how does family, parents, teachers and children involvement affect a child with autism?

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International Journal of Play Therapy 2018, Vol. 27, No. 1, 56 – 68 1555-6824/18/$12.00 © 2017 Association for Play Therapy http://dx.doi.org/10.1037/pla0000056 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Theraplay Impact on Parents and Children With Autism Spectrum Disorder: Improvements in Affect, Joint Attention, and Social Cooperation Amanda R. Hiles Howard Sandra Lindaman Samford University The Theraplay Institute, Evanston, Illinois Rachel Copeland David R. Cross Samford University Texas Christian University The goal of the study was to evaluate Theraplay using a sample of autistic children. Eight children diagnosed with mild to moderate autism participated in a 2-week intensive Theraplay intervention. The intervention consisted of each caregiver– child dyad having two 1-hr sessions each day over a 2-week period of time with a trained Theraplay therapist. Two series of measures were completed: (a) those completed during the intervention and (b) those completed during pretesting, posttesting 2 weeks following the intervention, and posttesting 3 months following the intervention. During the intervention, therapists completed a form following each session evaluating both the child and parent. Measures completed pre- and postintervention a caregiver– child interaction task (MIM) at pretesting and 2 posttesting time points. In order to evaluate change across time for the interaction task, a scoring system for the MIM interactions was adapted, per McKay and colleagues (1996). Data for intervention measures revealed that both parents and children significantly improved across session according to the therapist evaluation. These finding suggest that as the intervention progressed, both children and parents became better at interacting during the therapy sessions. Significant changes were observed in the MIM interaction tasks. Overall, caregiver– child dyads scored significantly higher on the MIM interaction task from pretesting to posttesting. Further, dyads scored significantly higher on several specific dimensions. The patterns of these findings lend support to the validity and usefulness of Theraplay as an intervention for special-needs children. Future studies should utilize larger and more diverse samples. Keywords: autism, Theraplay, Marschak Interaction Method Children who receive a diagnosis of Autism Spectrum Disorder (ASD), along with their parents, face a myriad of challenges from social and communication difficulties to parenting stress and difficulties in the parent– child relationship. The Centers for Disease Control and Prevention (CDC) estimates that the prevalence of ASD is approximately 1 in 68 children (Centers for Disease Control and Prevention, 2014). Early intervention for children with ASD is paramount, and children typically receive intensive Applied Behavioral Analysis (ABA) as the preferred treatment (Peters-Scheffer, Didden, Korzilius, & Sturmey, 2011). While ABA is an effective intervention, children and families often still face challenges in socialization, synchrony, joint attention, and communication skills. It is important to continue to find treat- This article was published Online First August 31, 2017. Amanda R. Hiles Howard, Department of Psychology, Samford University; Sandra Lindaman, The Theraplay Institute, Evanston, Illinois; Rachel Copeland, Department of Psychology, Samford University; David R. Cross, Karyn Purvis Institute of Child Development, Texas Christian University. Correspondence concerning this article should be addressed to Amanda R. Hiles Howard, Department of Psychology, Samford University, 800 Lakeshore Drive, Birmingham, AL 35229. E-mail: ahoward6@samford.edu 56 THERAPLAY WITH PARENTS AND CHILDREN WITH AUTISM ments that can support the gains of ABA, and that focus a developmental and relational context. This study examines the efficacy of an attachment-based, parent– child intervention called Theraplay. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Prevalence and Characteristics of ASD ASD is a neurodevelopmental disorder in which children display deficits in social interactions and communication. Affecting between 1.5–2.0% of the population in the United States (Jo et al., 2015), children with ASD tend to struggle with reciprocal social interactions, repetitive behaviors, abstract thinking, and symbolic play (Kossyvaki & Papoudi, 2016; Mohammadzaheri, Koegel, Rezaee, & Rafiee, 2014; Ramsey, Kelly-Vance, Allen, Rosol, & Yoerger, 2016; Siller & Sigman, 2002; Wetherby & Woods, 2006). The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM–5) has classified a spectrum of diagnoses from DSM–IV as ASD. Previous DSM–IV diagnoses of Asperger Syndrome, Pervasive Developmental Disorder, Autism, Rett Syndrome, and Childhood Disintegration Disorder have been included in the DSM–5 diagnosis of ASD (American Psychiatric Association, 2013). Children with ASD typically show deficits in early infancy, namely in the areas of play, stereotypical behaviors, and shared attention (Kossyvaki & Papoudi, 2016; Jo et al., 2015). They tend to struggle with symbolic play, they prefer to play alone, and they show a preference for toys based on sensory stimulation. Additionally, the repetitive and stereotypical quality to their play can be challenging for peers to navigate when attempting to engage a child with ASD. Deficits in shared or joint attention with others have proven to be particularly challenging, as these deficits have implications for both socialization and communication skills (Holmes & Willoughby, 2005; Prendeville, Prelock, & Unwin, 2006; Siller & Sigman, 2002). Joint attention can be defined as a set of behaviors that promote shared attention including eye gaze, shared affect, pointing to engage and direct mutual attention, and reciprocally sustained joint attention (Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Wetherby & Woods, 2006). Research that has found support for deficits in joint attention has implications for the develop- 57 ment of communication in children with ASD. Most children with ASD have delays in communication, and communication is often the first sign parents recognize that cue them to the possibility their child may have ASD. However, children who are unable to participate in joint attention with their caregivers have poorer development of communication and experience more delays and challenges in developing communication skills (Kasari et al., 2010; Mahoney & Perales, 2005; Siller & Sigman, 2002). Interventions for Autism Spectrum Disorder Children who receive appropriate intervention before the age of 3.5 tend to fare better than children who begin intervention after that time. Unfortunately, many children are not diagnosed until after this age, which can impede their ability to improve in the domains of communication and socialization (Jo et al., 2015). Traditionally, ABA has been considered the standard intervention for children with ASD (PetersScheffer et al., 2011). ABA was originally designed by Ivar Lovaas in the 1970s in response to the lack of success of traditional medical and psychodynamic interventions for children with ASD (Lovaas, 1987). The goal of ABA is to shape a child’s behavior through operant conditioning. ABA targets its intervention to the domains of language and social skills, while also attempting to reduce repetitive behaviors. ABA is successful in creating changes in a wide variety of behavioral areas, which is why it is one of the most common treatments for ASD. However, there are challenges with ABA, namely slow gains, poor generalizability to other behaviors, continuing difficulty with social skills, and escapist behaviors exhibited by children during therapy (Mohammadzaheri et al., 2014; Solomon, Necheles, Ferch, & Bruckman, 2007). More recently, researchers have been working to identify alternative intervention models to target some of the areas that have not been successful with ABA. Researchers have explored treatments that increase the motivational aspect of children, that occur in the natural environment of the child, and that work with the child and family in the context of each child’s unique developmental needs (Mohammadzaheri et al., 2014; Schertz & Odom, 2007; Whalen & 58 HILES HOWARD, LINDAMAN, COPELAND, AND CROSS This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Schreibman, 2003). Specifically, researchers have been interested in treatments that improve joint attention, as joint attention is important to both socialization and communication. The literature on several alternative, relationshipfocused interventions that are play-based and individually and developmentally focused is promising. Relationship-Focused Interventions Relationship-focused interventions have received more attention in the intervention literature for ASD. Research has demonstrated that responsiveness between caregiver and child is related to communication, cognition, and social and emotional development in children with ASD. Parenting aspects that affect the development of typically developing children have been found to also affect the development of children with ASD (Aali, Yazdi, Abdekhodaei, Chamanabad, & Moharreri, 2015; Hess, 2013; Kossyvaki & Papoudi, 2016; Mahoney & Perales, 2005). A combination of two models of ASD treatment, Floortime and DIR (the developmental, individual-differences, relationship-based model), were examined to determine the efficacy of this approach for children with ASD (Aali et al., 2015; Pajareya & Nopmaneejumruslers, 2011; Wieder & Greenspan, 2003). Floortime is an intervention that focuses on helping parents become more attuned to their child’s cues and to enhance feelings of parental competence. It also teaches caregivers to interact with their children based on the child’s level of development. DIR posits that human development occurs in the context of relationships and that the neurological deficits from ASD impede a child’s ability to develop fully (Aali et al., 2015). Researchers found that when Floortime and DIR were used together, children improved in self-regulation, attachment and engagement, communication, and creation of ideas (Aali et al., 2015; Pajareya & Nopmaneejumruslers, 2011; Wieder & Greenspan, 2003). Outside of the DIR/Floortime model, using relationship-based treatments for children with ASD can be helpful in addressing some of the key deficits that these children experience. Relationship-based interventions can help to improve joint attention and social engagement, which are important domains in children with ASD (Schertz & Odom, 2007). Relationship- based interventions often teach parents how to have more responsive