Domestic Partner” was combined

with the married group (n = 67 (76.1%)) and labeled as “Partnered.” For type of guardian

an “Other” group was formed from participants identifying as a ‘Step/foster/adoptive’

parent (n = 2 (2.3%) or grandparents (n = 2 (2.3%)). For the highest level of education, a

“Primary/Secondary” school group was created and included individuals that completed

“Some college” (n = 17 (19.3%)), ‘High School’ (n = 9 (10.2%)) and one individual who
 23

reported a grammar school degree. A College/Trade School group was made by

combining individuals that completed trade or technical school (n = 4 (4.5%)) or college

(n = 36 (40.9%)). Lastly, for the variable previously received therapies into an ‘Other

ASD Therapy’ group was comprised of participants reporting completion of

Occupational Therapy (n = 9 (10.2%)), ABA (n = 3 (3.4%)), Developmental Therapy (n

= 1 (1.1%)), (Physical Therapy n = 5 (5.7%)), and ‘Other’ (n = 3 (3.4%)) forms of

therapy. Participants were included in an ‘Outpatient Therapy’ group consisting of

individuals that previously compled CBT (n = 2 (2.3%)), DBT (n = 1 (1.1%)), and family

therapy (n = 28 (31.8%)).

No completion-dropout group differences for categorical variables were

significant: Ethnicity (χ2 (3) = 5.48, p = .14; V = .25), marital status (χ2 (1) = 1.37, p =

.24; V = .13), guardian education, (χ2 (2) = .55, p = .76; V = .08), secondary diagnosis (χ2

(1) = .56, p = .46, V = .08), relationship to dependent with ASD (χ2 (2) = 1.36, p = .51; V

= .12), type of insurance (χ2 (1) = .18, p = .67; V = .05) or previous therapies (χ2 (2) =

2.68, p = .26; V = .17).

No WL- PE differences, within the dropout participants, for categorical variables

were significant: Ethnicity (χ2 (3) = .50, p = .92; V = .13), marital status (χ2 (2) =

1.66, p = .4; V = .24), guardian education, (χ2 (3) = 4.15, p = .25 V = .37), secondary

diagnosis (χ2 (1) = .1.63, p = .20, V = .23), relationship to dependent with ASD (χ2 (2) =

2.17, p = ..4; V = .27), type of insurance (χ2 (1) = .18, p = .67; V = .05) or previous

therapies (χ2 (3) = 52, p = .92; V = .13).

 24

2.1.5 Demographics. The 58 participants that completed the study were on average

34.14 (SD = 9.03) years old and their dependent was on average 7.32 (SD = 3.85) years

old. The majority of participants were Caucasian (n = 37, 63.8%), partnered (n = 47,

81.1%), and reported having private insurance (n = 40, 69.0%). Mothers made up the

largest group of participants (n = 37, 63.8%). Most participants completed college/trade

school (n = 28, 48.3%). The most common previously attended therapy was speech

therapy (n = 27, 46.6%). Dependents of participants were diagnosed with ASD at 4.34

(SD = 2.65) years on average and did not have a secondary diagnosis (n = 30, 51.7%).

For dependents that had a secondary diagnosis, ADHD (n = 26, 44.8 %) was most often

reported. There was a total of 35 (60%) participants in the PE group, 23 (40%) in the WL

group.

2.2 Measures

2.2.1 Demographic Questionnaire. Participating parents and caregiver’s provided

basic demographic and background information (see Appendix B). The information

gathered included age and race of parent/caregiver, as well as child diagnosis, age at

diagnosis, type of insurance, marital status, and highest education achieved. Participants

were also asked about previous and current treatments related to ASD including type of

treatment and duration of treatment. Participants identified their guardianship role.

2.2.2 Measure of Parents’ Long-term Expectations. The measure used to assess

parents’ long-term expectations (Appendix C) was developed and contributed to by

several researchers over a number of years. The authors of all versions of the measure
 25

(Ivey, 2004; Mutua, 1999, 2001; Mutua & Dimitrov, 2001) proposed that the measure,

which assesses parent expectations, was consistent with Bandura’s construct of “other

efficacy”, which is one’s belief about another being able to accomplish a goal. The

purpose of the original scale (Mutua, 1999, 2001) was to assess expectations held by

parents for their children with learning disabilities and included scales for expectations,

beliefs, and importance of variables. The measure was observed to have high reliability

(α = .87, Mutua, 1999; α =.90, Mutua, 2001). A confirmatory factor analysis conducted

supported the proposed 3 factors of parent expectations (adult responsibilities, civil

rights, and social acceptance) for their version of the measure as indicated by chi-square

(χ2 (99) = 119.37, p =.08) and goodness-of-fit index (GFI = .95) statistics (Mutua &

Dimitrov, 2004). Ivey (2004) adapted the questionnaire by keeping only the 20 items

directly measuring expectations and importance (Mutua, 2001). The items were

specifically modified for parents of children with ASD (e.g., My child with Autism

will…). This version also retained the two subscales, Importance and Likelihood. The

two subscales ask about the same outcome (e.g., My child with autism will help with

household chores) and use a Likert scale. No validity statistics were reported for this

measure.

In the current study participants completed the version of the expectations

questionnaire used by Ivey (2004) in its entirety but the Likelihood subscale alone was

used to assess parent expectations. The Cronbach’s alpha reliability for the Likelihood

scale was high as reported by Ivey (2004) (α = .93) and in the current study (α= .95)
 26

2.2.3 Parents Expectations Questionnaire for Short Term Outcomes. Given the

future orientation of the measure of parents’ expectations (Ivey, 2004), five additional

items were developed to assess parents’ expectations of their child’s ability to

successfully engage in developmentally appropriate behaviors and activities in the near

future, for example following a recent intervention. Item responses were on a Likert type

scale of how likely it is that their child will achieve an outcome (from 1 = highly unlikely

to 5 = very likely). Cronbach’s alpha of .83 indicated good internal consistency. All of

the items appeared to be appropriate to retain in the measure. This scale was specifically

created for this study and there are no other published sources of validity or reliability for

this measure.

2.2.4 Autism Treatment Evaluation Checklist. The Autism Treatment Evaluation

Checklist (ATEC) is a parent questionnaire used to asses Autism Spectrum Disorder

(ASD) symptom severity. Multiple studies have validated the reliability, sensitivity, and

specificity of the ATEC. Magiati and colleagues (2011) administered the ATEC and

other standardized measures at baseline and at 1 year and 5-6 year follow ups to measure

caregiver reports of progress. The ATEC exhibited high internal consistency for the total

scale at time 1 (α = 0.91) and time 2 (α = 0.96). ATEC total and subscale scores at both

follow-ups (FU1 and FU2) were significantly correlated (p ≤ .01) with cognitive ability,

adaptive functioning, receptive and expressive language, and autism severity. FU1 ATEC

scores predicted 64% of the variance of FU2 summary scores (cognitive, language

functioning, adaptive behavior and autism behavior severity scores). ATEC scores at FU1

predicted 46% of the variance in summary change scores (FU2-FU1). The ATEC also
 27

was validated as a measure of ASD symptom severity by Geier, Kern, and Geier (2013).

The ATEC correlated highly (r = .71) with the Childhood Autism Rating Scale,

(Schopler, Reichier, & Renner, 1988), an established measure completed by a

professional that has high agreement with the Diagnostic and Statistical Manual, 4th

Edition (DSM-IV, American Psychiatric Association, 2004). The Cronbach’s alpha of .94

in this study for the total ATEC score indicated excellent internal consistency.

Mahapatra et. al. (2018) presented guidelines for interpreting ASD severity from

ATEC scores: mild (0 - 49), moderate (50 - 79), and severe (≥ 80). Participant scores for

the parent education group (M = 67.94 (32.66)) and waitlist (M = 67.22 (30.61)) indicated

that both groups fell in the moderate range of ASD severity.

2.2.5 Parent Training Protocol. The parent psychoeducation protocol at the Pediatric

Developmental Center (PDC) at Advocate Illinois Masonic Medical Center is required

for all parents/caregivers seeking behavioral based therapy services for their child.

Parents are not able to access behavior therapy until they complete parent

psychoeducation. The children may receive occupational or speech therapy at the facility

but not behavioral interventions. The program is an intensive four week, 2-hour weekly

group program which provides parents/caregivers with information about ASD as well as

teaches them about some of the basic principles and concepts that underlie evidence-

based therapies for ASD. In addition, parents/caregivers are provided with activities and

required to complete homework assignments to collect information about their child’s

behavior. Sessions are facilitated by a licensed clinical psychologist or Board Certified

Behavior Analyst ®, and co-facilitated by a doctoral student.

