Behavioural Family Intervention with par
Research in Autism Spectrum Disorders 3 (2009) 702–713
Contents lists available at ScienceDirect
Research in Autism Spectrum
Disorders
Journal homepage: http://ees.elsevier.com/RASD/default.asp
Behavioural Family Intervention with parents of children
with ASD: What do they find useful in the parenting
program Stepping Stones Triple P?
Koa Whittingham *, Kate Sofronoff, Jeanie Sheffield, Matthew R. Sanders
The University of Queensland, Queensland, Australia
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 12 January 2009
Accepted 27 January 2009
This study was conducted in conjunction with a randomised
controlled trial of the parenting program Stepping Stones Triple P
for parents of children with Autism Spectrum Disorders. The
current study concerned examination of the qualitative data arising
from the RCT as well as evaluation of the particular parenting
strategies that the parents found helpful. The results showed that
parents were satisfied with the program, including the partial group
format. Further, the majority of participants found the parenting
strategies within Stepping Stones Triple P to be helpful, including
timeout, physical guidance and blocking. In addition, many of the
parents also used the additional strategies of Comic Strip
Conversations and Social Stories and the majority of the parents
who attempted these strategies found them to be helpful. The
clinical implications of the findings are discussed.
Crown Copyright ß 2009 Published by Elsevier
Ltd. All rights reserved.
Keywords:
Parent training
Behavioural Family Intervention
Autism Spectrum Disorders
Stepping Stones Triple P
Autism Spectrum Disorders, including Autism and Asperger syndrome, are defined by three key
characteristics; social interaction impairments, communication and imagination impairments and
stereotyped interests or behaviours (Gillberg, 2002). The prevalence of emotional and behavioural
disturbance within the ASD population is significantly higher than within the intellectually disabled
population (Brereton, Tonge, & Einfeld, 2006) where it is 2–3 times higher than the normal population
(Einfeld & Tonge, 1996).
* Corresponding author at: Queensland Cerebral Palsy and Rehabilitation Research Centre, Paediatrics and Child Health,
School of Medicine, The University of Queensland, Herston Campus, Brisbane, Queensland 4006, Australia.
Tel.: +61 7 3656 5539; fax: +61 7 3656 5538.
E-mail address: koawhittingham@uq.edu.au (K. Whittingham).
1750-9467/$ – see front matter . Crown Copyright ß 2009 Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2009.01.009
K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
703
1. Parent training and Autism Spectrum Disorders
The treatment of children with ASD has long incorporated the use of specific training programs,
involving the training of parents and others to administer behavioural interventions (Koegel,
Schreibman, Britten, Burke, & O’Neill, 1982). These programs have been developed to treat specific
problems of children with ASD, aiming to improve social behaviour and increase language, as well as
to decrease inappropriate behaviours. Lovaas, Koegel, Simmons, and Long (1973) demonstrated that
training parents as co-therapists produced better outcomes for children with autism at follow-up than
clinic treatment alone.
These specific programs for ASD make use of operant techniques. In spite of the problems that
children with ASD may encounter, the core principles of operant conditioning apply to them, just as
they apply to typical children (Howlin & Rutter, 1987). Howlin and Rutter have themselves effectively
used operant techniques in treating children with autism, including strategies such as time out,
prompting, fading, reinforcement and the pairing of tangible rewards with attention, and note a
significant reduction in maladaptive behaviours in children in their program.
Specific parenting programs have also been successful in helping parents of children with Asperger
syndrome. Sofronoff, Leslie, and Brown (2004) evaluated a parenting program specifically targeting
parents of children with Asperger syndrome. The program included psychoeducation, management of
behaviour problems, routines, special interests and anxiety. Results from parent reports showed a
significant decrease in the number and intensity of problem behaviours and a significant increase in
parental self-efficacy (Sofronoff & Farbotko, 2002).
Although the efficacy of these specific parent training programs in treating children with ASD has
been well documented, little research has been conducted on the experiences of children with ASD
and their parents in standard parenting programs. The current study was conducted in tandem with a
randomised controlled trial of the parenting program Stepping Stones Triple P for the ASD
population.
2. Stepping Stones Triple P
Stepping Stones is a new variant of the Triple P positive parenting program that specifically targets
families of children with disabilities (Sanders, Mazzucchelli, & Studman, 2003). Triple P is a
Behavioural Family Intervention with social learning principles as the theoretical basis (Sanders,
1999). The Triple P approach to parenting focuses on providing children with positive attention and
managing children’s behaviour in a constructive way that does not hurt the child (Sanders et al., 2003).
To this end, the parents are encouraged to develop knowledge, skills and confidence (Sanders, 1999).
Stepping Stones Triple P incorporates standard Triple P strategies and includes additional strategies
arising from the disabilities literature, developed especially for this population (Sanders et al., 2003;
Sanders, Mazzucchelli, & Studman, 2004).