interactions with their children. Parental responsiveness is a key component in developing healthy attachment in children. A meta-analysis of attachment issues of children with ASD found that children with ASD are less likely to demonstrate attachment security than their nonclinical peers (Kahane & El-Tahir, 2015). Additionally, children who have more severe cases of autism are more likely to demonstrate poor attachment. Factors that influence attachment are parental sensitivity, caregiver insightfulness (understanding of their child’s inner world), and the caregiver’s own attachment category (Kahane & El-Tahir, 2015; Keenan, Newman, Gray, & Rinehart, 2016). While ASD is a neurologically based disorder, a child’s neurological impairment can be exacerbated by environmental factors such as a parent’s attachment behavior, and attachment category, and parenting style. Parents of children with ASD experience higher levels of stress and marital dissatisfaction, are more likely to get divorced, and have more attachment-related anxiety (van IJzendoorn, et al., 2007; Keenan et al., 2016). Additionally, parents of children with ASD are more likely to use control strategies to manage their children’s behavior and are more likely to experience parenting stress. Their autistic children are also less likely to demonstrate quality social interactions with their parents than are their nonclinical peers (Filippello, Marino, Chilà, & Sorrenti, 2015; van IJzendoorn et al., 2007). It is hypothesized that parents of children with ASD may engage in fewer attachment-related behaviors because they do not receive the social feedback from their children in the same way as do parents of nonclinical children. Helping parents improve attachment behaviors can help improve some of the deficits in socialization and joint attention commonly seen with this population (Kahane & El-Tahir, 2015). Play-Based Interventions There have been few play-based interventions that have been used with children with ASD. These interventions typically seek to improve children’s play and social skills, which are linked to gains in cognitive, social, and emotional growth (Holmes & Willoughby, This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. THERAPLAY WITH PARENTS AND CHILDREN WITH AUTISM 2005). Play has been found to be an important component of learning and skill development in the education setting (Kossyvaki & Papoudi, 2016; Wolfberg & Schuler, 2006). A 2016 meta-analysis of 14 studies examined the effectiveness of play-based interventions in a school setting with children with ASD (Kossyvaki & Papoudi, 2016). The researchers found that children improved in creative and symbolic play, communication, and social interactions with peers. Another study focused on a structure play-based intervention that included the caregiver and found that children with ASD improved in their ability to engage in more appropriate play (Thomas & Smith, 2004). Specifically, functional use of toys and in social interactions with peers improved from pre to postintervention. Finally, peer play interventions have been examined in the literature. These interventions typically use nonclinical peers to model and support social interactions. Peer play interventions have been found to help children with ASD improve peer interactions, play behaviors, and social skills (Prendeville et al., 2006). Theraplay Theraplay is an early intervention method that integrated attachment theory to impact the relationships between children and parents. Theraplay was first broadly used at Chicago Head Start in 1969, and the authors were heavily influenced by the work and writings of John Bowlby (Booth & Jernberg, 2010). Theraplay is based in the belief that a playful, interactive experience can help to improve parental attunement and sensitivity as well as child regulation and reflection. Theraplay focuses on the nonverbal aspects of child communication and uses playful interactions as the medium for intervention. Theraplay is a relatively short-term play therapy approach for treatment of children within a family context. Theraplay typically consists of at least one 30-min weekly session over a course of 4 to 6 months (Booth & Jernberg, 2010; Simeone-Russell, 2011). Theraplay is a highly structured treatment, typically beginning with a welcome, setting of the rules, social and sensory check-in, structured play activities related to the four dimensions, and a closing with feeding, a story, and swinging. The four dimensions of structure, 59 nurture, challenge, and engagement fit into various attachment and parenting goals of Theraplay. Structure activities allow the child to practice complying with directions from adults that can be generalized to both home and school. Nurture allows for a child to experience being cared for, valued, and accepted by adults. This is perhaps one of the most important dimensions of Theraplay, and while nurture is its own dimension, it is also a component of all dimensions of Theraplay (Booth & Jernberg, 2010; Simeone-Russell, 2011). Challenging activities empower the child by providing opportunities to step outside of his or her comfort zone. These activities provide opportunities for success while teaching the child how to manage feelings of anxiety or frustration. Finally, engagement activities allow the parent and child to build rapport and expand mutual enjoyment of playful interactions. These four dimensions work together to activate and enrich a child’s attachment system and allow the parent to relate to his or her child in a more playful and empathic manner (Booth & Jernberg, 2010). Because of its grounding in attachment theory, the relationship is the primary focus of treatment in Theraplay. A goal of Theraplay is to model the attachment relationship by establishing an empathic and attuned relationship between parent and therapist, which serves as a model for the relationship between parent and child. Additionally, Theraplay seeks to help parents understand and make sense of their own attachment experiences while being able to become more sensitive and empathic toward their own child (Booth & Jernberg, 2010). Finally, Theraplay seeks to work directly with the parent– child dyad in order to change the child’s inner working model and improve the overall attachment relationship between parent and child. Theraplay is also developmentally sensitive and individually flexible based on the developmental needs of the child. Theraplay enables children to respond to their parents appropriately and helps parents to better understand and respond to their children’s cues (Booth & Jernberg, 2010). One of the developers of Theraplay was a forerunner in arguing that autism was a neurological disorder and that social deficits were a key feature of the neurological deficit. He made his contributions to Theraplay development with the express intent that it be used as a This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 60 HILES HOWARD, LINDAMAN, COPELAND, AND CROSS method for addressing social interaction needs. A series of in-depth case studies of youth with a combination of intellectual delay and severe ASD demonstrated positive gains across a range of behaviors, including cooperation with others, social interaction, communication, and even daily adaptive functioning (DesLauriers & Carlson, 1969). Since then Theraplay has been used as a treatment component in numerous school, residential, and in-home therapeutic programs with case studies and classroom studies supporting its effectiveness in reducing behavior problems (Bundy-Myrow, Munns, & Coleman, 2009; Coleman, 2013). Theraplay research emphasis has been on general clinical populations rather than ASD. Theraplay has been found to be effective in improving social and emotional skills, internalizing problems, attention, and activity issues in children (Simeone-Russell, 2011; Munns, 2009; Wettig, Coleman, & Geider, 2011), but there has been some research on the efficacy of Theraplay with children with ASD specifically. Theraplay was found to improve internalizing symptoms of anxiety, depression, and somatic complaints in children with ASD (Simeone-Russell, 2011). Theraplay has also been researched on ASD, primarily using a single-study design to demonstrate improved attachment, communication, and engagement with others (Fuller, 1995; Booth & Jernberg, 2010). No research to our knowledge has examined Theraplay’s impact on both the family and children with ASD, nor used a time series model. Because Theraplay works to improve various deficits in children that are also found in children with ASD, this study sought to examine whether Theraplay could be an effective intervention for children with ASD. The aspects of Theraplay that are appropriate for parents of children who have ASD are joint attention, attunement, regulation, synchrony, communication, parental insight, and processing of sensory information (Booth & Jernberg, 2010). We expected that these domains would improve for both parents and children when a rigorous behavior tracking system was used. The Present Study The present study sought to investigate the efficacy of Theraplay using a sample of children diagnosed with mild to moderate autism. We hypothesized that the quality of parent– child interactions will improve from pre- to postintervention. Method Participants Participants were 8 children (2 female, 6 male) diagnosed by a medical doctor, psychologist, or psychiatrist with mild to moderate autism. Participants ranged in age from 3 to 9 (M ! 5.38, SD ! 1.92). Age at diagnosis ranged from 2 to 7 (M ! 3.61, SD ! 