 28

Each week parents/caregivers signed in, discussed the past week, homework was

collected, and sessions materials were distributed. According to the protocol the sessions

covered but were not limited to identifying antecedents and consequences that maintain

behavior, identifying functions of behaviors, identifying effective reinforcers,

communication, and use of visual supports, as well as knowledge about core deficits of

ASD that interfere with daily functioning. Parents/caregivers were also provided with

information about additional resources. During the sessions, participants were free to

interact during activities, however they are asked to limit conversation to the activity.

Throughout the training parents/caregivers were encouraged to complete the homework

assignments (collecting behavioral data) and observe their child’s preferences. This

information would be shared with a clinician after completion of parent psychoeducation

and used in therapy.

Participants recruited through Qualtrics were asked about duration of parent

psychoeducation and allowed to provide any further specifics about parent

psychoeducation. Of the participants in the parent psychoeducation group that completed

the study and provided information, the majority reported that they received training on

symptoms of ASD/Asperger's. Other topics reported included information about

medication management, and ASD/Asperger’s related interventions Two of the

participants reported ‘other’ topics. No other information was collected about the format

or content of psychoeducation being provided to these participants.

 29

2.3 Procedures

2.3.1 Pre-Training (Time 1). For participants recruited at the PDC, participants agreed

to participate after being contacted either over the phone or in person. They then

confirmed their participation by reading and agreeing per informed consent (Appendix

A). Surveys were sent via mail or picked up in person two weeks prior to the parent

psychoeducation group starting. The survey included nonidentifying demographic

information (Appendix B), Autism Treatment Evaluation Check list ATEC , a parent

expectations measure (Appendix C), and a short-term expectations questionnaire

(Appendix D). Although it was offered, no parents opted to complete measures over the

phone with the investigator.

Participants recruited through Qualtrics completed the same measures online via

the Qualtrics interface. Upon agreeing to participate by reading and agreeing per

informed consent, individuals answered screener questions for inclusion (Appendix E).

They were then directed to the online survey. The survey included the demographic

questionnaire (Appendix B), Autism Treatment Evaluation Check list (ATEC), parent

long-term expectations measure (Appendix C), and short-term expectations questionnaire

(Appendix D). The measures took on average 13 minutes to complete.

2.3.2 Post-Training (Time 2). Parents completing training at the PDC were contacted

one to two weeks prior to the completion of the 4-week parent psychoeducation for the

training group. Packets were mailed or picked up in person and participants were asked to

complete and turn in after the 4th week parent psychoeducation group was completed.

Time 2 (post) surveys included the parent long-term (Appendix C) and short-term
 30

expectations questionnaires (Appendix D). New parent psychoeducation groups began

every four weeks and so these procedures were repeated at the beginning and end of

every training cohort. When parents returned completed post-test packets, they received a

$10 gift card.

Four weeks after completing the first set of questionnaires, Qualtrics participants

were contacted to complete the Time 2 survey (parent long-term and short-term

expectations questionnaires) which took approximately 7 minutes to complete. Qualtrics

participants were reimbursed according to the company’s standard procedures, Qualtrics

panelist paid participants $5 completion of the first and second surveys. Participants

reported again their parent psychoeducation status at T1 and completed the online survey.
 31

CHAPTER 3

RESULTS

3.1 Preliminary Analysis

3.1.1 Pre-treatment Group Differences. On categorical variables (Table 2), no

significant group differences were observed for Ethnicity (ꭓ2 (3) = 1.92, p = .59; V = .18),

marital status (ꭓ2 (1) = 1.26, p = .26; V = -.15), guardian education, (ꭓ2 (2) = 2.88, p =

.24, V = .22), secondary diagnosis (ꭓ2 (1) = .003, p = .96, V = .91), relationship to

dependent with ASD (ꭓ2 (2) = 2.88, p = .24; V = .22), type of insurance (ꭓ2 (1) = .25, p =

.62; V = .07) or previous therapies (ꭓ2 (2) = .80, p = .67; V= .12).

For continuous demographic measures and T1 parent expectation scores (Table

3), no significant differences were observed for autism severity (t (56) = .085, p = .93),

participants’ age (t (56) = 1.17, p = .29), age of dependent (t (56) = 1.91, p = .06), or

dependent age at diagnosis (t (56) = 1.85, p = .07). Similarly, there were no differences in

long-term expectation scores (t (38.95) = .27, p = .79) or short-term expectations (t (56) =

.48, p = .63).
 32

Table 2

Participant Characteristics (categorical variables) by Group

PE WL
(n = 35) (n = 23)
n (%) n (%)
Ethnicity
Caucasian 22 (62.9) 15 (65.2)
African Descent 5 (14.3) 5 (21.7)
Latino 6 (17.1) 3 (13.0)
Other 2 (5.7) 0

Relationship to dependent
Mother 20 (57.1) 17 (73.9)
Father 12 (34.3) 6 (26.1)
Other 3 (8.6) 0

Insurance Type
Private 25 (71.4) 15 (65.2)
Public 10 (28.6) 8 (34.8)

Education
Primary /Secondary 11 (31.4) 6 (26.1)
College/Trade 14 (40.0) 14 (60.9)
Graduate School 10 (28.6) 3 (13.0)

Marital Status
Partnered 30 (85.7) 17 (73.9)
Not Partnered 5 (14.3) 6 (26.1)

Previous Therapy
Speech 15 (42.9) 12 (52.2)
Outpatient 13 (37.1) 6 (26.1)
Other ASD 7 (20.0) 5 (21.7)

Secondary Diagnosis
ADHD/Anxiety 17 (48.6) 11 (47.8)
(ADHD) 15 (42.9) 0
(Anxiety) 2 (5.7) 0
None 18 (51.4) 12 (52.2)

Note: No group differences were significant using chi-square analyses

(see text).
 33

Table 3

Participant Characteristics (continuous variables) by Group

PE Range WL Range
(n = 35) (min-max) (n = 23) (min-max)
Mean (SD) Mean (SD)
Age 35.17 (10.25) 22-60 32.57 (6.67) 19-44
Age of Dependent* 8.09 (3.95) 2-16 6.15 (3.46) 2-14
Age at Diagnosis 4.86 (3.00) 2-12 3.57 (1.80) 2-8
T1 LE 77.26 (13.12) 55-100 76.13 (3.52) 50-100
T1 SE 20.60 (4.50) 12-25 20.04 (3.97) 12-25
ATEC 67.94 (32.66) 1-121 67.22 (30.61) 1-140

Note: No group differences were significant using independent t- test (see text).

Note: T1 LE= long-term expectations, T1 SE = short term- expectations, PE= Psychoeducation

Group, WL= Waitlist Group, Age in years

*Included in ANCOVA

3.1.2 Preliminary Data Analysis. Data screening was conducted to identify entry

errors and missing data, and to evaluate if any assumptions of the proposed analyses were

violated (Howell, 2002). No data were missing on the independent or outcomes variables

for the 58 participants included in the analysis. The data set was split by the independent

variable (group) and further analyses were conducted by group. To identify outliers for

each continuous variable, modified z-scores (Iglewicz & Hoaglin, 1993) were calculated.

Scores were considered outliers of they were greater than or equal to +/- 3.5. No outliers

were identified for T1 parent expectations (long- term outcome), T1 behavior

expectations questionnaire (short term outcome), or ASD severity for either group. Visual

inspection of Q-Q plots and histograms (Ghasemi & Zahediaslm, 2012), as well as
 34

skewness and kurtosis statistics (Kim, 2013), indicated that the dependent variables

(parent expectations and severity) were relatively normally distributed.

Homogeneity of variance for T1 parent long-term expectation scores was violated

when all scores were included. The lowest 2 values for the WL and 1 lowest value for the

T1 parent expectation score was Winsorized to 1 point below the next lowest score. The

analysis was not robust to this violation because the sample sizes were not similar. The

Levene’s test was still significant; however, when the lowest score from the WL was

dropped, the variance was no longer significantly different across groups (F (1, 55) =

3.48, p = .07). After this participant’s score from the WL group was omitted for the

analyses (N = 22), 57 participants remained. Homogeneity of variance was not violated

for T1 short term expectations.