Triple P has an impressive evidence base and has been shown to produce statistically significant
and clinically meaningful decreases in the problem behaviour of children that are maintained over
time (Sanders, 1999; Sanders, Markie-Dadds, Tully, & Bor, 2000). Triple P’s treatment effect has been
replicated in several studies and has been typically associated with high levels of acceptance and
satisfaction on the part of the participating parent (Sanders, 1999). Initial research on Stepping Stones
Triple P demonstrated that it too has a meaningful treatment effect (Roberts, Mazzucchelli, Studman,
& Sanders, 2006). The first randomised controlled trial of Stepping Stones Triple P was conducted with
families of children with disabilities including Down’s syndrome, Cerebral Palsy, other genetic
syndromes, disability due to accident or disease and developmental disability of unknown origin.
Within this trial Stepping Stones Triple P was associated with significant reductions in child problem
behaviours as well as significant improvements in parental styles.
3. The current study
The current study was conducted in tandem with a randomised controlled trial of Stepping
Stones Triple P for the ASD population. This RCT found that Stepping Stones Triple P significantly
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reduced child behaviour problems and dysfunctional parenting styles. The results of the RCT
are discussed in detail elsewhere (Whittingham, Sofronoff, Sheffield, & Sanders, in press). The
current study involves an interpretation of the qualitative data arising from the RCT and an
exploration of which of the Stepping Stones parenting strategies the parents found most useful.
Stepping Stones as delivered in the trial included the strategies of Comic Strip Conversation and
Social Stories (Gray, 1998) and the usefulness of these strategies for parents will also be
considered.
4. Methods
4.1. Design
The treatment group received Stepping Stones Triple P and the wait-list group received Stepping
Stones after the treatment group had completed the program.
4.2. Participants
The participants were parents/carers of a child aged between two and nine (at point of recruitment)
with an Autism Spectrum Disorder. Fifty-nine families participated in total, 29 in the treatment group
and 30 in the wait-list group.
All children included in this study had a primary diagnosis of an Autism Spectrum Disorder from a
paediatrician. A semi-structured diagnostic interview based upon DSM-IV criteria for Autism and
Pervasive Developmental Disorder Not Otherwise Specified and Gillberg’s criteria (Gillberg, 2002) for
Asperger syndrome was used to verify a diagnosis of ASD. Participants were matched for functioning
according to diagnosis and reported language and randomly allocated to the treatment and wait-list
control groups.
No significant differences in demographics were found at pre-intervention between the treatment
and the wait-list groups using Chi-Square tests and t-tests as appropriate. Participant characteristics
are detailed in the following table, Table 1.
4.3. Procedure
The therapists conducting the intervention were all postgraduate students enrolled in the clinical
psychology programe at the University of Queensland. All of the therapists completed a two-day
training workshop in Stepping Stones delivered by an accredited practitioner prior to commencing the
intervention. Therapist adherence to the protocols was also targeted through weekly supervision
sessions with an accredited practitioner. Ethical approval for the study was gained from the University
of Queensland research ethics committee in accordance with the standards required by the National
Health and Medical Research Council of Australia.
4.4. Intervention
The intervention was run in a partial group format. Participants were placed into groups of four or
five, where the target children were at a similar level of functioning. A summary of session content is
found in Table 2.
Group format was used for the sessions that involved teaching parenting strategies and an
individual format for sessions involving observation, practice and feedback. During the fortnight of
practice sessions (sessions five and six) the parents were given one to three individual sessions, as
required to achieve competency (Sanders et al., 2003).
On the basis of information received from a focus group (Whittingham, Sofronoff, & Sheffield,
2006), Comic Strip Conversations and Social Stories (Gray, 1998) were added to the program to
address feature prominent in ASD. A reference table for each of the Stepping Stones Triple P parenting
strategies used in the intervention as well as Comic Strip Conversations and Social Stories is found in
Table 3.
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K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
Table 1
Sample characteristics.
Variables
Age of target child
Sex of the child
Male
Female
Treatment (N = 29)
5.62 (SD = 1.74)
Control (N = 30)
6.20 (SD = 2.04)
Combined (N = 59)
5.91 (SD = 1.90)
24
5
23
7
47
12
Specific diagnosis on the ASD spectrum (reported)
ASD
11
Autism
4
Asperger syndrome
12
ASD-NOS
2
11
4
15
0
22
8
27
2
Current language abilities (for age)
No language
Little language
Verbal
4
7
19
5
13
41
Professional help sought for child emotional or behavioural problems
Not sought
17
Sought
12
17
13
34
25
Current martial status of parents
Married
Defacto
Divorced
Separated
Never married/defacto
21
2
2
3
1
26
2
1
1
0
47
4
3
4
1
Type of family in which child is currently living
Original
Step-family
Sole parent
Extended
Both parents
22
1
5
1
15
27
1
2
0
20
49
2
7
1
35
25
4
1
54
4
1
1
6
22
Relationship of primary participating parent to the child
Mother
29
Father
0
Grandmother (and primary care-giver)
0
4.5. Measures
4.5.1. Family Background Questionnaire
The Family Background Questionnaire consists of demographic data, information on the child’s
disability and contact details (Sanders et al., 2003).
4.5.2. Client Satisfaction Questionnaire
This is an adaptation of the Therapy Attitude Inventory developed by Eyberg (1993, as cited in
Sanders et al., 2003). It measures the quality of service provided, congruency between the program
and the parent’s needs, increased parental skills and decreases in the child’s disruptive behaviours, as
well as whether the parent would recommend the program to others. The measure uses 7-point Likert
scales and a composite score of program satisfaction can be derived (a maximum score of 91 and a
minimum score of 13 are possible). Parents are also asked to provide written comments or suggestions
if they wish.