1.58). No participants were biologically related or from the same family. Measures The measure completed at pre- and posttesting was a caregiver– child interaction task. Measures completed during the therapy period included therapist-report evaluations for both the parent and the child following each therapy sessions and independent evaluations for both the parent and the child behaviors obtained from videotapes of each therapy session. Marschak Interaction Method (MIM). The MIM is an observational technique in which the parent– child dyad interacts with one another as they perform a series of structured tasks. The MIM is used to assess the parent– child relationship. In order to evaluate change across time, a scoring system for the MIM interactions was adapted from that of McKay and colleagues (1996). The parent, child, and dyad were rated on 16 dimensions for each of the six tasks. All dimensions were rated on a 5-point scale, where lower scores indicated the less optimal behavior and higher scores indicated the more optimal behavior. The coding scheme consists of six behavioral dimensions for the parent, seven behavioral dimensions for the child, and three behavioral dimensions for the parent– child dyad. A summary of dimensions scored for the MIM can be found in Table 1. The scoring system produces a global score, three composite subscale scores, and 16 dimension scores. The scores for each dimension were averaged across tasks to create the composite subscale scores. Finally, all dimensions were averaged to create a global score. MIM scoring. Raters attended four groupcoding sessions in which they scored interaction THERAPLAY WITH PARENTS AND CHILDREN WITH AUTISM 61 Table 1 MIM Scoring Dimensions Scored Dimension Definition Parent Facial expression Facial expression (smiling, relaxed vs. frowning, tense) or observed affect of parent (frustrated, happy). Encouraging, comforting toward child vs. harsh, criticizing toward child. Body oriented towards child vs. oriented away from child. Responsive to affective/behavioral cues of child vs. unresponsive to affective/behavioral cues of child. Looking at child most of the time and maintaining eye contact vs. looking away from child most of the time or avoiding eye contact. Offering help or guidance to the child without being too controlling or too passive vs. offering inappropriate, too much or too little help and guidance to the child. Facial expression (smiling, relaxed vs. frowning, tense) or observed affect of child (frustrated, happy). Positive toward parent vs. harsh, demanding toward parent. Body oriented towards parent vs. oriented away from parent. Responsive to affective/behavioral cues of parent vs. unresponsive to affective/behavioral cues of parent. Looking at parent most of the time and maintaining eye contact vs. looking away from parent most of the time or avoiding eye contact. Accepting help or guidance from the parent without being too controlling or too passive vs. becoming angry or frustrated towards the parent when help is offered. Attentive to task most of the time vs. not attentive to task for most of the time. Parent and child are almost always socially involved/engaged with each other vs. parent and child are almost never socially involved/engaged with each other. A balance of initiating and controlling behaviors between parent and child vs. one person is in control/dominant during most of the interaction. Overall impression of interaction. Vocalization Proximity Responsivity This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Gaze fixation Offer guidance Child Facial expression Vocalization Proximity Responsivity Gaze fixation Accept guidance Dyad Task focus Social Balance Global quality Note. MIM ! Marschak Interaction Method. sessions independently and then collaborated responses. Raters were told to keep the age appropriateness of behaviors in mind while scoring. Discussion of any disagreements between raters was encouraged and continued until consensus was reached. Further, raters met regularly throughout the scoring process to assure the scoring schema remained consistent across raters. Interactions were randomized and scored on the 16 dimensions by two independent raters who were blind to the time point of the interactions they were scoring. Approximately 30% of the interactions were scored by both raters to establish interrater reliability (" ! .91). Therapy sessions. All therapy sessions were videotaped and videotapes were scored using a system similar to that used for scoring the MIM sessions. Raters were told to keep the age appropriateness of behaviors in mind while scoring. The parent and child gaze fixation dimensions were removed to accommodate differences in the therapy sessions. Specifically, because the therapy requires quite a bit of movement, camera angles were much wider in the therapy session footage. Due to this difference, scorers were unable to reliably code for eye contact (e.g., it was unclear if the child was looking at the parent/therapist or just in the general direction). All behaviors were rated on a 5-point scale, where lower scores indicated the less optimal behavior and higher scores indicated the more optimal behavior. The parent, child, and dyad were rated on each dimension for every 5-min time block during the therapy session (i.e., each dimension was scored for the 0 –5-min time block, then scored again for the 6 –10-min time block, etc.) for a total of six time blocks. For sessions extending past the six time block only the first 30 min were used. The scores for each dimension were averaged across blocks to create an overall dimension score. Finally, dimensions on each subscale were averaged to create a composite score for that subscale, and all dimensions were averaged to create a total scale score. Therapy session scoring. A separate set of raters were used for scoring the therapy session. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 62 HILES HOWARD, LINDAMAN, COPELAND, AND CROSS Raters attended three group-coding sessions in which they scored therapy sessions independently and then collaborated on responses. Discussion of any disagreements between raters was encouraged and continued until consensus was reached. Further, raters met regularly throughout the scoring process to assure the scoring schema remained consistent across raters. Interactions were randomized and scored on each dimensions by two independent raters who were blind to the time point of the sessions they were scoring. Approximately 30% of the sessions were scored by both raters to establish interrater reliability (" ! .87). Child Behavior Sheet. After each therapy session the therapist completed a Child Behavior Sheet. This sheet consisted of 10 items evaluating the child’s ability to interact with the parent or therapist during therapy sessions. Items were scored on a (0) never or rarely (#20% of the opportunities), (1) occasionally (20 to 40% of the opportunities), (2) sometimes (40 to 60% of the opportunities), (3) most of the time (60 to 80% of the opportunities), (4) nearly all the time or all the time ($80% of the opportunities) scale. On average children participated in 17.38 of the 19 possible sessions. Parent Behavior Sheet. After each session in which the parent participated, the therapist completed a Parent Behavior Sheet. This sheet consisted of eight items evaluating the parent’s ability to interact with the child during therapy sessions under the supervision of the therapist. Items were scored on a (0) not observed, (1) parent noticed or made verbal comment, (2) parent followed therapist’s model/suggestion, (3) parent independently responded to child, (4) parent anticipated child’s needs/behavior, and modified his or her own actions accordingly scale. On average parents participated in 16.75 of the 19 possible sessions. Procedures Families participated in a pretesting 2 weeks prior to the intervention, a 2-week Theraplay intervention, and two posttestings, 2 weeks following the intervention and 3 months following the intervention. Pretesting. The parent and child came to the laboratory during a scheduled testing time and participated in the MIM. At the beginning of the MIM session, the parent and child were seated at a small table. A video camera was located on the wall in the testing room facing the parent– child dyad, and recorded their heads, torsos and arms, and the tabletop. The parent was given six instruction cards (selected from the set as indicated in the MIM manual) and corresponding packets that contained materials needed for each task. Parents were instructed to read each instruction card aloud, and to perform each task in order using the contents of the appropriate packet while spending 3 to 5 minutes on each task. The tasks included activities such as (a) putting hats on each other, (b) drawing a picture and having the child copy it, (c) tickling each other’s feet, (d) playing peek-a-boo, (e) telling the child to care for a baby doll, and (f) feeding each other a snack. MIM procedures were identical for all testing. Theraplay intervention. The intervention consisted of each caregiver– child dyad having two 1-hr sessions each day for 9 days with a trained Theraplay therapist. Only one session was conducted the first day of the intervention in order for the children to acclimate to the therapy environment. Therefore, families completed up to 19 therapy sessions. During the sessions dyads would engage in a wide range of attachment-based Theraplay activities. Two-week posttesting. Approximately 2 weeks following intervention, the parent– child dyads came into the laboratory in individual sessions and completed the MIM interaction task. Three-month posttesting. Approximately 3 months following intervention, the parent– child dyads came into the laboratory in individual sessions and completed the MIM interaction task. Results The results section is organized in three sections corresponding to the three methods of evaluations. First, observational changes in quality of parent– child interactions from pre- to posttesting are presented. Second, observational changes in the quality of parent and child behavior during the therapy sessions are presented. Finally, therapist-reported changes in the behavior of the parent and child following each therapy session are presented. THERAPLAY WITH PARENTS AND CHILDREN WITH AUTISM This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. MIM Sample means for each of the MIM dimensions for each time period can be found in Table 2. There was a marginally significant main effect for time for overall score, F(2, 14) ! 3.42, p # .10. Overall interaction scores increased over time. Further, there was a significant main effect for time for overall parent score, F(2, 14) ! 4.04, p # .05, and a marginally significant main effect for time for overall child score, F(2, 14) ! 3.21, p # .10. Parent and children interaction scores increased over time. No significant differences were found for specific dyad dimensions or the overall dyad interaction. Several, pre–post differences were found on both parent and child dimension. For parent dimensions, significant differences were found for facial expression and affect, F(2, 14) ! 3.87, p # .05, contingent responsivity, F(2, 14) ! 4.50, p # .05, gaze fixation/aversion, F(2, 14) ! 14.65, p # .05, and tendency to offer guidance, F(2, 14) ! 12.88, p # .05. For child dimensions, significant differences were found for quality of vocalization, F(2, 14) ! 6.44, p # .05, gaze fixation/aversion, F(2, 14) ! 6.25, p # .05, and tendency to accept guidance, F(2, 14) ! 4.71, p # .05. Marginally significant 63 differences were found for proximity/body orientation, F(2, 14) ! 