3.2 Hypothesis Testing

The main hypothesis asserted that changes in expectations over time would differ

across groups (PE vs WL). More specifically, parents attending parent psychoeducation

for ASD (PE) would report greater expectation scores at follow up (T2) compared to their

pre-training scores (T1) and the PE group would report greater expectations at follow up

(T2) compared to the WL group. Both of these hypotheses were tested as parts of a 2

(group) x 2 (time) mixed ANOVA.

In the ANOVA for long term expectations (Figure 1) the hypothesized time by

group interaction was not significant (F (1, 55) = .37, p = .55, η2 = .007). The main effect

of time also was not significant (F (1, 284.916849) = 2.87, p = 096, η2 = .50). Thus, there
 35

was no evidence for treatment group differences or for changes in long term expectations

across the time of the study.

In the ANOVA for short term expectations (Figure 2) the hypothesized time by

group interaction was not significant (F (1,1.49) = .41, p = .53, η2 = .007). The main

effect of time also was not significant (F (1, 14.01) = 3.84, p = .06, η2 = .65). Thus, again

there was no evidence for treatment group differences or for overall changes in short term

expectations across the time of the study.

 36

Figure 1. Mean Long Term Expectation Scores by Group

*Note: bars indicate standard error (se)

Figure 2. Mean Short Term Expectation Scores by Group

 37

The hypotheses also were tested for PDC and Qualtrics by recruitment sites

separately. For participants recruited at the PDC, the ANOVA for long term expectations,

the hypothesized time by group interaction was not significant (F (1, 2.32) = .090, p =

.77, η2 = .006). The main effect of time also was not significant (F (1,41.85) = 1.62, p =

.22, η2 = .098). for participants recruited at Qualtrics, the ANOVA for long term

expectations, the hypothesized time by group interaction was not significant (F (1, 61.87)

= .47, p = .50, η2 = .01). The main effect of time also was not significant (F (1,199.82 =

1.51, p = .23., η2 = .038). Thus, there was no evidence for treatment group differences or

for changes in long term expectations across the time of the study, across recruitment

groups.

Similarly, for participants recruited at the PDC, the ANOVA for short- term

expectations the hypothesized time by group interaction was not significant (F (1, 6.24) =

.3.17, p = .095, η2 = .17). The main effect of time also was not significant (F (1,35) = .18,

p = .68, η2 = .01). Thus, there was no evidence for treatment group differences or for

changes in short term expectations across the time of the study. For participants recruited

at Qualtrics, the ANOVA for short term expectations the hypothesized time by group

interaction was not significant (F (1, 5.78) = .1.39, p = .25, η2 = .035). The main effect of

time also was not significant (F (1,16.18 = 3.90, p = .056, η2 = .093). Thus, there was no

evidence for treatment group differences or for changes in short term expectations across

the time of the study, across recruitment groups.

 38

3.3 Additional Analyses

Bivariate correlations were examined to assess possible association of ASD

severity and parent expectations, as reported in the literature (Poon, Koh, & Magiati,

2013). ATEC scores were not significantly related to parent expectation for T1 long term

(r (57) = .17, p = .21), T1 short term (r (57) = -.02, p = .78), T2 long term (r (57) = .04, p

= .79), or T2 short term (r (57) = -.13, p = .32) scores. Furthermore, expectation change

scores were calculated (T2 - T1) for both short- term and long-term expectations. ATEC

scores were not significantly related to parent expectation for T1 long term change (r (57)

= -.20, p = .13), T1 short term change (r (57) = -.12, p = .39). In looking at group

difference, ATEC scores were not significantly related to parent expectation for WL T1

long term change (r (22) = -.42, p = .051), WL T1 short term change (r (22) = -.26, p =

.25), PE T1 long term change (r (35) = -.07, p = .71), PE T1 short term change (r (35) =

.01, p = .96).

There was non-significant trend for a PE-WL group difference in age (t (56) =

1.91, p = .06), with the WL having a lower mean age. Therefore, age was used as a

covariate to examine whether age differences impacted the results of the 2x2 mixed

ANOVAs. In the ANCOVA for long-term expectations, the time by group interaction

was not significant controlling for age (F (1, 96.91) = .98, p = .33). Similarly, the group

by time interaction for short term expectations was not significant controlling for age (F

(1, 2.98) = .83, p = .37).

 39

CHAPTER 4

DISCUSSION

4.1 Findings

The purpose of this study was to assess the impact of parent psychoeducation for

ASD on parent’s expectations for future outcomes for children with ASD. The main

hypothesis that expectation scores would change over time as a function of group

membership (PE vs. WL) was not supported for long-term or short- term expectations. In

fact, the small difference that was observed was in the opposite direction of the predicted

outcome for long term expectations. Additionally, ASD symptom severity, a possible

covariate, was not correlated with guardian expectations at either time point or with the

change in guardian expectations (T2-T1). Lastly, covarying for child age also did not

change the results.

Regarding the lack of change in expectations and the lack of group differences at

follow up (Time 2), these results suggest that brief psychoeducation on ASD does not

have an impact on parent expectations for individuals with ASD. It is possible that the

same factors that result in lower expectations for individuals with ASD (i.e. symptom

heterogeneity and unknown prognosis) result in parent expectations being highly resistant

to change (Ogston, Mackintosh, & Myers, 2011). That is at least in part by current parent

psychoeducation groups for ASD. This has implications for both the conceptualization of

expectation mechanisms for change in parents of children with ASD and/or parent

psychoeducation protocols for ASD.

Another possible consideration is that parents acquired information outside of and

prior to the formal parent psychoeducation. Tzanakaki and colleagues (2012) reported
 40

that parents of children with ASD that seek services more often do so after learning about

services from other parents, books, and the internet. Therefore, it is possible that parents

already accessed information about ASD prior to signing up for and/or completing parent

psychoeducation, and then went on to attain more formal services. These parents’

expectations were not then altered based on parent psychoeducation. Similarly, parents

on the WL group may have procured information while they waited for formal parent

psychoeducation to start. The hypothesized mechanism of parental expectation in this

study, originally proposed by Poon and colleagues (2013), assumed limited access to

resources about ASD. The participants in the present study were predominantly white,

college graduates, with private insurance. Therefore, it is unlikely that these participants

lacked the level of access purported by Poon and colleagues (2013).

It has been observed that the various components of training differentially impact

child and parent outcomes (Brookman-Frazee et al., 2006; Kaminski eat al., 2008). The

parent psychoeducation protocol and the topics reported by internet recruited participants

both included information on ASD symptomatology, ASD interventions, and medication

management. It is possible that the components required to directly impact expectations

were not present in standard parent psychoeducation curricula for ASD. A study that

assessed changes in teacher’s expectations of their pupils suggested that changes in other

expectation may require 1) increase in the adults’ knowledge and 2) progress in the

dependent (Timperley & Phillips, 2003). These results indicate that it may not be possible

to alter guardian expectations until after parent psychoeducation is completed and

evidence-based intervention has commenced. This is consistent with Bandura’s assertion

that changes in expectations may arise after new learning experiences. The level of
 41

change, however, is dependent on the strength of the expectation and therefore would

also need to be considered.

The failure to find a relationship between ASD severity and parent expectations is

inconsistent with studies that have examined these variables using both the Autism

Treatment Evaluation Checklist (ATEC) (Poon, Koh, & Magiati, 2013) and the Gillam

Autism Spectrum Disorder Scale (Thomas, King, & Mendelson, & Nelson-Gray, 2017).

The mean ATEC scores in the study by Poon, Koh, and Magiati (2013) (M (SD) = 65.35

(20.83)) were similar to those observed in the PT group (M (SD) = 67.94 (32.66)) and

WL group (M (SD) = 65.91 (30.66)). Thus, even though the sample in the current study

presented with relatively the same ASD severity levels, the relationship between severity

and expectations was different in the present study.

Given the nearly significant difference of dependent’s age across groups, a mixed-

factorial ANCOVA was conducted. However, results still were not significant, indicating

that even when controlling for age parent expectations did not change as a function of

parent psychoeducation. In the current study, age was not significantly correlated with

expectations scores. The results of this study are inconsistent with earlier results that age

negatively correlated with parent expectations for part time work and full-time work

attainment (Bluestein et al., 2017). However, Poon et al. (2013) did not find that age

accounted for a significant amount of variance in expectations. Additionally, the focus on

employment as an outcome variable in the study by Bluestein et al. (2017) and outcomes

in a variety of areas in the current study, suggests that age may be differentially related to

expectations for different outcomes.