4.5.3. Strategies Questionnaire
The strategies questionnaire was designed for the study. It consists of a list of the strategies that
were taught in the intervention including Comic Strip Conversations and Social Stories. The
participants were required to indicate whether or not they used each strategy and if they did, whether
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Table 2
Stepping Stones Triple P content.
Week
Format
Topic
Week one: Introduction
Group
Week two: Observation and feedback
Individual
Week three: Promoting children’s
development
Week four: Managing misbehaviour
Group
Group
Week five: Practise
Individual
Week six: Practise
Individual
Week seven: Planned activities training
Group
Week eight: Implementing planned
activities training
Individual
Week nine: closure
Group
The basic principles of positive parenting are introduced
and the parents are taught to monitor their child’s behaviour
An observation of a parent-child interaction is performed
and there is feedback of assessment findings including
the observation, questionnaires and monitoring
The parenting strategies that focus on developing positive
relationships and encouraging desirable behaviour are taught
The parenting strategies that relate to the management of
misbehaviour are taught
The parents are able to set goals and practise specific
parenting strategies in session. Feedback is given.
Implementation of the strategies at home is discussed
The parents are able to set goals and practise specific parenting
strategies in session. Feedback is given. Implementation of
the strategies at home is discussed
The ability to plan for high-risk situations is taught. In addition,
parents are introduced to the strategies of Comic Strip
Conversations and Social Stories. These strategies are not
currently in Stepping Stones Triple P
Planned activities skills are practised with a visit to the clinic
being the high-risk situation. Feedback is given. Implementation
of the strategies at home is discussed
Maintenance of change and family survival tips are discussed
or not they found it helpful. There was also a series of statements about satisfaction with the group
format, to which participants responded on a 5-point Likert scale. The Strategies Questionnaire was
completed at post-intervention and at follow-up six months later.
5. Results
5.1. Parenting strategies used during program delivery
On the Strategies Questionnaire, participants were asked whether they attempted to use each
parenting strategy throughout the program, and if they did attempt the strategy whether it was
helpful. Fig. 1 illustrates usage for the treatment group and the wait-list group (after receiving
treatment) combined. Three participants in the wait-list group elected not to receive Stepping Stones
Triple P and therefore are not included in the analyses (N = 56). From the figure it can be observed that
for each strategy, including the additional strategies of Comic Strip Conversations and Social Stories,
the majority of participants who used a strategy reported that it was helpful.
5.2. Parenting strategies used after completion of program
At follow-up participants were asked which strategies they had used in the six months since
completing the program. If they did use a strategy during that six-month period they were also asked if
they found the strategy helpful. Fig. 2 illustrates those frequencies for the treatment group only
excluding the three participants who did not complete the follow-up (N = 26). For each of the
strategies the majority of participants who attempted the strategy reported that it was helpful.
5.3. Satisfaction ratings
The ratings of Client Satisfaction as measured by the Client Satisfaction Questionnaire (min = 13,
max = 91) were high with a mean rating of 74.25 (SD = 9.98) for the treatment group alone, and a mean
of 73.50 (SD = 10.15) collapsed across the treatment and the wait-list groups (after treatment
K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
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Table 3
Strategies included in the Stepping Stones Triple P parenting program.
Strategy
Developing positive relationships
Spending quality time with children
Communicating with your children
Showing affection
Encouraging desirable behaviour
Using descriptive praise
Giving attention
Providing other rewards
Providing engaging activities
Setting up activity schedules
Teaching new skills and behaviours
Setting a good example
Description
Applications
Spending frequent, brief amounts of time
(as little as 1 or 2 min) involved in
child-preferred activities
Opportunities for parents to
become associated with
rewarding activities and events,
and also for children to share
experiences and practice
conversational skills
Promoting vocabulary,
conversational and social
skills
Opportunities for children
to become comfortable with
intimacy and physical affection
Having brief conversations or interactions
with children about an activity or
interest of the child
Providing physical affection (e.g., hugging,
touching, cuddling, tickling, patting)
Providing encouragement and approval
by describing the behaviour that
is appreciated
Providing positive non-verbal attention
(e.g., smile, wink, stroke on the cheek, pat
on the back, watching)
Providing tangibles desired by the
child (e.g., a toy, mirror, torch,
article of clothing, food) with praise
and attention
Arranging the child’s physical and
social environment to provide
interesting and engaging activities,
materials, and age-appropriate
toys (e.g., board games,
paints, tapes, books, construction toys)
Arranging a series of pictures or words
representing activities that children
can engage in
Demonstrating desirable behaviour
through parental modeling
Using physical guidance
Providing just enough pressure to gently
move a child’s arms or legs through the
motions of a task
Using incidental teaching
Using a series of questions and prompts
to respond to child-initiated interactions
and promote learning
Using verbal, gestural, and manual
prompts to teach new skills
Using ask, say, do
Teaching backwards
Using verbal, gestural, and manual
prompts to teach new skills beginning
with the last steps of the task
Encouraging appropriate
behaviour (e.g., speaking in a
pleasant voice, playing
cooperatively, sharing, drawing