3.53, p # .10. Although some of the differences revealed a linear relationship, such that as time increased scores on the interaction task also increased, several were also curvilinear in nature, such that the highest value occurred during the first posttesting and then decreased by the second posttesting. This finding suggests that for some dimensions (Parent Responsivity and Parent and Child Gaze Fixation) the strongest effects occurred immediately following the intervention and diminished over time. Therapy Sessions Therapy Sessions 1 through 5 were averaged to create a Time 1 point, Sessions 6 through 10 created the Time 2 point, 11 through 16 the Time 3 point, and 16 through 19 the Time 4 point. Sample means for the dimensions for each time period can be found in top section of Table 3. An ANOVA of each time point for the sessions was computed with time (Time 1, Time 2, Time 3, Time 4) as the repeated measure. There was a marginally significant main effect for time for overall score, F(3, 18) ! 4.42, p # .05. Overall session scores increased over time. Table 2 Means and F Values for the MIM at Each Time Frame (n ! 8) MIM Dimension Pretest Posttest 1 Posttest 2 F value Overall Parent Facial expression/Affect Vocalization Proximity Responsivity Gaze fixation Offer guidance Child Facial expression/Affect Vocalization Proximity Responsivity Gaze fixation Accept guidance Task focus Dyad Social Balance Global quality 3.26 3.67 3.76 3.82 3.97 3.93 3.28 3.24 3.02 3.26 2.84 3.11 3.20 2.78 2.71 3.23 3.02 3.10 3.07 2.88 3.52 3.85 3.13 3.90 4.11 4.22 4.15 3.57 3.34 3.65 3.61 3.23 3.23 3.65 3.09 2.93 3.28 3.40 3.17 3.28 3.72 4.03 3.80 3.87 4.30 4.15 3.97 4.08 3.50 3.51 3.67 3.71 3.49 3.30 3.67 3.16 3.61 3.56 3.67 3.59 3.42! 4.04!! 3.87!! ns ns 4.50!! 14.65!! 12.88!! 3.21! ns 6.44!! 3.53! ns 6.25!! 4.71!! ns ns ns ns ns Note. MIM ! Marschak Interaction Method. ! p # .10. !! p # .05. 64 HILES HOWARD, LINDAMAN, COPELAND, AND CROSS Table 3 Means and F Values for the Therapy Sessions at Each Time Frame (n ! 8) This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Sessions Session dimension 1–5 6–10 11–16 16–19 F value Overall Parent Facial expression/Affect Vocalization Proximity Responsivity Offer guidance Child Facial expression/Affect Vocalization Proximity Responsivity Accept guidance Task focus Dyad Social Balance Global quality 3.06 3.45 3.14 3.71 3.95 3.39 3.08 2.89 2.90 3.16 2.48 2.78 2.61 3.42 2.72 3.01 2.89 2.26 3.40 3.93 3.76 3.87 4.13 3.72 4.19 3.17 2.98 3.42 3.16 3.13 3.01 3.32 2.98 3.06 3.36 2.51 3.61 4.10 3.89 3.96 4.22 4.16 4.27 3.42 3.13 3.61 3.63 3.54 3.61 2.99 3.15 3.15 3.79 2.52 3.87 4.33 4.01 4.12 4.13 4.67 4.71 3.69 3.34 3.91 3.76 3.98 3.79 3.34 3.49 3.51 4.34 2.61 3.01! 5.07!! 4.87!! 6.42!! ns 4.21!! 9.76!! 4.91!! ns 5.12!! 3.92!! 3.09! 3.87!! ns 3.01! ns 4.03!! ns ! p # .10. !! p # .05. Further, there was a significant main effect for time for overall parent score, F(3, 18) ! 5.07, p # .05, a significant main effect for time for overall child score, F(3, 18) ! 4.91, p # .05, and a significant marginally main effect for time for overall dyad, F(3, 18) ! 3.01, p # .10. Parent, child, and dyad session scores increased over time. Several, pre–post differences were found on parent, child, and dyad dimensions. For parent dimensions, significant differences were found for facial expression and affect, F(3, 18) ! 4.87, p # .05, contingent responsivity, F(3, 18) ! 4.21, p # .05, quality vocalization, F(3, 18) ! 6.42, p # .05, and tendency to offer guidance, F(3, 18) ! 9.76, p # .05. For child dimensions, significant differences were found for quality of vocalization, F(3, 18) ! 5.12, p # .05, proximity, F(3, 18) ! 3.92, p # .05, and tendency to accept guidance, F(3, 18) ! 3.87, p # .05. Marginally significant differences were found for responsivity, F(3, 18) ! 3.09, p # .10. For dyad dimensions, significant differences were found for balance of control, F(3, 18) ! 4.03, p # .05. Overall scores on the dimensions improved over time. Therapist-Report Evaluations Child Behavior Sheet. Child Behavior Sheets for Sessions 1 through 5 were averaged to create a Time 1 point, Sessions 6 through 10 created the Time 2 point, 11 through 16 the Time 3 point, and 16 through 19 the Time 4 point. Sample means for the Child Behavior Sheets for each time period can be found in top section of Table 4. An ANOVA of each time point for the Child Behavior Sheet was computed with time (Time 1, Time 2, Time 3, Time 4) as the repeated measure. The main effect for time was significant, F(3, 18) ! 8.14, p # .05. Reports of child behavior improved over time. Parent Behavior Sheet. Parent Behavior Sheets for Sessions 1 through 5 were averaged to create a Time 1 point, Sessions 6 through 10 created the Time 2 point, 11 through 16 the Time 3 point, and 16 through 19 the Time 4 point. Sample means for the Parent Behavior Sheets for each time period can be found in Table 4 Means and F Values Therapist Reports for Child and Parent at Each Time-Frame (n ! 8) Sessions Session 1–5 6–10 11–15 16–19 F value Parent Child 1.84 1.94 2.34 2.57 2.73 3.09 2.90 3.45 7.64!! 8.14!! ! p # .10. !! p # .05. THERAPLAY WITH PARENTS AND CHILDREN WITH AUTISM This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. bottom section of Table 4. An ANOVA was computed with time (time-one, time-two, timethree, time-four) as the repeated measure. An ANOVA of each time point for the Parent Behavior Sheet was computed with time (Time 1, Time 2, Time 3, Time 4) as the repeated measure. The main effect for time was significant, F(3, 12) ! 7.64, p # .05. Reports of parent behavior improved over time. Discussion and Implications The goal of the present study was to investigate the efficacy of Theraplay using a sample of children diagnosed with mild to moderate autism. The intervention was evaluated in three respects. First, we observed pre–post changes in quality of parent– child interactions. Second, we observed changes in the parent and child behavior during therapy sessions. Third, we noted therapist-reported changes in the parent and child behavior following each therapy session. Improvements in these three areas across time would suggest that Theraplay was an effective therapeutic technique in this population. Results show that the observed parent– child interactions improved from pre- to postintervention. On a general level, the overall score and the parent and child composite scales improved over time. Specifically, parents demonstrated more affect, were more responsive to their child, maintained better eye contact, and offered more guidance following the intervention. Children were more vocal, maintained closer proximity to their parents, had better eye contact, and were more likely to accept guidance following the intervention. Results of the observed parent and child behavior during the therapy sessions show improvement across sessions. On a general level, the overall score and all three composite scales improved over time. Specifically, parents demonstrated more affect, had more vocalization, were more responsive to their child, and offered more guidance across sessions. Children were more vocal, maintained closer proximity to their parents, were more responsive to their parents, and were more likely to accept guidance across sessions. Further, parent– child dyads had better balance of control across sessions. Therapist reports for both the parents and children showed improvement in behaviors across sessions. Further, these reports closely parallel the observed 65 therapy session data, which was scored by independent blind raters. Taken as a whole, these findings provide support for the use of Theraplay in children with mild to moderate autism. These findings have implications for addressing issues of parenting as well as issues of joint attention in children with ASD. The fact that parents demonstrated a better balance of control is promising as an intervention for parents who typically struggle with an overreliance on controlling discipline strategies (Siller & Sigman, 2002). Parents of children with ASD experience more parenting stress, and the gains found in parental responsivity and guidance as well as child gains in behavior and accepting guidance could alleviate some parenting stress. Creating appropriate discipline structures for children is a challenge for all parents, and for parents of children with ASD, frustration over behavioral, social, and communication issues can intensify parental attempts to control their child’s behavior. Additionally, when parents are stressed and frustrated with their children, their ability to be engaged, attuned, and have insight into their children can be diminished (Aali et al., 2015; Kasari, Freeman, & Paparella, 2006; Wetherby & Woods, 2006). This feedback loop can exacerbate existing challenges for parents of children with ASD. Aspects of joint attention were also improved because of Theraplay. Children with ASD commonly struggle with eye gaze, proximity, and responsiveness, all of which are components of joint attention (Kasari et al., 2006; Wetherby & Woods, 2006). Joint attention has been found to be linked to communication and language delays in children with ASD (Schertz & Odom, 2007; Solomon et al., 2007). Joint attention improves when parents are able to synchronize their behavior to their children. The children’s gains in eye gaze, proximity, and responsiveness demonstrate that Theraplay can help improve some aspects of joint attention. Additionally, one of the goals of Theraplay is for parents to become more attuned, responsive, and engaged with their children, which was demonstrated by the findings of improvement in the parent– child dyad. Joint attention is a dyadic process, and improving a parent’s ability to engage in interactions that promote joint attention is important in improving joint attention in children (Kasari et al., 2006; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Solomon et al., 66 HILES HOWARD, LINDAMAN, COPELAND, AND CROSS 2007 Additionally, the principles of Theraplay can easily be implemented at home without the presence of a therapist, which provides an opportunity for parents and children to continue experiencing the benefits of this intervention after it ends. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Limitations Although the findings are compelling, the current study had several limitations. Although the pre–post design is commonly used, it may be necessary to have comparison groups in the future in order to better evaluate the intervention. Further, these findings need to be replicated using a larger and more diverse sample. This limitation encompasses several issues. One area of potential concern in the current sample is that the participants range in age from 3 to 9. This wide age range raises issues about the varying developmental stages of the participants and the appropriateness of the scoring system utilized. Behaviors that may be appropriate in a preschool-age child (little vocalization or use of short phrases) would be considered extremely inappropriate for a participant in late childhood. Due to the small sample size we were unable to analyze age differences on the individual dimensions. Upon careful examination of the scoring criterion one realizes that the dimension anchors were worded such that they can be generalized across developmental stages, making the wide age range less of a concern. Further, raters were instructed to score behaviors while keeping relative age of the participant in mind. Regardless, future work utilizing a larger sample should investigate potential age differences. Further, the sample consisted primarily of males (2 female, 6 male) and almost exclusively of children of Caucasian descent. Considering the diversity in the population of children diagnosed with autism, future research should focus on obtaining a more representative sample. Conclusion Until recently, Theraplay research has emphasized general clinical populations rather than children with ASD. To our knowledge, this is the first study to examined Theraplay’s impact on both the family and children with ASD using a time series model. 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Promoting social reciprocity and symbolic representation in children with autism spectrum disorders: Designing quality peer play interventions. In T. Charman & W. Stone (Eds.), Social and communication development in autism spectrum disorders: Early identification, diagnosis, and intervention (pp. 180 –218). New York, NY: Guilford Press. Received February 7, 2017 Revision received April 20, 2017 Accepted May 8, 2017 ! School Psychology Quarterly 2016, Vol. 31, No. 4, 478 – 490 © 2016 American Psychological Association 1045-3830/16/$12.00 http://dx.doi.org/10.1037/spq0000157 Family Involvement and Parent–Teacher Relationships for Students With Autism Spectrum Disorders S. Andrew Garbacz, Laura Lee McIntyre, and Rachel T. Santiago This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. University of Oregon Family educational involvement and parent–teacher relationships are important for supporting student outcomes and have unique implications for families of children with autism spectrum disorder (ASD). However, little research has examined child and family characteristics among families of children with ASD as predictors of family involvement and parent–teacher relationships. The present study examined child and family variables that may affect family involvement and parent–teacher relationships for families of children with ASD. Findings suggested (a) parents of children with higher developmental risk reported less family involvement and poorer relationships with their child’s teacher and (b) family histories accessing services predicted family involvement and parent–teacher relationships. Limitations of the current study and implications for science and practice are discussed. Keywords: autism spectrum disorder, family involvement, parent–teacher relationships berd, & Ozsivadjian, 2013; Konst et al., 2014; Ozonoff & Rogers, 2003). Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by pervasive and sustained impairments in social interaction and communication, and restricted, repetitive behaviors, interests, or activities (American Psychiatric Association, 2013). Recent prevalence rate estimates of ASD in the United States indicated 1 in 68 children are affected (Centers for Disease Control & Prevention, 2014). The course, symptom severity, and behaviors can vary widely among individuals with ASD (C. L. Chang, Lung, Yen, & Yang, 2013). Services children with ASD may benefit from include supports for adaptive behavioral needs (Konst, Matson, Goldin, & Rieske, 2014), including social and communication skills (National Research Council, 2001), as well as for hyperactivity and inattention (Kingston, Hib- Service Histories S. Andrew Garbacz, Laura Lee McIntyre, and Rachel T. Santiago, Department of Special Education and Clinical Sciences, University of Oregon. This research was funded in part by a grant from the Fairway Foundation and the National Institutes of Health (R01 HD059838) awarded to Laura Lee McIntyre. Correspondence concerning this article should be addressed to Laura Lee McIntyre, Department of Special Education and Clinical Sciences, 5208 University of Oregon, Eugene, OR 97403-5208. E-mail: llmcinty@uoregon .edu Services for children with ASD often take place in multiple settings, frequently at home and at school (Matson, Mahan, & Matson, 2009). Many families of children with ASD begin to receive services when their child is younger than 3 years old (Friend, 2014). Thus, these families may be involved with the service delivery system for a number of years before their child enters kindergarten. Early intervention services play a critical role in supporting children with ASD (e.g., MacDonald, ParryCruwys, Dupere, & Ahearn, 2014), and family involvement is critical (National Research Council, 2001). Services often continue into elementary school. Compared to children with non-ASD diagnoses, school-age children with ASD are four times more likely to receive services (Mandell, Walrath, Manteuffel, Sgro, & Pinto-Martin, 2005). Given the lifelong course of ASD, individuals with ASD and their families may be involved in one or more service delivery systems for the entirety of the individual’s life (Colver et al., 2013; Marcus, Kunce, & Schopler, 2005). Parents of children with ASD often consider themselves to be the primary care coordinators 478 SCHOOL RELATIONSHIPS FOR CHILDREN WITH ASD This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. for their children, and they face many responsibilities as they navigate the service delivery system (Carbone, Behl, Azor, & Murphy, 2010). For example, many parents implement interventions at home (Knoche et al., 2012). In addition, through interfacing with educators and other professionals, parents form relationships with service providers (Carbone et al., 2010). Family Involvement The importance of family involvement in services is supported by ecological systems theory. Ecological systems theory identifies the important influence the home and other microsystems have on a child (Bronfenbrenner, 1977). Just as children are influenced by their microsystems, they are similarly affected by the interactions between microsystems, in the mesosystem (Bronfenbrenner, 1977). As children with ASD begin elementary school, two forms of mesosystem interactions, family educational involvement (hereinafter referred to as family involvement) and parent–teacher relationships may have an important impact on outcomes for students with ASD. Minke, Sheridan, Kim, Ryoo, and Koziol (2014) defined family involvement as “a multidimensional construct that encompasses parenting behaviors that support children’s learning” (p. 528). Clarke, Sheridan, and Woods (2009) defined parent–teacher relationships as “a child-centered connection between individuals in the home and school settings who share responsibility for supporting the growth and development of children” (p. 61). Family involvement has been associated with a number of positive outcomes for children without ASD, including higher levels of academic achievement (Fan & Chen, 2001; Jeynes, 2011; Kohl, Lengua, & McMahon, 2000; Manz, Fantuzzo, & Power, 2004), lower levels of child problem behavior (Domina, 2005), and increased social– emotional skills (Sheridan, Ryoo, Garbacz, Kunz, & Chumney, 2013). This involvement is unique for families of children with ASD (Zablotsky, Boswell, & Smith, 2012). Given the cross-setting nature of support for children with ASD and the potential for lifelong involvement with service providers, family involvement is likely to increase the effectiveness of treatments (Matson et al., 2009). 479 Parent–Teacher Relationships Parent–teacher relationships have been studied for years (Minke et al., 2014), particularly with regard to areas of relationship tension (Kaplan, 1950). Recently, research has established that quality parent–teacher relationships can support children’s academic and behavioral outcomes (Garbacz, Sheridan, Koziol, Kwon, & Holmes, 2015; Minke et al., 2014) and can be strengthened through family school partnership collaborations (e.g., Garbacz & McIntyre, 2015). For families of children with ASD, parent–teacher relationships are particularly important during the transition from early childhood education to kindergarten, which includes the shift from individual family service plans to individualized education programs (Stoner et al., 2005). Thus, it is important to identify factors that predict family involvement and parent– teacher relationships for families of children with ASD. Factors Associated With Family Involvement and Parent–Teacher Relationships A number of factors influence family involvement and parent–teacher relationships, including child characteristics, maternal education, sources of support, and satisfaction with services. Conceptual work on family involvement suggests that parent beliefs about their role in their child’s education, including decisions about whether to become involved in their education, can include a consideration of their child’s needs (Walker, Wilkins, Daillaire, Sandler, & Hoover-Dempsey, 2005). Indeed, child characteristics (e.g., child behavior) can influence parenting (Marshall, Tilton-Weaver, & Bosdet, 2005; Wang, Dishion, Stormshak, & Willett, 2011). Children with ASD frequently encounter difficulty with developing language and communication skills (National Research Council, 2001) and hyperactivity (Konst et al., 2014). The scope of the child’s adaptive behavior support needs may influence the degree to which families are involved in educational programming. In addition, severity of behavior difficulties (Benson, Karlof, & Siperstein, 2008) and social interaction difficulties (Kasari & Sigman, 1997) among children with ASD may influence family involvement. For example, par- This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 480 GARBACZ, MCINTYRE, AND SANTIAGO ents of children who exhibit behavior problems may be more likely to seek out support from school staff. One parent factor that has been consistently identified as a predictor of family involvement is maternal education, with higher levels of maternal education predicting more family involvement (e.g., Fantuzzo, Tighe, & Childs, 2000). Beyond parent and child characteristics, sources of support and satisfaction with services are important to consider and may influence parent willingness to partner with school professionals in the care of the child. For example, sharing information about ASD may act as a form of social support for families of children with ASD (Dunst, Trivette, & Cross, 1986). With regard to