 42

4.2 Limitations and Future Directions

A number of limitations may have affected findings and/or the generalization of

findings. One of these limitations is the lack of control of parent psychoeducation

content, format, and other factors that may have influenced how the parent

psychoeducation influenced expectations. Given that the results suggest parent

psychoeducation does not impact expectations, adjustments to current common

components used by ASD psychoeducation programs may be warranted to optimize

effectiveness and improve child outcomes. Additionally, an alternative approach to

addressing parent expectations for children with ASD should be considered. As a

contextualized approach has been observed to result in better outcomes for children with

ASD, clinicians should evaluate the use of parent expectation as a contextual variable in

programming (Moes &Frea, 2000). A contextualized approach consists of the therapist

assessing and including family related variables (e.g. routines, resources, practices) and

concerns in creating a treatment plan for the individual with ASD (Moes &Frea, 2000).

For example, clinicians could measure parent expectations and use the information to

individualize the intervention to the family.

Although research has found that the group or individual format of parent training

does not have an impact on effectiveness of training (Kaminski et al., 2008), the lack of

control of psychoeducation content in the current study did not allow for an analysis of

possible mediating and moderating factors of parental expectations. Furthermore, this

study lacked the ability identify the content and format of psychoeducation received by

the Qualtrics participants. This also makes it difficult to evaluate the effectiveness of

specific parent psychoeducation components or the ability to interpret the results of the
 43

study with any definiteness. Future studies should systematically assess components of

psychoeducation for ASD to identify which, if any, components or combination of

components relate to parent expectations. If standard psychoeducation programs do not

impact expectations, other interventions for parent expectations should be pursued.

The current study did not randomly assign participants to groups and therefore,

qualifies as a quasi-experimental design. Although information was collected and

evaluated to assess pretest differences that may account for outcomes, the ability to

identify group differences was limited by the variables collected. In order to identify a

true causal relationship between parent expectations and psychoeducation, participants

should be randomized to psychoeducation and other comparative treatment to identify the

actual impact of psychoeducation.

Besides self-identified parent psychoeducation status and reported attendance

dates, no formal measures were administered to assess the actual and/or perceived

effectiveness of parent psychoeducation. Evaluating parent attitudes and perceived

effectiveness of parent psychoeducation would identify if parent expectations vary with

how they perceived the information. It also would be prudent to measure actual

information and/or skills acquired to identify if the levels of information or skills

acquired variably impacts expectations. Additionally, level of participant engagement in

parent psychoeducation was not assessed. Research has indicated that degree of

engagement influences outcomes (Dowell, 2010; Lebeau et al., 2013). Guardian

engagement in parent psychoeducation can be measured by attendance rates, active

participation, and completion of homework in parent psychoeducation courses.

measuring parent engagement for participants.

 44

Another limitation of this study was the failure to identify and control other forms

of access to ASD-related information that may have been accessed prior to and/or outside

of formal parent psychoeducation. The present study addressed only one modality of

access: parent psychoeducation. If parents accessed similar information via parent group,

books, internet, etc. a failure to identify changes in expectations may have resulted from

these accessory activities. Additionally, given the large amount of unsolicited information

individuals come across via targeted internet/social media ads, email spam, social in-

group involvement, and news media, it is difficult to account for or control these sources

of information. It is difficult to determine the extent to which other forms of information

and training, not considered ‘parent psychoeducation’ contributed to parent expectations.

This challenge could be addressed in future studies by asking parents to report current

and prior sources of information about ASD and/or asking participants to refrain from

accessing other possible ASD resources. This would allow investigators to identify the

incremental impact each of the solicited and unsolicited forms of information has on

parent attitude and expectations.

Poon et al. (2013) proposed that limited access to ASD information is associated

with a general lack of resources in the ASD community. This is particularly relevant for

this study given that the majority of participants were Caucasian, privately insured, and

formally educated. Therefore, it is likely these participants had relatively more resources

than those envisioned by the Poon et al. (2013). Providing psychoeducation will likely be

more salient in populations with limited resources, such as low income and minority

populations. Future studies should include populations with known resource limitations

in order to better address the relationship between access to resources and expectations.
 45

Furthermore, future studies should first identify specific areas of needs and systematically

measure expectations as those areas of need are accessed. Including a qualitative

component to better understand what forms of resources different groups are lacking

would allow for follow-up with quantitative analysis to determine how improving access

to these variables improves expectations. Using these methods also would help identify if

themes of needs vary by group and how these difference impact expectations. This will

be important as attitude toward mental health and interventions is also largely cultural.

It is also reasonable to suggest that some families that may have the resources to

attend parent psychoeducation may not do so because of beliefs about ASD services. This

would indicate a reverse relationship where expectations determine parent

psychoeducation attendance and not vice versa. If parent psychoeducation is looked at as

the behavior, then this model would align with Bandura’s construct of expectations and

cognitive motivation. This alternative model would also account for the lack of

expectations observed in the current study, as parents’ expectations would be consistent

in the PE and WL groups whom both intended on attending training. This would be a

proxy for them having expectations of benefit already and thus their expectations would

not change.

Another limitation of this study was the small sample size, which resulted in

lower power than anticipated based on the a priori power analysis. The total number of

participants in the final analysis (N = 57) was smaller than the targeted sample size of 90

participants for the desired power of .80 in the 2x2 ANOVAs. As a result, we cannot

make definitive statements about the non-significant results obtained. The lower power

made it less likely that even true effects would be statistically significant. It is possible
 46

that with more participants different trends in expectation scores within and across groups

could have been captured. Thus, future studies should ensure adequate sample sizes.

The measure used on the study (Ivey, 2004) has consistently been reported to

have high internal reliability. However, a lack of validity studies have been conducted to

verify that the measure is accurately quantifying the construct of parent expectations for

their child. Mutua and Dimimtrov (2001) and Ivey (2004) have argued for the face

validity of the measure and also indicated that confirmatory factor analyses have yielded

consistent factors (education/employment, access to the community, and life satisfaction).

None of these studies have assessed validity by comparing parent responses of children

with ASD to neurotypical children or compared the measure to assessments of

convergent or divergent constructs. Future studies should establish the validity of this

measure to ensure results are accurately capturing this phenomenon.

Another area for consideration is identifying the optimal level of parent

expectations. More specifically, it is unclear if parent expectations are most beneficial to

child outcomes the higher they are, or if the aim should be realistic expectations. No

studies have established a target for expectations making it difficult to measure and

identify a goal for expectation change. Future studies should aim to identify the

differential impact of varying levels of expectations (e.g. below vs. same vs. above

parents’ expectations of same aged peers) on child outcomes. Establishing “realistic”

expectations may be more difficult for the ASD population given the heterogeneity of

symptoms and interventions consumed. Establishing parameters for “appropriate” levels

of parent expectations might include these variables (symptoms, intervention, etc.) for
 47

determining an ideal level. This would result in expectation levels being individualized

for each person.

4.3 Implications and Conclusions

To our knowledge, this was the first study to examine the relationship between

parent psychoeducation and expectations of guardians of individuals with ASD. Although

parent psychoeducation was not found to affect expectations, the study may contribute to

the literature by steering future studies to address study limitations and to better identify

if expectations for guardians of individuals with ASD can be changed. In addition, the

conceptualization of this study contributed to the literature by bringing together two

different bodies of research (parent expectations and psychoeducation) that will allow

other investigators to identify how these areas can benefit individuals with ASD when

considered in the same context.

The results of this study have potential practical implications for parent

psychoeducation for ASD. Given a lack of change in parent expectations over time as a

function of psychoeducation, clinicians should consider the content of current programs,

including evaluating the current components of parent psychoeducation for ASD to

identify possible areas for modification to better target parent expectations. Results from

the study by Timperly and Phillips (2003) provide some suggested methods and/or

components (i.e. child behavior monitoring and feedback) that could be considered.

In conclusion, brief (4 week) parent psychoeducation does not appear to be a

mechanism of expectation change. The ability to interpret these findings was constrained

by the limitations of the study itself as well as a dearth of previously published studies
 48

with which to compare the results. It will be important to for investigators to identify to

specific mechanisms that help to change parent expectations for the better. This need

arises from the fact that parent expectations have been observed to influence their

engagement in their child’s medical care.