pictures, reading, compliance)
As above
As above – particularly for
children who do not respond
to praise and attention
Encouraging independent play,
promoting appropriate
behaviour when in the
community (e.g., shopping,
travelling)
Prompting participation in the
daily routine of activities
Showing children how to behave
appropriately (e.g., speak calmly,
wash hands, tidy up, solve
problems)
Teaching self-care skills
(e.g., brushing teeth, making
bed) and other new skills
(e.g., playing with toys
appropriately). Also, ensuring
compliance with an instruction
(e.g., ‘‘put your hands down’’)
Promoting language, problem
solving, cognitive ability,
independent play
Teaching self-care skills
(e.g., brushing teeth, making bed)
and other new skills (e.g.,
tidying up)
As above
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Table 3 (Continued )
Strategy
Using behaviour charts
Managing misbehaviour
Using diversion to another activity
Establishing ground rules
Description
Applications
Setting up a chart and providing social
attention and back-up rewards contingent
on the absence of a problem behaviour
or the presence of an appropriate
behaviour
Encouraging children for
appropriate behaviour
(e.g., playing cooperatively,
asking nicely) and for the
absence of problem behaviour
(e.g., tantrums, swearing, hitting)
Using instructions, questions,
and prompts to divert a child who
may soon misbehave
to another activity
Negotiating in advance a set of fair,
specific and enforceable rules
To prevent problem behaviours
(e.g., self-injurious behaviour,
damaging property, running
away)
Clarifying expectations
(e.g., for watching TV, shopping
trips, visiting relatives, going
out in the car)
Correcting occasional rule breaking
(e.g., leaving school bag on floor
in kitchen, running through
the house)
Ignoring attention seeking
behaviour (e.g., answering back,
protesting after a consequence,
whining, pulling faces)
Initiating an activity (e.g., getting
ready to go out, coming to the
dinner table), or terminating a
problem behaviour (e.g., fighting
over toys, pulling hair) and saying
what to do instead (e.g., share,
keep your hands to yourself)
Dealing with noncompliance,
temper outbursts, self-injurious
behaviour, pica
Dealing with noncompliance,
mild problem behaviours that
do not occur often (e.g., not
taking turns)
Dealing with dangerous
behaviour (e.g., reaching for
an iron, running out onto the
road, attempting to hit
themselves) or terminating
a problem behaviour
(e.g., hitting another person)
Dealing with self-injurious
behaviour, repetitive
behaviour, or struggling
during physical guidance
Dealing with noncompliance,
children repeating a problem
behaviour after a logical
consequence
Dealing with children not sitting
quietly in quiet time, temper
outbursts, serious misbehaviour
(e.g., hurting others)
To prevent out-of-home
disruptions (e.g., on shopping
trips, visiting, travelling in a
car, bus, train)
Using directed discussion for
rule breaking
The identification and rehearsal of the
correct behaviour following rule breaking
Using planned ignoring for minor
problem behaviour
The withdrawal of attention whilst the
problem behaviour continues
Giving clear calm instructions
Giving a specific instruction to start a
new task, or to stop a problem behaviour
and start a correct alternative behaviour
Teaching children to communicate
what they want
Teaching a functionally equivalent way
of making needs known or met
Backing up instructions with
logical consequences
The provision of a specific consequence
which involves the removal of an activity
or privilege from the child or the child
from an activity for a set time
Catching or blocking hands, legs to
prevent the completion of a behaviour
Blocking
Using brief interruption
Having a child sit quietly were a problem
has occurred for a set time
Using quiet time for misbehaviour
Removing a child from an activity in
which a problem has occurred and having
them sit on the edge of the activity for
a set time
The removal of a child to an area away
from others for a set time
Using time-out for serious
misbehaviour
Planned activities
Providing engaging activities in specific
high-risk situations
K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
709
Table 3 (Continued )
Strategy
Additional strategies
Social stories
Comic strip conversations
Description
Applications
Facilitation of social
understanding through
the creation of a short
story about a
particular situation
Using simple drawings as
visual supports
to aid conversation
Facilitation of social
understanding
Promoting conversational
and social skills
received). Additionally, the ratings of satisfaction with the partial group format as measured by the
Strategies Questionnaire (min = 5, max = 25) were high with a mean rating of 19.52 (SD = 3.58) for the
treatment group alone and a mean of 19.13 (SD = 3.41) collapsed across the treatment and wait-list
groups.
5.4. Qualitative findings
The Client Satisfaction Questionnaire and the follow-up Questionnaire offered opportunities for
qualitative feedback and this was analysed from the combined group (N = 56). The majority of the
Fig. 1. The number of participants who attempted each of the strategies during the program, grouped according to those who
found the strategy helpful, sometimes helpful and not helpful. Key to strategies utilised:
Number
Strategy
Number
Strategy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Quality time
Communicating with children
Showing affection
Praise
Giving attention
Other rewards
Providing engaging activities
Activity schedules
Setting a good example
Physical guidance
Incidental teaching
Ask, say, do
Teaching backwards
Behaviour charts
15
16
17
18
19
20
21
22
23
24
25
26
27
Diversion
Establishing clear ground rules
Directed discussion
Planned ignoring
Giving clear, calm instructions
Teaching to communicate
Logical consequences
Blocking
Brief interruption
Quiet time
Time out
Comic strip conversations
Social stories
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Fig. 2. The number of participants who attempted each of the strategies at follow-up, grouped according to those who found the
strategy helpful, sometimes helpful and not helpful. For ‘Key to strategies utilised’ see Fig. 1.
feedback was of a positive nature (66.07%). The positive feedback fell into four key themes.