satisfaction, satisfaction with services often differs between families of individuals with ASD and families of individuals with other disabilities (Bitterman, Daley, Misra, Carlson, & Markowitz, 2008), suggesting satisfaction with services is important to consider in children’s education. Satisfaction with the special education eligibility process has been associated with parental collaboration with professionals, a key component of family involvement (Moh & Magiati, 2012). More work is needed to examine the relations between these factors, and family involvement and parent–teacher relationships for families of children with ASD. The Present Study Children with ASD have needs that entail home- and school-based services, rendering coordination and communication across settings as critical. To date, research has not examined child and family characteristics among families of children with ASD as predictors of family involvement and parent–teacher relationships. Furthermore, research is needed that uncovers the influence family histories accessing services has on family involvement and parent–teacher relationships. The present study aims to address those gaps by examining child and family variables that may influence family involvement and parent– teacher relationships. This study is unique in that the sample was recruited when children with ASD were in early childhood (Time 1) and has followed them into elementary school (Time 2). The following research questions are examined: (1) Do child characteristics and fam- ily histories accessing services in early childhood predict family involvement in elementary school? (2) Do child characteristics and family histories accessing services in early childhood predict the parent–teacher relationship in elementary school? (3) What are the relations among maternal education, child characteristics, family histories accessing services, family involvement, and the parent–teacher relationship? Method This study is part of a larger investigation examining child, family, and community variables associated with early identification and treatment of ASD in the northwestern United States. Data for the current study represent a subsample of children and families (N ! 31) who participated in data collection at two time points (Time 1 ! early childhood; Time 2 ! elementary school). At Time 1, eligible children (a) were 6 years old or younger, (b) had a prior diagnosis of an ASD, and (c) lived with their primary caregiver for 1" years. Recruitment of children and families at Time 1 occurred via early intervention and early childhood education programs and developmental evaluation clinics. Interested caregivers responded to invitation letters and contacted the research office. Participants were screened by telephone for eligibility. Approximately 3 years later, families were recontacted and invited to participate in a second interview. We were successful in reaching 60% of the original sample. Of those who could be reached, 86% (n ! 31) agreed to participate in Time 2 data collection. Four declined to participate (n ! 2 out-of-state; n ! 2 too busy). Those who declined to participate did not significantly differ from those who participated at Time 2 on child or family demographic variables collected at Time 1, with the exception of gross annual income. Those who declined to participate at Time 2 reported significantly lower incomes than those chose to participate at Time 2 (t ! #2.06, p ! .04). The 31 children and their caregivers who participated at both time points comprise the sample for the current study. Data at both time points were collected via in-person interviews with parents in the family homes and through a mail-home packet of questionnaires. This study SCHOOL RELATIONSHIPS FOR CHILDREN WITH ASD was approved by the authors’ institutional review board, and participating caregivers provided their informed consent. Caregivers were provided with a small honorarium for their participation ($25 gift card at Time 1 and $50 gift card at Time 2). This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Participants Children were an average of 4.80 years old (SD ! 1.10) at Time 1 and an average of 8 years old (SD ! 1.46) at Time 2. The majority of children (87%) were boys. Approximately 60% of caregivers (n ! 18) reported their child was White/Caucasian, with the remaining children identified as more than one race/ethnicity (n ! 12; 38.7%), or Latino/Hispanic (n ! 1; 3.2%). The child’s mother served as primary caregiver in 97% of families. Table 1 provides demographic data collected at Time 2. Measures Demographics and service history. A family demographics and service history questionnaire was created for this study and comTable 1 Child and Family Demographics of Elementary Sample Demographic N Child age in years, M (SD) 8.00 (1.46) Sex (male) 27 Race White/Caucasian 18 Hispanic/Latino 1 Multiple 12 Grade Kindergarten to 2nd grade 12 3rd to 5th grade 17 Other 2 Currently receive special education 28 Educational setting Regular class 1 80% or more regular class 12 40%–79% regular class 1 Less than 40% regular class 8 Private special school 1 Parentally placed at home 8 Vineland-II standard score, M (SD) 74.39 (10.91) Mother’s employment, % employed 16 Household median income/year in US$ $53,000 Receive state Medicaid program 15 % 87.10 58.10 3.23 38.71 38.71 54.84 6.45 90.32 3.23 38.71 3.23 25.81 3.23 25.81 51.61 48.39 481 pleted as an interview with the primary caregiver at Time 1 and Time 2. A range of child and family demographic questions were included as well as the child’s current educational and therapeutic services. Parents used a 5-point Likert-type scale to report on satisfaction with the child’s current services (1 ! very dissatisfied; 3 ! neutral; 5 ! very satisfied). At Time 1 parents also identified the number of sources of information that they had about autism by endorsing items from a list of nine sources (teachers/school, therapists, pediatrician/ physician, Internet, books/magazines, conferences, autism parent support groups, family members/friends, other parenting groups) plus an additional “other” source. A total sources of information about autism was created by summing the number of sources (possible range 0 –10). Adaptive behavior. Research assistants administered the Survey Interview Form of the Vineland Adaptive Behavior Scales (2nd ed.; Vineland-II; Sparrow, Cicchetti, & Balla, 2005) with the primary caregiver to assess the child’s adaptive functioning in the areas of communication, daily living skills, socialization, and motor skills at both Times 1 and 2. These domains are combined to yield an overall Adaptive Behavior Composite standard score, with a mean of 100 and standard deviation of 15. Strong evidence of reliability and validity exist for this widely used measure of adaptive behavior (Sparrow et al., 2005). Autism symptomatology. Research assistants administered the Childhood Autism Rating Scale (2nd ed.; CARS 2; Schopler, Van Bourgondien, Wellman, & Love, 2010) to rate children’s autism symptoms in 15 areas. Ratings on the CARS-2 are made on a 7-point scale reflecting numerical values of 1 to 4 (higher scores indicate greater impairment). Scores reflect the degree to which the child’s behavior deviates from that of a typically developing child of the same age. Scores on the 15 items are summed to form an overall score ranging from 15 to 60. Internal consistency reliability for the CARS-2 in the present sample was $ ! .87. Problem behavior. Caregiver informants completed the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) to assess problem behavior and prosocial behavior of their child with ASD. The SDQ is a 25-item This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 482 GARBACZ, MCINTYRE, AND SANTIAGO measure assessing both positive and negative attributes. Items form four problem scales: emotional symptoms (5 items), conduct problems (5 items), hyperactivity/inattention (5 items), and peer relationship problems (5 items), and one prosocial behavior scale (5 items). Respondents rate statements about their child on a 3-point scale (0 ! not true; 1 ! somewhat true; 2 ! certainly true). There is strong evidence of reliability and validity for this instrument, and it has been used with a variety of clinical and nonclinical samples worldwide (e.g., Goodman, 1997, 2001; Janssens & Deboutte, 2009), including children with autism spectrum disorders (Iizuka et al., 2010; Jones, Hastings, Totsika, Keane, & Rhule, 2014). In this study we used the overall mean for the hyperactivity/inattention scale ($ ! .56 current sample). Parent–teacher relationship. Parent perceptions of the parent–teacher relationship were examined using the parent version of the Parent–Teacher Relationship Scale—II (PTRS-II; Vickers & Minke, 1995). The PTRS-II includes 24 items (e.g., “We cooperate with each other”) rated on a 5-point scale (1 ! almost never; 5 ! almost always). Two subscales, Joining (n ! 19 items) and Communication (n ! 5), comprise the total score. The PTRS-II total score was used in the present study as an overall mean. Previous investigations have found strong evidence for internal consistency reliability (e.g., $ ! .93; Minke et al., 2014). The internal consistency reliability for the current sample was $ ! .69. Family involvement in education. The Family Involvement Questionnaire—Elementary version (FIQ-E; Manz et al., 2004) was used to measure parents’ involvement in their elementary-aged child’s education. The FIQ-E is a 46-item (e.g., “I volunteer in my child’s classroom”) parent-report of school-based involvement, home-based involvement, and home–school communication. All items are rated on a 4-point scale (1 ! rarely; 4 ! always), indicating the frequency with which parents engage in each behavior or activity. The FIQ-E total score was used in the current sample as an overall mean. Evidence for FIQ-E internal consistency reliability is strong across international samples (e.g., Garbacz, McDowall, Schaughency, Sheridan, & Welch, 2015; Manz et al., 2004). The internal consistency reliability for the current sample was $ ! .94. Data Analysis IBM SPSS Statistics 21 was used for data review and analysis. Descriptive statistics were examined and data were screened and evaluated for common assumptions of multiple linear regression (e.g., normality). In addition, multicollinearity diagnostics were run and examined. Data were deemed acceptable to answer the study research questions. To address Research Question 1, multiple regression was used to examine the prediction of family involvement from child characteristics and family histories accessing services. To address Research Question 2, multiple regression was used to examine the prediction of parent–teacher relationship from child characteristics and family histories accessing services. Multiple regressions for Research Questions 1 and 2 were conducted using an iterative model-building strategy based on Hosmer and Lemeshow (2000) that included considering bivariate correlations (p % .20) and significant predictors. For Research Question 3, Pearson product–moment correlation coefficient analyses were conducted to examine the relation among maternal education, child characteristics, family histories accessing services, family involvement, and the parent–teacher relationship. The value set for statistical significance testing was p % .05. Results Table 2 presents descriptive statistics for study variables. On average, parents reported fairly favorable relationships with their child’s teacher, and moderate involvement with educational activities. Most parents reported high satisfaction with early childhood services and the special education eligibility process. Table 3 presents results for the final multiple regression model that examined the prediction of family involvement. All child characteristic variables (e.g., ASD symptoms) and family histories accessing services (e.g., early childhood satisfaction) were included in the first model. Following the iterative model-building approach, communication, the number of sources of information about ASD, and satisfaction with early childhood services were predictors in the final model. The model was statistically significant, F(3, 21) ! 