 49

APPENDIX A

PARENTAL INFORMED CONSENT

 50

Title: Assessing the Impact of Parent Education Program on Parents’ Expectations for
Children with Autism Spectrum Disorder

Investigators: Michael Young, PhD, Megan Mims, MA, BCBA

We are asking you to participate in a research study. Please take your time to
read the entire document.

Purpose: This research will examine parents’ expectations of their child with
Autism Spectrum Disorder (ASD) and how expectations might be affected by parent
training groups. This issue has not been addressed by previous research and expectations
may influence the outcomes of children with ASD.

Procedures: After providing consent to participate, participants will complete a

survey that takes about 12-15 minutes to complete. After 4 weeks you be contacted and
asked to complete the follow up survey, which takes about 10 minutes. The research
panel service you are part of will reimburse you $5 for each of the two surveys you
complete .

Risk to participants: There are no risks expected beyond those that occur in
everyday life.Participants may feel emotional distress when completing questionnaires
since they ask about personal attitude and knowledge related to their child. If after
completing this survey you feel that you need mental health services, you can contact the
National Alliance on Mental Illness via the internet at: https://www.nami.org/Find-
Support or phone by 800-950-NAMI. You can also contact your local Health Department
via internet: https://www.naccho.org/membership/lhd-directory by choosing your state.

Benefits: Participants may not directly benefit from this study. The information
gathered in this study may be used to help the clinicians guide future group parent
training to improve outcomes.

Confidentiality: All information collected in this study will remain confidential.

All identifying information will be coded and kept on a password protected computer.
Data will be stored on password protected laptop computer for 5 years in compliance
with requirements of the Institutional Review Board and the American Psychological
Association. Data will be deleted after 5 years.

Questions or Concerns: If you have any question or concerns regarding your

participation in this study you may contact the principal investigator Michael Young at
(312) 567-3503 or youngm@iit.edu, or the secondary investigator Megan Mims at
mmims@hawk.iit.edu. Illinois Institute of Technology is not responsible for any injuries
or medical conditions research participants may suffer during the time of the research
study unless those injuries or medical conditions are due to IIT’s negligence. Questions
and complaints can be addressed to the Executive Officer of IIT Institutional Review
Board at 312-567-7141.
 51

I have the read the information in this consent form and

I consent, begin the study
I do not consent, I do not wish to participate
 52

APPENDIX B

DEMOGRAPHIC QUESTIONS
 53

Age of participant ____________

Age of Child________ Age at diagnosis of ASD_________ Other dx______________
Relationship to Child
1. Mother
2. Father
3. Step/Foster/Adoptive Mother
4. Step/Foster/Adoptive Father
5. Other: ______________________________

Marital Status: Never married ___ Married___ Divorced__ Separated___ Widowed___

Ethnicity of Participant
1. African Decent
2. Caucasian
3. Latino
4. Asian
5. Other: ______________________________

Insurance: Private________ Public Aid______________

Highest Education Achieved by Participant Completing Form
1 grammar school 5 college
2 some high school 6 technical/trade school
3 high school 7 graduate level
4 some college

Previous Therapy
1. Speech 5. PT
2. OT 6. DT
3. ABA 7. CBT
4. Family 8. Other
 54

APPENDIX C

PARENT EXPECTATIONS MEASURE

 55

Please answer the following questions about how important the following items are
for your child in the future.
Highly Not Somewhat Important Very
unimportant important important important
My child
with autism
will
1. ...be
happy and
satisfied.
2. . . . attend
school.
3. . . . get
married
4. . . . own a
house
5. . . .
support
network of
friends
6. . . .
practice
religion of
choice.
7. . . . be
accepted in
the
community.
8. . . . have
a secure
financial
future.
9. . . . be
safe from
physical
harm.
10. . . .
attain
highest
education
possible.
11. . . . help
with
household
 56

chores.
12. . . . be
socially
responsible/
law abiding.
13. . . . take
care of
parent in
old age.
14. . . .
participate
in
citizenship
activities.
15. . . . live
independent
ly.
16. . . . have
time to
play/watch
games.
17. . . . hold
a
job/vocatio
n.
18. . . . have
own
children.
19. . . . use
community
services.
20. . . . be
successful
in school.
TOTAL
 57

Please answer the following questions about how likely your child will do the
following things in the future.
Highly Not Somewhat Likely Very
Unlikely Likely Likely
Likely
My child
with
autism will
1. ...be
happy and
satisfied.
2. . . .
attend
school.
3. . . . get
married
4. . . . own
a house
5. . . .
support
network of
friends
6. . . .
practice
religion of
choice.
7. . . . be
accepted
in the
communit
y.
8. . . . have
a secure
financial
future.
9. . . . be
safe from
 58

physical
harm.
10. . . .
attain
highest
education
possible.
11. . . .
help with
household
chores.
12. . . . be
socially
responsibl
e/law
abiding.
13. . . .
take care
of parent
in old age.
14. . . .
participate
in
citizenship
activities.
15. . . . live
independe
ntly.
16. . . .
have time
to
play/watch
games.
17. . . .
hold a
job/vocatio
n.
 59

18. . . .
have own
children.
19. . . . use
communit
y services.
20. . . . be
successful
in school.
 60

APPENDIX D

PARENTS EXPECTATIONS QUESTIONNAIRE FOR SHORT TERM

OUTCOMES
 61

Please answer the following questions about how Important the following items are
for your child in the future
Highly Not Somewhat Important Very
unimporta important important important
nt
My child
with
autism will
1. ….learn
to use
function
al
commu
nication
2. …devel
op
indepen
dent
play
skills
3….reduce
inappropri
ate
behavior
4.…be
able to
sit and
attend
during
instruct
ion
5….indepe
ndently
carryout
activitie
s of
daily
living
 62

Please answer the following questions about how Likely the following items are for
your child in the future
Highly Not Somewhat Likely Very
Unlikely Likely Likely
Likely
My child
with
autism will
1….learn
to use
functional
communic
ation
2…develo
p
indepe
ndent
play
skills
3….reduce
inappropri
ate
behavior
4.…be
able to
sit and
attend
during
instruct
ion
5….indepe
ndently
carryout
activitie
s of
daily
living
 63

APPENDIX E

SCREENING QUESTIONS
 64

In order to ensure you are able to enroll in this study, please answer these screening
questions.
If you qualify, you will then be asked to give your consent before completing study
questions.

Please select all conditions your child has been diagnosed with

• Autism Spectrum Disorder (Aspergers/PDD NOS)

• Attention Deficit/Hyperactivity Disorder
• Anxiety Disorder/OCD
Depression
Other

Has your child ever been diagnosed with Autism Spectrum Disorder (including
Aspergers/PDD NOS)

YES

NO
Please select the best that currently describes you
I am not enrolled in any type of parent training and do not plan to
•
I am enrolled or on wait-list for parent training/education but have not started my
training

I am currently in parent training/education group

How long is/will parent training be?

Start Date(dd/mm/yy)
End Date(dd/mm/yy)
Total Hours
 65

BIBLIOGRAPHY

Abraham, R., Smyth, J., Lopoo, L., & Dusek, J. (2009). Great expectations: The biasing
effects of reported child behavior problems on educational expectancies and
subsequent adamic achievement. Journal of Social and Clinical Psychology, 28
(3), 392-413.

Adams, J. (2001). The impact of parent training on family functioning. Child and
Behavior Therapy, 23 (1), 29-42.

Amman, M., McDougle, C., Scahill, L., Handen, B., Arnold, L et al. (2009). Medication
and parent training in children with pervasive developmental disorders and
serious behavior problems. Journal of the American Academy of child and
Adolescent Psychology, 48, 1143-1154.

Amman, M., Singh, N., Stewart, A., & Field, C. (1985). The aberrant behavior checklist:
a behavior rating scale for the assessment of treatment effects. American Journal
of Mental Deficiency, 89, 484-491.

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental

Disorders (5th Ed.) Washington, DC: American Psychiatric Association.

Anan, R., Warner, L., McGillivary, J., Chong, I, & Hines, S. (2008). Group Intensive
Family Training (GIFT) for preschoolers with autism spectrum disorders.
Behavioral Interventions, 23,165−180.

Andrews, N., Martin, C., Field, R., Cook, R., & Lee, J. (2016) Development of
Expectancies about own- and other- gender group interactions and their school-
related consequences. Child Development, 87 (5), 1423-1435.