Participants felt that the program was sound, participants reported noticing an improvement in their
child’s behaviour, participants reported improvements in their own parenting skills and confidence
and, finally, participants felt they had established rapport with their therapists. Areas where
participants offered suggestions for improvement included the program having more specific
information about ASD, the program containing more information about promoting emotional
regulation in their children and changes to the format of the program (particularly longer breaks in
between sessions and longer group sessions).
The Client Satisfaction Questionnaire offered participants the opportunity to report other problems
with their child that they felt might be related to the original difficulty. The majority of the
participants (73.21%) answered ‘no’ or left this question blank. The responses were found to contain
three themes: Autistic traits (8.93%), emotional management (7.14%) and continued behaviour
management difficulties (12.5%).
The Strategies Questionnaire offered the participants the opportunity to comment on the partial
group format. The majority of the feedback was positive (87.1%). The positive feedback contained four
key themes. Participants reported desiring more group time, finding the groups supportive,
participants appreciated the opportunity to share ideas with other parents and, finally, participants
reported that they felt understood and that the experience normalised their own difficulties. The only
negative feedback came from a small percentage (6.78%) of parents who were uncomfortable in their
group or with working in groups generally.
6. Discussion
6.1. Strategies used
Participants reported attempting the majority of the strategies during the course of the program
and for each strategy the majority of the parents who attempted a strategy found it to be helpful.
From clinical experience parents of children with ASD frequently report concern about using the
parenting strategy ‘timeout’ with their children. It is thus noteworthy that 75% of parents reported
that they had tried timeout during the program and found it to be helpful. In addition, 68.2% of parents
reported that they had used timeout in the six months following the program and found it to be
helpful. This indicates that the majority of parents of children with ASD can expect to experience
success with the strategy timeout if it is applied correctly and for appropriate behaviours.
Pilot research on the acceptability of Stepping Stones Triple P for parents of children with ASD
indicated that the parents were concerned about the physical contact involved in the strategies of
K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
711
physical guidance and blocking (Whittingham et al., 2006). However, 81.8% of the parents involved in
this study indicated that they had used physical guidance through out the program and found it to be
helpful and 84.5% reported that they had used physical guidance and found it to be helpful by followup. In addition, 64.3% of parents reported that they had used blocking through out the program and
found it to be helpful and 69.2% reported that they had used blocking and found it to be helpful by
follow-up. These results show that, for the majority of parents, concerns about the physical contact
involved in these strategies are unfounded.
Comic Strip Conversations and Social Stories (Gray, 1998) were added to the Stepping Stones Triple
P program as part of Planned Activities Training on the basis of the focus group research (Whittingham
et al., 2006). The majority of parents reported attempting Social Stories in the course of the program
(65.4%) and over half of the parents were using Social Stories at follow-up six months later (53.8%).
Additionally, of the parents who used Social Stories the majority found it to be helpful. Comic Strip
Conversations was attempted by 23.3% of parents during the course of the program and this rose to
38.4% of parents at follow-up six months later. Again, the majority of parents who used Comic Strip
Conversations found it to be helpful. Thus, there appears to be a significant number of parents of
children with ASD who appreciate the opportunity to learn Comic Strip Conversations and Social
Stories and find such strategies useful when implemented. Further use of Comic Strip Conversations
and Social Stories with the ASD population may address the desire of some parents for ASD specific
strategies.
6.2. Parent satisfaction
Overall, the level of participant satisfaction was high and this was demonstrated in the qualitative
feedback. Participants felt that the program was sound, they reported noticing an improvement in
their child’s behaviour, reported that they were now more skilled and confident as parents and finally,
participants wrote notes of thanks and appreciation to their own therapists.
The areas that the parents believed could be improved fell into three areas. Firstly, parents would
like to have a program that was specialised for ASD. Some were concerned that it focussed too much
upon ‘‘normal tendencies’’ of children and expressed a desire to spend more time in session on comic
strip conversations and social stories. One implication of this feedback is that it emphasises the
importance of psychoeducation to enable the parents to understand the relevance of behavioural
management techniques to the ASD child.
Another area raised by parents was their continued concern about the emotional regulation skills
of their child, particularly the role that their child’s anxiety and anger plays in their behaviour. Many of
the Stepping Stones Triple P strategies can be used to foster emotional regulation skills in children
(e.g., rewards for ‘brave’ behaviour). However, this concern demonstrates that some parents may need
particular assistance to understand how the Stepping Stones strategies may be used to improve
emotional regulation skills. It also suggests that some parents may benefit from specific information
about how to foster emotional regulation skills in their child as part of the parenting program. Further
investigation is necessary but Acceptance and Commitment Therapy may provide a promising adjunct
to parenting interventions if this is the case. Lastly, some parents made suggestions for changing the
format of the program. Mostly, this consisted of requesting longer group sessions and/or longer time in
between sessions. It may be that some parents from this population need longer to process the
information and make the parenting changes. Of course, in a normal clinical context this adaptation
could have been made more easily than was possible in a controlled trial. It is also possible that a
better outcome may be achieved by spending more time addressing general parent concerns prior to
commencing the parenting program. This could be achieved by training parents in mindfulness based
strategies via an Acceptance and Commitment Therapy workshop.