12.63, p % .05, and accounted for approximately 64% of the variance in family SCHOOL RELATIONSHIPS FOR CHILDREN WITH ASD 483 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Table 2 Descriptive Statistics for Study Variables Variable M (SD) or % Skewness Kurtosis Data wave Maternal educationa Autism spectrum disorder symptomsb Child communicationc Child hyperactivityd Total sources of information about autism spectrum disorder Education eligibility satisfactione Satisfied or very satisfied Early childhood services satisfactionf Satisfied or very satisfied Family involvementg Parent–teacher relationshiph 15.13 (2.32) 35.85 (6.22) 76.94 (18.13) 1.39 (.42) .62 #.61 .43 #.45 #.71 #.15 .63 #.18 2 2 2 2 5.19 (1.70) 3.73 (1.23) 60% 3.77 (1.31) 58% 2.66 (.47) 4.24 (.68) #.19 #.52 #.73 #.91 1 1 #.79 #.27 1 #.58 #.66 #.40 #.29 2 2 a Maternal education measured in total years of education. b Autism spectrum disorder symptoms (measured on the Childhood Autism Rating Scale, 2nd ed.) sum scores range from 15 to 60. c Communication (measured by the Vineland Adaptive Behavior Scales) is a standard score (M ! 100, SD ! 15). d Hyperactivity (measured on the Strengths and Difficulties Questionnaire, Hyperactivity factor) was rated on a 1 (not true) to 3 (certainly true) scale. e Educational eligibility satisfaction was rated on a 1 (dissatisfied) to 5 (very satisfied) scale. f Early childhood services satisfaction was rated on a 1 (dissatisfied) to 5 (very satisfied) scale. g Family involvement (measured on the Family Involvement Questionnaire—Elementary version) was rated on a 1 (rarely) to 4 (always) scale. h Parent– teacher relationships (measured on the Parent–Teacher Relationship Scale—II) was rated on a 1 (almost never) to 5 (almost always) scale. involvement scores (R2 ! .643). Child communication, the number of sources of information about ASD, and satisfaction with early childhood services all significantly predicted family involvement. Standardized beta coefficients, as seen in Table 3, reflect the relative influence of the variables in the model. Satisfaction with early childhood services had the strongest effect, followed by communication, and then the number of sources of information about ASD. All predictors had positive effects, indicating that higher scores on the predictors (e.g., more Table 3 Results of the Multiple Regression Predicting Family Involvement Variable B SE & t Child communication Total sources of information about autism spectrum disorder Early childhood services satisfaction .008 .003 .315 2.31! .085 .038 .300 2.25! .201 .051 .537 3.96! ! p % .05. sources of information about ASD) predicted higher family involvement scores. Table 4 presents results for the final multiple regression model that examined the prediction of parent–teacher relationship. As with the family involvement model, all child characteristics and family histories accessing services were included in the first model. Following the model-building approach, child hyperactivity and satisfaction with the educational eligibility process were predictors in the final model. The model was statistically significant, F(2, 22) ! 8.68, p % .05, and accounted for approximately 44% of the variance in parent–teacher relationship scores (R2 ! .441). Child hyperactivity and Table 4 Results of the Multiple Regression Predicting Parent–Teacher Relationship Variable B SE & t Child hyperactivity Education eligibility satisfaction #1.116 .298 #.674 #3.74! .385 .115 .604 3.36! ! p % .05. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 484 GARBACZ, MCINTYRE, AND SANTIAGO satisfaction with the educational eligibility process significantly predicted parent–teacher relationship. Child hyperactivity had a stronger effect than satisfaction with the educational eligibility process. The child hyperactivity effect was negative, indicating that higher child hyperactivity scores predicted lower parent– teacher relationship scores. In contrast, educational eligibility process satisfaction had a positive effect, indicating that higher satisfaction scores predicted higher parent–teacher relationship scores. Table 5 presents Pearson product–moment correlation coefficients for maternal education, child characteristics, family histories accessing services, family involvement, and the parent– teacher relationship. Child communication, information about ASD, and satisfaction with early childhood services were significantly positively correlated with family involvement. This indicates that as scores on child communication, information about ASD, and satisfaction with early childhood services increase, so did family involvement scores. ASD symptoms was significantly negatively correlated with parent– teacher relationship while child communication was significantly positively correlated with the parent–teacher relationship. This indicates that as children’s ASD symptoms increase, parent report of the parent–teacher relationship decreases. In contrast, as child communication scores increase, parent report of the parent– teacher relationship increases. Maternal education was not significantly correlated with family involvement or the parent–teacher relationship. In addition to relations with family involvement and the parent–teacher relationship, several other important associations emerged. Ma- ternal education was significantly positively correlated with child communication, indicating that more years of maternal education was associated with higher ratings of child communication. In addition, ASD symptoms was significantly positively correlated with child hyperactivity, which suggests children with more ASD symptoms may also be viewed by parents as having higher hyperactivity. Finally, child ASD symptoms was not significantly correlated with the number of sources of information about ASD that parents reported having. Discussion The purpose of this study was to advance the understanding of school experiences and support services for children with ASD through examining child and family variables that may influence family involvement and parent– teacher relationships in elementary school. Children with ASD were first assessed in early childhood, and then approximately 3 years later when they were in elementary school. Thus, snapshots of child and family experiences in early childhood and in early elementary school were ascertained. The majority of children in the sample were boys. On average, children in the sample had mild-to-moderate symptoms of ASD based on the CARS-2. Children’s communication was, on average, nearly 1 standard deviation below the mean. Most parents reported that they were satisfied or very satisfied with their child’s early childhood services. On average, in the present study, parents reported favorable relationships with their child’s teacher (M ! 4.24). This finding is comparable to other descriptive findings with the PTRS-II. For ex- Table 5 Correlations Among Study Variables Variable 1. 2. 3. 4. 5. 6. 7. 8. 9. ! Maternal education Autism spectrum disorder symptoms Child communication Child hyperactivity Information about autism spectrum disorder Education eligibility satisfaction Early childhood satisfaction Family involvement Parent–teacher relationship p % .05. 1 2 3 4 5 6 7 8 9 — #.00 .45! #.14 .05 .07 .02 .00 .10 — #.25 .38! .22 .28 .07 #.13 #.46! — #.35 .13 #.06 .23 .51! .45! — .17 .41! .12 #.19 #.39 — #.10 .16 .43! #.04 — .09 #.24 .29 — .66! .18 — .23 — SCHOOL RELATIONSHIPS FOR CHILDREN WITH ASD This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. ample, a sample of parents who had a child referred for behavioral consultation reported average ratings from 4.41 to 4.43 (Sheridan et al., 2012). While the current study was small in scope, findings may inform implications and directions for future research. The sections that follow include a discussion of the study’s main findings in terms of implications for science and practice. Implications for Science Findings from the present study revealed child and family variables significantly predicted family involvement and the parent– teacher relationship. Findings for child factors indicated that parents of children with higher developmental risk reported less family involvement and poorer relationships with their child’s teacher. Specifically, parents of children with lower communication skills reported less family involvement and parents of children with higher hyperactivity reported poorer relationships with their child’s teacher as compared to parents of children with higher communication skills and lower hyperactivity. This pattern of findings is consistent with other studies that examine the influence of child characteristics. For example, Goldberg and Smith (2014) found that parents who reported negative school contacts (e.g., about child behavior concerns) also reported lower school satisfaction. Family histories accessing services revealed several important findings. Satisfaction with early childhood services and satisfaction with the special educational eligibility process, both assessed at Time 1 in early childhood, explained unique variance on parent report of family involvement and the parent–teacher relationship, respectively. In addition, parent-report of the sources of information they accessed about ASD significantly