Anthony, L., Anthony, B., Glanville, D., Naiman, D., Waanders, C., & Shaffer, S. (2005).
The relationships between parenting stress, parenting behaviour and preschoolers’
social competence and behaviour problems in the classroom. Infant and Child
Development, 14, 133–154.

Areepattamannil, S. & Lee, D. (2014). Linking immigrant parents’ educational

expectations and aspirations to their children’s school performance. The Journal
of Genetic Psychology, 175 (1), 1-57.

Baio, J., Wiggins, L., Chrsitensen, D., Maenner, M., Daniels, J., Warren, Z., et al. (2018).
Prevalence of Autism Spectrum Disorder among children aged 8 years- Autism
and developmental disabilities monitoring network, 11 sites, United States, 2014.
Morbidity and Mortality Weekly Report: Surveillance Summaries, 67 (6), 1-23.
 66

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change.

Psychological Review, 84,191–215.

Bandura, A. (1992). Exercise of personal agency through the self-efficacy mechanism. In

R. Schwarzer (Ed.), Self-efficacy: Thought control of action. Washington, DC:
Hemisphere.

Bandura, A. (1995). Self-efficacy in changing Societies. New York: Cambridge

University Press.

Barlow, J., Powell, L., Gilchrist, M., & Fotiadou, M. (2008) The effectiveness of the
training and support program for parents of children with disabilities: A
randomized control trial. Journal of Psychosomatic Research, 64, 55-62.

Barros, M. (2004). Self-efficacy expectation and the change of drinking behavior in men
excessive drinkers, hospitalized due to clinic pathologies. Psico, 35 (1), 15-22.

Behavior Analyst Certification Board, Inc. (2015) Applied Behavior Analysis treatment
of Autism Spectrum Disorder: Practice guidelines for healthcare funders and
managers.

Brookman-Frazee, L., Stahmer, A., Baker-Ericzen, M., & Tsai, K. (2006). Parenting
interventions for children with autism spectrum and disruptive behaviour
disorders: Opportunities for cross-fertilization. Clinical Child and Family
Psychology Review, 9, 181–200.

Cedar, B., & Levant, R. (1990). A meta-analysis of the effects of Parent Effectiveness
Training. The American Journal of Family Therapy, 18, 373–384.

Chlebowski, C., Magana, S., Wright, B., & Brookman-Frazee, L. (2018) Implementing
an intervention to address challenging behaviors for Autism Spectrum Disorder in
publicly -funded mental health services: Therapist and parent perceptions of
delivery with Latinx families. Cultural Diversity and Ethnic Minority Psychology,
24 (4), 552-563.

Cunningham, C., Bremner, R., & Boyle, M. (1995). Large group community-based
parenting programs for families of preschoolers at risk for disruptive behavior
disorders: Utilization, cost effectiveness, and outcome. Journal of Child
Psychology and Psychiatry, 36, 1141–1159.

Dale, E., Jhoda, A., & Knott, F. (2006). Others’ attributions following their child’s
diagnosis of autistic spectrum disorder. Autism, 10, 463-479.
 67

Dawson, G., & Osterling, J. (1997). Early intervention in autism: Effectiveness and
common elements of current approaches. In Guralnick (Ed.), The effectiveness of
early intervention: Second generation research, 307–326. Baltimore: Brookes.

Deater-Deckard, K. (1998). Parenting stress and child adjustment: Some old hypotheses
and new questions. Clinical Psychology: Science and Practice, 5, 314–332.

Dowell, K. & Ogles, K. (2011) The effects of parent participation in child psychotherapy
outcome: A meta-analytic review. Journal of Clinical Child and Adolescent
Psychology, 39(2), 151-162.

Dumas, J., & Wekerle, C. (1995). Maternal reports of child behavior problems and
personal distress as predictors of dysfunctional parenting. Development and
Psychopathology, 7, 465–479.

Dumas, J., Wolf, L., Fisman, S., & Culligan, A. (1991). Parenting stress, child behaviour
problems, and dysphoria in parents of children with autism, Down syndrome,
behaviour disorders, and normal development. Exceptionality, 2, 97–110.

Duncan, A. & Bishop, S. (20015). Understanding the gap between cognitive abilities and
daily living skills in adolescents with autism spectrum disorders with average
intelligence. Autism, 19 (1), 64-72.

Dunlop, W., Beattyy, D., & Beauchamp, M. (2011). Examining the influence of other –
efficacy and self-efficacy in personal performance. Journal of Sports and
Exercise Psychology, 33 (4), 585-593.

Dunn, M., Burbine, T., Bowers, C., & Tantleff-Dunn, S. (2001). Moderators of stress in
parents of children with autism. Community Mental Health Journal, 37, 39–52.

Eikeseth, S., smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral treatment at
school for 4-7-year old children with autism. Behavior Modification, 26, 49-68.

Eglung, M., Luckner, A., Whaley, G., & Egeland, B. (2004) Children’s achievement in
early elementary school: Longitudinal effects of parental involvement,
expectations, and quality of assistance. Journal of Educational Psychology, 69
(4), 723-730.

Eldevik, S., Eikeseth, S., Jahr, E., & Smith, T. (2006). Effects of low-intensity behavioral
treatment for children with autism and mental retardation. Journal of Autism and
Developmental Disorders, 36, 211−224.

Eldevik, S., Hastings, R., Hughes, J., Jahr, E., & Eikeseth, S. (2009). Meta-analysis of
early intensive behavioral intervention for children with autism. Journal of Child
and Adolescent Psychology, 38, 439−450.
 68

Englund, M., Luckner, A., Whaley, G., & Egeland, B. (2004) Children’s Achievement in
early elementary school: Longitudinal Effects of parental involvement,
Expectations, and Quality of Assistance. Journal of Educational Psychology, 99
(4), 723-730.

Eyeberg, H. & Matarazzo, R. (1980). Training parents as therapists: A comparison

between individual parent-child interaction training and parent group didactic
training. Journal of clinical Psychology, 36, 492-499.

Faul, F., Erdfelder, E., Lang, A., & Buchner, A. (2007). G*Power 3: A flexible statistical
power analysis program for the social, behavioral, and biomedical sciences.
Behavior Research Methods, 39, 175-191.

Feather, N. (1982). Introduction and overview. In N. Feather (Ed.) Expectations and

actions: Expectancy-value models in psychology. Hillsdale, NJ: Erlbaum

Field, S. & Hoffman, A. (1999) The importance of family involvement for promoting
self-determination in adolescents with autism and other developmental
disabilities. Focus on Autism and Other Developmental Disabilities, 14(1), 36–41.

Gau, S., Chou, M., Chiang, H., Lee, J., Wong, C., Chou, W., & Wu, Y. (2012). Parental
adjustment, marital relationship, and family function in families of children with
autism. Research in Autism Spectrum Disorders, 6, 263-270.

Geier, D., kern, J, & Geier, M. (2013). A comparison of the Autism treatment
Evaluations Checklist (ATEC) and Childhood autism rating scale (CARS) for the
quantitative evaluation of autism. Journal of Mental Health Research in
Intellectual Disabilities, 6, 255-267.

Ghasemi, A. & Zahediasl, S. (2012). Normality tests for statistical analysis: A guide for
non-statisticians. International Journal of Endocrinology and Metabolism, 10(2):
486–489.

Gilliam, J. (2001). Gilliam Asperger’s Disorder Scale manual second printing. Austin,
TX: Pro-Ed.

Gilliam, J. (1995). Gilliam Autism Rating scale. Austin, TX: Pro-Ed.

Green, G., Brennan, L., & Fein. D. (2002). Intensive behavioral treatment for a toddler at
high risk for autism. Behavior Modification, 26, 69-102.

Hastings, R. (2002). Parental stress and behaviour problems of children with

developmental disability. Journal of Intellectual and Developmental Disability,
27, 149–160.
 69

Hastings, R. (2003). Child behaviour problems and partner mental health as correlates of
stress in mothers and fathers of children with autism. Journal of Intellectual
Disability Research, 47, 231–237.

Hastings, R. & Brown, T. (2002). Behavior problems of children with autism, parental
self-efficacy, and mental health. American Journal on Mental Retardation, 107,
222–232.

Hastings, R., & Johnson, E. (2001). Stress in UK families conducting intensive home-
based behavioral intervention for their young child with autism. Journal of Autism
and Developmental Disorders, 31, 327–336.

Holmes, L., Himle, M., & Strassberg, D. (2016). Parental romantic expectations and
parent-child sexuality communication in autism spectrum disorders. Autism,
20(6), 687-699.