6.3. Group format
Overall, the level of satisfaction with the group format was high. Qualitatively, participants
reported several advantages of the group sessions including the ability to share ideas with each other,
increased support, understanding from the other parents and the normalisation of their own
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difficulties. However, a minority of parents reported a negative experience of the partial group format.
This negative experience consisted of either discomfort in group situations or a dislike of the particular
group in which they were placed. Participants who reported disliking their group commented that
their group found it difficult to ‘‘remain focussed in their discussions’’ and one participant simply
commented, ‘‘a strange group’’. Thus, whilst we can conclude that a partial group format is beneficial
to many parents of children with ASD, there is a caveat that practitioners ensure that the group
remains focussed during the session.
Additionally, it may be the case that the presence of autistic traits in some of the parents also
contributed to these less positive experiences. Practitioners working with parents of children with
ASD should be aware that some parents may have autistic traits themselves. This may contribute to
feelings of discomfort or other difficulties in a group situation.
6.4. Limitations and future directions
The parents within this study were highly satisfied with the partial group format. In addition, many
parents used the additional strategies of Comic Strip Conversations and Social Stories and of those that
did use these strategies the majority found them to be helpful. However, it remains to be tested
whether the partial group format and the additional strategies of Comic Strip Conversations and Social
Stories added anything above and beyond the effect of standard Stepping Stones Triple P. Some
parents also desired specific information about how to foster emotional regulation skills in their child.
Future research could explore this further with an Acceptance and Commitment Therapy adjunct to
parent training being one potential way to address this.
6.5. General conclusions
Overall, participants reported a high level of satisfaction with the Stepping Stones Triple P program
and for each strategy the majority of parents who attempted it found it to be helpful, including
timeout and strategies involving physical contact. In addition, it is suggested that some parents may
benefit from learning Comic Strip Conversations and Social Stories. The partial group format was
popular, contributing to feelings of support and normalisation as well as the sharing of ideas, however,
it should be noted that a minority of the parents did not feel comfortable in groups. In addition, parents
of children with ASD may require particular direction about the use of the parenting strategies in
fostering emotional regulation skills in their children.
Acknowledgements
The study was supported by a small grant from the School of Psychology, The University of
Queensland. We would like to acknowledge the participation of the parents who took part in the study
and the clinical interns who helped to conduct the program.
References
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Contents lists available at ScienceDirect
Research in Autism Spectrum
Disorders
Journal homepage: http://ees.elsevier.com/RASD/default.asp
Behavioural Family Intervention with parents of children
with ASD: What do they find useful in the parenting
program Stepping Stones Triple P?
Koa Whittingham *, Kate Sofronoff, Jeanie Sheffield, Matthew R. Sanders
The University of Queensland, Queensland, Australia
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 12 January 2009
Accepted 27 January 2009
This study was conducted in conjunction with a randomised
controlled trial of the parenting program Stepping Stones Triple P
for parents of children with Autism Spectrum Disorders. The
current study concerned examination of the qualitative data arising
from the RCT as well as evaluation of the particular parenting
strategies that the parents found helpful. The results showed that
parents were satisfied with the program, including the partial group
format. Further, the majority of participants found the parenting
strategies within Stepping Stones Triple P to be helpful, including
timeout, physical guidance and blocking. In addition, many of the
parents also used the additional strategies of Comic Strip
Conversations and Social Stories and the majority of the parents
who attempted these strategies found them to be helpful. The
clinical implications of the findings are discussed.
Crown Copyright ß 2009 Published by Elsevier
Ltd. All rights reserved.
Keywords:
Parent training
Behavioural Family Intervention
Autism Spectrum Disorders
Stepping Stones Triple P
Autism Spectrum Disorders, including Autism and Asperger syndrome, are defined by three key
characteristics; social interaction impairments, communication and imagination impairments and
stereotyped interests or behaviours (Gillberg, 2002). The prevalence of emotional and behavioural
disturbance within the ASD population is significantly higher than within the intellectually disabled
population (Brereton, Tonge, & Einfeld, 2006) where it is 2–3 times higher than the normal population
(Einfeld & Tonge, 1996).
* Corresponding author at: Queensland Cerebral Palsy and Rehabilitation Research Centre, Paediatrics and Child Health,
School of Medicine, The University of Queensland, Herston Campus, Brisbane, Queensland 4006, Australia.
Tel.: +61 7 3656 5539; fax: +61 7 3656 5538.
E-mail address: koawhittingham@uq.edu.au (K. Whittingham).
1750-9467/$ – see front matter . Crown Copyright ß 2009 Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2009.01.009
K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
703
1. Parent training and Autism Spectrum Disorders
The treatment of children with ASD has long incorporated the use of specific training programs,
involving the training of parents and others to administer behavioural interventions (Koegel,
Schreibman, Britten, Burke, & O’Neill, 1982). These programs have been developed to treat specific
problems of children with ASD, aiming to improve social behaviour and increase language, as well as
to decrease inappropriate behaviours. Lovaas, Koegel, Simmons, and Long (1973) demonstrated that
training parents as co-therapists produced better outcomes for children with autism at follow-up than
clinic treatment alone.