predicted family involvement. These findings may suggest that a family’s history accessing services and with service providers in early childhood can influence their educational involvement and perceptions of the parent–teacher relationship in elementary school. Prior research has found that parents can play a key role in their young child’s development (Knoche et al., 2012) and form positive relationships with service providers (Carbone et al., 2010). Thus, it may be that a family’s experience with services and service providers in 485 early childhood can prepare them to support their children and develop positive relationships with their teachers into elementary school by educating them on the importance of supportive cross-setting connections. Furthermore, a parent’s competence for supporting their child may improve through these early experiences (cf. Sheridan, Ryoo, Garbacz, Kunz, & Chumney, 2013), which may in turn increase their capability or confidence to partner with their child’s elementary school teachers. The association between maternal education and family involvement and parent–teacher relationship was examined, but no statistically significant findings emerged. This nonsignificant finding is in contrast to a large body of literature that identifies parent education as a potent predictor of family involvement (e.g., Fantuzzo et al., 2000; Kohl et al., 2000; Manz et al., 2004). This may suggest that for parents of children with ASD there are other parent or family factors that are more salient for family involvement. However, the range in the maternal education variable for this sample was somewhat restricted given that 55% of mothers were reported to have between 13 and 15 years of education. Furthermore, the sample size in the current sample is small which may have limited power to detect significance. In addition to the relation between maternal education and family involvement, an interesting finding was observed between ASD symptoms and the total number of sources of information about ASD. In particular, the relation between ASD symptoms and the total number of sources of information was nonsignificant. Although the sample size is small, so these findings are preliminary, this finding is interesting as it could be expected that parents of children with more ASD symptoms would have more sources of information about ASD either provided to them by a provider or independently retrieved as this may serve as a form of social support (Dunst et al., 1986). Alternatively, it may be that they type of information is more important than the total number of sources of information. In the current study all sources of information were treated equally and summed to form a total score. Implications for Practice In this study, parents of children with lower communication skills and higher hyperactivity This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 486 GARBACZ, MCINTYRE, AND SANTIAGO reported less family involvement and poorer parent–teacher relationships than children with higher communication skills and lower hyperactivity. These skills and behaviors are malleable targets for intervention (Goldingay et al., 2015). Family histories accessing services also emerged as significant predictors of family involvement and parent–teacher relationships. Children’s skills and behaviors, and family histories accessing services can be addressed together in two ways. First, parents and early childhood service providers can discuss a family’s interests and needs at the outset of their work and tailor the approach in a manner that addresses the family’s needs to increase overall satisfaction. Second, families of elementary schoolchildren can be engaged in their child’s education in an authentic manner that is linked with their needs. In fact, it has been recommended that school staff reach out to families to lay the foundation of open and trusting family school relationships that serve as the basis for academic and behavior supports for children (Christenson & Reschly, 2009). In turn, these open and trusting relationships can influence family involvement (Santiago et al., 2015). A best practice for addressing children’s behavior and engaging families in educational supports is to use a tiered system of support (McIntyre & Garbacz, 2014). In this manner, children and families are linked with the tier of support for their needs. Findings from the present study have specific implications for Tiers I and III. At Tier I, school behavior support teams, of which school psychologists can be a key member, can engage families in systemslevel planning, and school staff can offer families scoped and sequenced plans for supporting their child’s behavior at home in a manner that is linked with school systems (Garbacz, McIntosh, et al., 2016). In addition, a multiple gating assessment strategy (Dishion & Patterson, 1993) can be embedded at Tier I, but reordered so that families report on child behavior at Gate 1 (Moore et al., in press). School staff could use information obtained from families at Gate 1 to make proactive positive contacts to families. When concerns arise for children, school staff would have information about a broad range of their strengths and needs, as reported by families, which they could use to inform their discussion to address child needs and facilitate collaboration across home and school. This as- sessment approach could increase the quantity of contacts and quality of family school interactions. High-quality interactions have been highlighted as particularly important for healthy family school relationships (Adams & Christenson, 1998). Families of children with ASD benefit from cross-setting supports (Garbacz & McIntyre, 2015). In the present study, parent-report of information about ASD explained unique variance on family involvement. At Tier I, school teams or school psychologists can identify resources for families who have a child with ASD and make them available at the school or at community night events. In this way, school staff can be brokers of information and serve as a clearinghouse for sources of information that can provide access to empirically validated supports in the community. In a climate of thin resources and lean economic times, school staff cannot provide individual support to all families that may benefit. A tiered approach that emphasizes linking home systems with the school and connecting families with community resources can be an efficient and effective way to address the needs of children with ASD and their families. Findings from the present study speak to the important role family histories accessing services can have on family involvement and parent–teacher relationships. Families of children with ASD are involved in their child’s services from a young age (Friend, 2014). Moreover, children with ASD are in need of supports across settings (National Research Council, 2001). Family school partnership interventions can increase parent competence about how to support their child (Sheridan et al., 2013), improve child behavior and parenting skills (Dishion et al., 2008), and enhance the home–school connection (Sheridan et al., 2013). School psychologists are well equipped to use family school partnership interventions for children with ASD who are in need of Tier III support. One family school partnership intervention, the Family Check-Up (FCU; Dishion & Stormshak, 2007), shows particular promise for use with families who have children with ASD. The FCU is a school-based intervention that targets behavior problems, parenting skills, and school skills in students with or at-risk for adjustment or behavioral problems and is informed by an ecological systems perspective. An ecological This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. SCHOOL RELATIONSHIPS FOR CHILDREN WITH ASD model of school adjustment suggests the need for a comprehensive framework of conditions that supports the child during elementary school, including parents and teachers (Mashburn & Pianta, 2006). The FCU has been shown in numerous studies to increase parenting skills and improve academic and social success for typically developing high-risk students across early childhood and adolescence (e.g., H. Chang, Shaw, Dishion, Gardner, & Wilson, 2014; Fosco, Stormshak, Dishion, & Winter, 2012). In brief, the FCU is an assessment driven model that uses family observations, ecological assessments, and tailored strength-based feedback to motivate caregivers to make changes in parenting and engage in family school partnering activities (Dishion & Stormshak, 2007). Although the FCU was not developed for use with families with children ASD, the model seems appropriate for use with this population given its flexible nature and menu of intervention options that can be tailored according to family need. The FCU, one example of family–school partnership intervention, provides a framework for engaging families and schools together as partners and is compatible with other multitiered systems of support (McIntyre & Garbacz, 2014). Limitations and Future Research Directions There were several important findings in the present study, which revealed critical implications for science and practice. These findings and implications should be considered within study limitations, which point to important future research directions. A strength of this study is that data were considered from two different time points. Snapshots in early childhood and 3 years later in elementary school were used. However, this study design precluded an examination of change or growth over time. Future research should seek to use a strong longitudinal design to track growth. In addition, the sample for this study was relatively small. Thus, these findings may not generalize to a large and diverse sample of children and families. Future research should aim to include larger samples of families of children with ASD. Next, parent perceptions were the basis for measurement the study variables. For many of the variables (e.g., satisfaction with early childhood services), this is appropriate. However, future research should 487 include multisource assessments, such as direct observations of child behavior at home and school. Conclusion Family involvement and parent–teacher relationships hold unique importance for families of children with ASD. The present study examined child and family characteristics for families of children with ASD as predictors of family involvement and parent–teacher relationships. Limitations notwithstanding, findings indicated developmental risk and family histories accessing services predicted family involvement and parent–teacher relationships. Findings from the present study ...
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