Howard, J., Sparkman, C., Cohen, H., Green, G., & Stanislaw, H. (2005). A comparison
of intensive behavior analytic and eclectic treatments for young children with
autism. Research in Developmental Disabilities, 26, 359−383.

Hutchings, J., Appleton, P., Smith, M., Lane, E., & Nash, S. (2002). Evaluation of two
treatments for children with severe behaviour problems: Child behaviour and
maternal mental health outcomes. Behavioural and Cognitive Psychotherapy, 30,
279–295.

Hyman, S. & Johnson, J. (2012) Autism and pediatric practice: Toward a medical home.
Journal of Autism and Developmental Disorders, 42(6), 1156-1164.

Iglewicz, B. & Hoaglin, D. (1993). How to Detect and Handle Outliers: ASQC Basic
References in Quality Control (16). Milwaukee, WI: ASQ Quality Press.

Ingersoll, B. & Berger, N. (2015) Parent engagement with a telehealth-based parent-

mediated intervention program for children with autism spectrum disorders:
Predictors of program use and parent outcome. Journal of Medical Internet
Research, 17(10), 1-15.

Ingersoll, B. & Hambrick, D. (2011). The relationship between the broader autism
phenotype, child severity, and stress and depression in parents of children with
autism spectrum disorder. Research in Autism Spectrum Disorders. 5, 337-344.

Ivey, J. (2004). What do parents expect? A study of likelihood and importance issues for
children with autism spectrum disorders. Focus on Autism and Other
Developmental Disabilities 19, 27-33.
 70

Jellett, R., Wood, C., Giallo, R., & Seymour, M. (2015). Family functioning and
behaviour problems in children with Autism Spectrum Disorders: The mediating
role of parent mental health. Clinical Psychologist, 19(1), 39-48.

Kaminski, J., Vallae, L., Filene, J., & Boyle, C. (2008). A meta-analytic review of the
components associated with parent training program effectiveness. Journal of
abnormal Child Psychology, 36, 567-589.

Keen, D., Couzens, D., Muspratt, S., & Rodger, S. (2010). The effects of a parent-
focused intervention for children with a recent diagnosis of autism spectrum
disorder on parenting stress and competence. Research on Autism Spectrum
Disorder, 4, 229-241.

Kim, H. (2013). Statistical notes for clinical researchers: Assessing normal distribution
using skewness and kurtosis. Restorative Dentistry and Endodontics, 38 (1), 52-
54.

Kirby, A. (2016). Parent expectations mediate outcomes for young adults with Autism
Spectrum Disorder. Journal of Autism and Developmental Disorders, 46, 1643–
1655.

Koegel, R., Glan T., Niemen, G. (1978) Generalization of parent training results. Journal
of Applied Behavior Analysis, 11, 95-109.

Koegel, R., Schriebman, L., Loos, L., Dirlich-Wilheim, H., & Dunlap, L. (1992).
Consistent stress profiles in mothers of children with autism. Journal of Autism
and Developmental Disorders, 22, 205–216.

Koegel, R., Schreibman, L., O’Neil, R., & Burke, J. (1983). The personality and family
interaction characteristics of parents of autistic children. Journal of Consulting
and Clinical Psychology, 51, 683–692.

Koydemira S, Tosuna U. (2009) Impact of autistic children on the lives of mothers.

Social and Behavioral Sciences, 1(1), 2534–2540.

Lafaskis, M. & Sturney, P. (2007). Training parent implementation of discrete trial

teaching: Effects on generalization of parent teaching and correct child
responding. Journal of Applied Behavior Analysis, 40, 685-689.

Lebeau, R., Davies, C., Culver, N., & Craske, M. (2013) Homework compliance counts
in cognitive-behavioral therapy. Cognitive Behavior Therapy, 42 (3), 171-179.

Leigh, P., & Du, J. (2015) Brief Report: Forecasting the economic burden of Autism in
2015 and 2025 in the United states. Journal of Autism and Developmental
Disorder, 45 (12), 4135-4139.
 71

Levi, U., EInav, M., Ziv, O., Raskind, I., Margalit, M. (2014) Academic expectations and
actual achievements: The roles of hope and effort. European Journal of
Psychology of Education, 29 (3), 367-386.

Lobst, E., Nabors, L., Rosenzweig, L., Srivorakiat, L., Champlin, R., Campbell, J., &
Segall, M. (2009) Adults’ perception of a child with autism. Research in Autism
Spectrum Disorders, 3, 401-408.

Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. (2012). Autism
diagnostic observation schedule, second edition. Torrance, CA: Western
Psychological Services.

Lopez, F., & Lent, R. (1991) Efficacy-based predictors of relationship adjustment and
persistence among college students. Journal of College Student Development, 36,
223-229.

Lovaas, O., Koegel, R., Simmons, J., & Stevens-Long, J. (1979). Some generalization
and follow-up measures on autistic children in behavior therapy. Journal of
Applied Behavior Analysis, 6, 131-166.

Lovaas, O. (1981). Teaching developmentally disabled children: The me book.

Baltimore: University Park Press.

Lovaas, O. (1987). Behavioral treatment and normal educational and intellectual

functioning in young autistic children. Journal of Consulting and Clinical
Psychology, 55, 3−9.

Lundahl, B., & Harris, N. (2006). Delivering parent training to families at risk to abuse:
Lessons from three meta-analyses. The APSAC Advisor, 18, 7–11.

Lundahl, B. W., Nimer, J., & Parsons, B. (2006a). Preventing child abuse: A meta-
analysis of parent training programs. Research on Social Work Practice, 16, 251–
262.

Lundahl, B., Risser, H., & Lovejoy, M. (2006b). A meta-analysis of parent training:
Moderators and follow-up effects. Clinical Psychology Review, 26, 86–104

Magana, S. & Lopez, K. (2013) Access to diagnosis and treatment services among Latin
children with Autism Spectrum Disorder, 51 (3), 141-153.

Magiati, I., Charman, T., & Howlin, P. (2007). A two-year prospective follow-up study
of community-based early intensive behavioural intervention and specialist
nursery provision for children with autism spectrum disorders. Journal of Child
Psychology and Psychiatry, 48, 803−812.
 72

Magiati, I., Moss, J., Yates, R. Charman, T., & Howlin, P. (2011). Is the Autism
Treatment Evaluation checklist a useful tool for monitoring progress in children
with autism spectrum disorders. Journal of Intellectual and Disabilities Research,
55, 302-312.

Mahapatra, S., Khokhlovich, E., Martinez, S,, Kannel, B., Edleson, S., Vyshedskly, A.
(2018) Longitudinal epidemiological study of autism subgroups using Autism
Treatment Evaluation Checklist (ATEC) score. Journal of Autism and
Developmental Disorders, 1-12.

Matthews, R., Booth, S., Taylor, C., & Martin, M. (2011) A qualitative examination of
the work–family interface: Parents of children with autism spectrum disorder.
Journal of Vocational Behavior, 79 (3), 625-639.

Matson, M., Mahan, S., & Matson, J. (2009). Parent training: A review of methods for
children with autism spectrum disorder. Research in Autism Spectrum Disorder,
3, 868-875

Matsumura, L., Garnier, H., & Gallimore, R. (1998). Parents' developmental expectations
and child characteristics: Longitudinal study of children with developmental
delays and their families. American Journal of Mental Retardation, 103, 117-129.

McGowan, J., Lavender, T., & Garety, P. (2005). Factors in outcome of cognitive-
behavioral therapy for psychosis: users’ and clinicians’ views. Psychology and
Psychotherapy: Theory, Research and Practice,78, 513–529.

McMurran, M., Huband, N., & Overton, E. (2010) Non-completion of personality

disorder treatments: a systematic review of correlates, consequences, and
interventions. Clinical Psychology Review, 30 (3), 277-287.

Moes, D. & Frea, W. (2000). Using family context to inform intervention planning for
the treatment of a child with autism. Journal of Positive Behavior Interventions,
2, 40-46.

Mugno, D, Rural. D’Arrigo, V., & Mazzone, L. (2007). Impairment of quality of life in
parents of children and adolescents with pervasive developmental disorder.
Health and Quality of Life Outcomes, 5, 22.

Mutua, N. (1999). Macro- and micro-level factors that predict educational access among
children with disabilities in Kenya. Unpublished doctoral dissertation, Kent State
University, Ohio.
 73

Mutua, N. (2001). Importance of parents’ expectations and beliefs in the educational

participation of children with mental retardation in Kenya. Education and
Training in Mental Retardation and Developmental Disabilities, 36, 148–159.