These specific programs for ASD make use of operant techniques. In spite of the problems that
children with ASD may encounter, the core principles of operant conditioning apply to them, just as
they apply to typical children (Howlin & Rutter, 1987). Howlin and Rutter have themselves effectively
used operant techniques in treating children with autism, including strategies such as time out,
prompting, fading, reinforcement and the pairing of tangible rewards with attention, and note a
significant reduction in maladaptive behaviours in children in their program.
Specific parenting programs have also been successful in helping parents of children with Asperger
syndrome. Sofronoff, Leslie, and Brown (2004) evaluated a parenting program specifically targeting
parents of children with Asperger syndrome. The program included psychoeducation, management of
behaviour problems, routines, special interests and anxiety. Results from parent reports showed a
significant decrease in the number and intensity of problem behaviours and a significant increase in
parental self-efficacy (Sofronoff & Farbotko, 2002).
Although the efficacy of these specific parent training programs in treating children with ASD has
been well documented, little research has been conducted on the experiences of children with ASD
and their parents in standard parenting programs. The current study was conducted in tandem with a
randomised controlled trial of the parenting program Stepping Stones Triple P for the ASD
population.
2. Stepping Stones Triple P
Stepping Stones is a new variant of the Triple P positive parenting program that specifically targets
families of children with disabilities (Sanders, Mazzucchelli, & Studman, 2003). Triple P is a
Behavioural Family Intervention with social learning principles as the theoretical basis (Sanders,
1999). The Triple P approach to parenting focuses on providing children with positive attention and
managing children’s behaviour in a constructive way that does not hurt the child (Sanders et al., 2003).
To this end, the parents are encouraged to develop knowledge, skills and confidence (Sanders, 1999).
Stepping Stones Triple P incorporates standard Triple P strategies and includes additional strategies
arising from the disabilities literature, developed especially for this population (Sanders et al., 2003;
Sanders, Mazzucchelli, & Studman, 2004).
Triple P has an impressive evidence base and has been shown to produce statistically significant
and clinically meaningful decreases in the problem behaviour of children that are maintained over
time (Sanders, 1999; Sanders, Markie-Dadds, Tully, & Bor, 2000). Triple P’s treatment effect has been
replicated in several studies and has been typically associated with high levels of acceptance and
satisfaction on the part of the participating parent (Sanders, 1999). Initial research on Stepping Stones
Triple P demonstrated that it too has a meaningful treatment effect (Roberts, Mazzucchelli, Studman,
& Sanders, 2006). The first randomised controlled trial of Stepping Stones Triple P was conducted with
families of children with disabilities including Down’s syndrome, Cerebral Palsy, other genetic
syndromes, disability due to accident or disease and developmental disability of unknown origin.
Within this trial Stepping Stones Triple P was associated with significant reductions in child problem
behaviours as well as significant improvements in parental styles.
3. The current study
The current study was conducted in tandem with a randomised controlled trial of Stepping
Stones Triple P for the ASD population. This RCT found that Stepping Stones Triple P significantly
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K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
reduced child behaviour problems and dysfunctional parenting styles. The results of the RCT
are discussed in detail elsewhere (Whittingham, Sofronoff, Sheffield, & Sanders, in press). The
current study involves an interpretation of the qualitative data arising from the RCT and an
exploration of which of the Stepping Stones parenting strategies the parents found most useful.
Stepping Stones as delivered in the trial included the strategies of Comic Strip Conversation and
Social Stories (Gray, 1998) and the usefulness of these strategies for parents will also be
considered.
4. Methods
4.1. Design
The treatment group received Stepping Stones Triple P and the wait-list group received Stepping
Stones after the treatment group had completed the program.
4.2. Participants
The participants were parents/carers of a child aged between two and nine (at point of recruitment)
with an Autism Spectrum Disorder. Fifty-nine families participated in total, 29 in the treatment group
and 30 in the wait-list group.
All children included in this study had a primary diagnosis of an Autism Spectrum Disorder from a
paediatrician. A semi-structured diagnostic interview based upon DSM-IV criteria for Autism and
Pervasive Developmental Disorder Not Otherwise Specified and Gillberg’s criteria (Gillberg, 2002) for
Asperger syndrome was used to verify a diagnosis of ASD. Participants were matched for functioning
according to diagnosis and reported language and randomly allocated to the treatment and wait-list
control groups.
No significant differences in demographics were found at pre-intervention between the treatment
and the wait-list groups using Chi-Square tests and t-tests as appropriate. Participant characteristics
are detailed in the following table, Table 1.
4.3. Procedure
The therapists conducting the intervention were all postgraduate students enrolled in the clinical
psychology programe at the University of Queensland. All of the therapists completed a two-day
training workshop in Stepping Stones delivered by an accredited practitioner prior to commencing the
intervention. Therapist adherence to the protocols was also targeted through weekly supervision
sessions with an accredited practitioner. Ethical approval for the study was gained from the University
of Queensland research ethics committee in accordance with the standards required by the National
Health and Medical Research Council of Australia.