Mutua, N., & Dimitrov, D. (2001). Prediction of school enrollment of children with
intellectual disabilities in Kenya: The role of parents’ expectation, beliefs, and
education. International Journal of Disability, Development and Education,
48(2), 179-191.

Nevison, C. & Blaxill, M. (2017) Diagnostic substitution for intellectual disability:

A flawed explanation for the rise in autism. Journal of Autism and Developmental
Disorders, 47, 2733-2742.

Nock, M. & Kazdin, A. (2005) Randomized controlled trial of a brief intervention for
increasing participation in parent management training. Journal of Counseling
and Clinical Psychology, 73 (5), 872-879.
Ogston, P., Mackintosh, V., & Myers, B. (2011). Hope and worry in mothers of children
with an autism spectrum disorder or Down syndrome. Research in Autism
Spectrum Disorder, 5, 1378-1384.

Oliver, C., Momcilovic, N., Rossiter, R., Stumbles, E., & Taylor, E. (2001). A
randomized trial of brief or individual versus group parent training for behaviour
problems in children with severe learning disabilities. Behavioural and Cognitive
Psychotherapy, 29, 151-167.

Olson, M. & Hwang, P. (2001). Depression in mothers and fathers of children with
intellectual disability. Journal of Intellectual Disability Research, 45, 535–543.

Ortega, J. (2010). Applied behavior analytic intervention for autism in early childhood:
Meta-analysis, meta-regression, and dose-dependent meta-analysis of multiple
outcomes. Clinical Psychology Review, 30- 387-399.

Osborne, L., McHugh, L., Saunders J., & Reed, P. (2008) The effect of parents training
on subsequent child behavior problems in autism spectrum conditions. Research
in Autism Spectrum Disorders, 2, 249-263.

Poon, K. (2013) Parental expectations regarding post-school social attainments of

adolescents with autism spectrum disorder in Singapore. American Journal on
Intellectual and Developmental Disabilities, 2, 95-107.

Poon, K., Koh, L., & Magiati, I. (2013). Parental perspectives on the importance and
likelihood of adult outcomes for children with autism spectrum disorders,
intellectual disabilities or multiple disabilities. Research in Autism Spectrum
Disorders, 7, 382-390.
 74

Ramey, S. & Ramey, C. (1999). Early experiences and interventions for children at risk
for developmental delay and mental retardation. Mental Retardation and
developmental Disabilities Research Reviews, 5, 1-10.

Reichow, B. (2012). Overview of meta-analyses on early intensive behavioral

interventions for young children with autism spectrum disorders. Journal of
Developmental Disorders, 42, 512-520.

Rimland, B. & Edelson, M. (1999). Autism Treatment Evaluation Checklist. Autism

research Institute, San Diego, CA.

Roberts, J., Williams, K., Carter, M., Evans, D., Parmenter, T., Silove, N., Clark, T., &
Warren, A. (2011). A randomized control trial of two early intervention programs
for young children with autism: Centre –based with parent program and home-
based. Research in Autism Spectrum Disorders, 5. 1553-1566.

Rodgers, S., Herbison, J., Lewis, H., Pantone, J., & Reiss, K. (1986). An approach for
enhancing the symbolic, communicative, and interpersonal functioning of young
children with autism and severe emotional handicaps. Journal of the Division for
Early Childhood, 10, 135-148.

Rodgers, S., & Vismara, I. (2008). Evidenced-based comprehensive treatments for early
autism. Journal of Clinical Child and Adolescent Psychology, 37, 8-38.

Ruble, L., & Dalrymple, N. (1996). An alternative view of outcomes in autism. Focus on
Autism and Other Developmental Disabilities, 11, 3–14

Schopler, E., Reichler, R., DeVillis, R., & Daly, K. (1980). Towards objective
classification of childhood autism: Childhood autism rating scale (CARS).
Journal of Autism and Developmental Disorders, 10, 91-103.

Schopler, E., Reichler, R., & Renner, B. (1994). The Childhood Autism Rating Scale.
Western Psychological services, Los Angeles, CA.

Simons, L., Logan, D, Chastain, L., & Cerullo, M. (2010). Engagement in

multidisciplinary interventions for pediatric chronic pain: Parental expectations,
barriers, and child outcomes. The Clinical Journal of Pain, 26 (4), 291-299.

Singer, G. (2006). Meta-analysis comparative studies of depression in mothers with and

without developmental disabilities. American Journal on Mental Retardation,
111, 155-169.

Sitlington, P., Clark, G., & Kolstoe, O. (2000). Transition Education Services for
Adolescents with Disabilities (3rd Ed). Boston, MA: Allyn & Bacon.
 75

Stahmer, A., & Gist, K. (2001). The effects of an accelerated parent education program
on technique mastery and child outcome. Journal of Positive Behavior
Interventions, 3, 75-82.

Straus, K., Mancini, F., Fava, L. (2013). Parent inclusion in early intensive behavior
interventions for young children with ASD: A synthesis of meta-analyses from
2009 to 2011. Research in Developmental Disabilities, 34 (9), 2967-2985.

Taylor, J., & Warren, Z. (2011). Maternal depressive symptoms following autism
spectrum diagnosis. Journal of Autism and Developmental Disorders, 42, 1411–
1418.

Tetley, A., Jonks, M., Huband, N., & Howells, K. (2011). A Systematic Review of
Measures of Therapeutic Engagement in Psychosocial and Psychological
Treatment. Journal of Clinical Psychology, 67 (9), 927-941.
Timperley, H. & Phillips, G. (2003) Changing and sustaining Teachers; Expectations
through professional development in literacy. Teaching and Teacher Education,
19 (6), 627-641.

Thomas, P., King, J., Mendelson, J., & Nelson-Gray, R. (2017). Parental
psychopathology and expectations for the futures of children with autism
spectrum disorder. Journal of Applied Research in Intellectual Disabilities, 31 (1),
98-105.

Tonge, B., Brereton, A., Kiomall, M., Mackinnon, A., King, N., & Rinehart, N. (2006).
Effects on parental mental health of an education and skills training program for
parents of young children with autism: A randomized controlled trial. Journal of
the American Academy of Child and Adolescent Psychiatry, 45, 561–569.

Tonge, B., Brereton, A., Kiomall, M., Mackinnon, A., King, N., & Rinehart, N. (2014). A
randomised group comparison controlled trial of ‘preschoolers with autism’: A
parent education and skills training intervention for young children with autistic
disorder. Autism, 18, 166-177.

Twyman, K., Maxim, R., Leet, T., & Ultman. (2009). Parents’ developmental concerns
and age variance at diagnosis of children with autism spectrum disorder. Research
in Autism Spectrum Disorder, 3, 489-495.

Tzanakakai, P., Grindle, C., Hastings, R., Hughed, J., Kovshoff, H., & Remington, B.
(2012). How and why do parents choose early intensive behavioral intervention
for their young child with autism? Education and Training in Autism and
Developmental Disabilities, 47(1), 58–71.

Wang B., Stanton. D., Deveaux, C., Li, X., Kocci, V., et al. (2014). The impact of parent
involvement in an effective adolescent risk reduction intervention on sexual risk
 76

communication and adolescent outcomes. AIDS Education and Prevention, 26

(6), 500-520.

Weinberg, R., Gould, D., Jackson, A. (1979) Expectations and performance: An

empirical test of Bandura's self-efficacy theory. Human Kinetics Journal, 1 (4),
320-331.

Wietlauf, A., Vehorn, A., Taylor, J., & Warren, Z. (2014). Relationship satisfaction,
parenting stress, and depression in mothers of children with autism. The
International Journal of research and Practice, 2, 194-198.

Wong, C., Odom, S., Hune, K., Cox, A., Fettig, A., Kucharczyk, S., Brock, M., Plavnick,
J., Fleury, V., & Schultz, T. (2015). Evidence-based practices for children, youth,
and young adults with autism spectrum disorder: A comprehensive review.
Journal of Autism and Developmental Disorders, 45, 1951-1966.

Young, K., Boris, A., Thomson, K., martin, G., & You, C. (2012). Evaluations of a self-
instructional package on discrete trail teaching to parents of children with autism.
Research in Autism Spectrum Disorders, 6, 1321-1130.

Reproduced with permission of copyright owner. Further reproduction prohibited without permission.