4.4. Intervention
The intervention was run in a partial group format. Participants were placed into groups of four or
five, where the target children were at a similar level of functioning. A summary of session content is
found in Table 2.
Group format was used for the sessions that involved teaching parenting strategies and an
individual format for sessions involving observation, practice and feedback. During the fortnight of
practice sessions (sessions five and six) the parents were given one to three individual sessions, as
required to achieve competency (Sanders et al., 2003).
On the basis of information received from a focus group (Whittingham, Sofronoff, & Sheffield,
2006), Comic Strip Conversations and Social Stories (Gray, 1998) were added to the program to
address feature prominent in ASD. A reference table for each of the Stepping Stones Triple P parenting
strategies used in the intervention as well as Comic Strip Conversations and Social Stories is found in
Table 3.
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K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
Table 1
Sample characteristics.
Variables
Age of target child
Sex of the child
Male
Female
Treatment (N = 29)
5.62 (SD = 1.74)
Control (N = 30)
6.20 (SD = 2.04)
Combined (N = 59)
5.91 (SD = 1.90)
24
5
23
7
47
12
Specific diagnosis on the ASD spectrum (reported)
ASD
11
Autism
4
Asperger syndrome
12
ASD-NOS
2
11
4
15
0
22
8
27
2
Current language abilities (for age)
No language
Little language
Verbal
4
7
19
5
13
41
Professional help sought for child emotional or behavioural problems
Not sought
17
Sought
12
17
13
34
25
Current martial status of parents
Married
Defacto
Divorced
Separated
Never married/defacto
21
2
2
3
1
26
2
1
1
0
47
4
3
4
1
Type of family in which child is currently living
Original
Step-family
Sole parent
Extended
Both parents
22
1
5
1
15
27
1
2
0
20
49
2
7
1
35
25
4
1
54
4
1
1
6
22
Relationship of primary participating parent to the child
Mother
29
Father
0
Grandmother (and primary care-giver)
0
4.5. Measures
4.5.1. Family Background Questionnaire
The Family Background Questionnaire consists of demographic data, information on the child’s
disability and contact details (Sanders et al., 2003).
4.5.2. Client Satisfaction Questionnaire
This is an adaptation of the Therapy Attitude Inventory developed by Eyberg (1993, as cited in
Sanders et al., 2003). It measures the quality of service provided, congruency between the program
and the parent’s needs, increased parental skills and decreases in the child’s disruptive behaviours, as
well as whether the parent would recommend the program to others. The measure uses 7-point Likert
scales and a composite score of program satisfaction can be derived (a maximum score of 91 and a
minimum score of 13 are possible). Parents are also asked to provide written comments or suggestions
if they wish.
4.5.3. Strategies Questionnaire
The strategies questionnaire was designed for the study. It consists of a list of the strategies that
were taught in the intervention including Comic Strip Conversations and Social Stories. The
participants were required to indicate whether or not they used each strategy and if they did, whether
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K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
Table 2
Stepping Stones Triple P content.
Week
Format
Topic
Week one: Introduction
Group
Week two: Observation and feedback
Individual
Week three: Promoting children’s
development
Week four: Managing misbehaviour
Group
Group
Week five: Practise
Individual
Week six: Practise
Individual
Week seven: Planned activities training
Group
Week eight: Implementing planned
activities training
Individual
Week nine: closure
Group
The basic principles of positive parenting are introduced
and the parents are taught to monitor their child’s behaviour
An observation of a parent-child interaction is performed
and there is feedback of assessment findings including
the observation, questionnaires and monitoring
The parenting strategies that focus on developing positive
relationships and encouraging desirable behaviour are taught
The parenting strategies that relate to the management of
misbehaviour are taught
The parents are able to set goals and practise specific
parenting strategies in session. Feedback is given.
Implementation of the strategies at home is discussed
The parents are able to set goals and practise specific parenting
strategies in session. Feedback is given. Implementation of
the strategies at home is discussed
The ability to plan for high-risk situations is taught. In addition,
parents are introduced to the strategies of Comic Strip
Conversations and Social Stories. These strategies are not
currently in Stepping Stones Triple P
Planned activities skills are practised with a visit to the clinic
being the high-risk situation. Feedback is given. Implementation
of the strategies at home is discussed
Maintenance of change and family survival tips are discussed
or not they found it helpful. There was also a series of statements about satisfaction with the group
format, to which participants responded on a 5-point Likert scale. The Strategies Questionnaire was
completed at post-intervention and at follow-up six months later.
5. Results
5.1. Parenting strategies used during program delivery
On the Strategies Questionnaire, participants were asked whether they attempted to use each
parenting strategy throughout the program, and if they did attempt the strategy whether it was
helpful. Fig. 1 illustrates usage for the treatment group and the wait-list group (after receiving
treatment) combined. Three participants in the wait-list group elected not to receive Stepping Stones
Triple P and therefore are not included in the analyses (N = 56). From the figure it can be observed that
for each strategy, including the additional strategies of Comic Strip Conversations and Social Stories,
the majority of participants who used a strategy reported that it was helpful.
5.2. Parenting strategies used after completion of program
At follow-up participants were asked which strategies they had used in the six months since
completing the program. If they did use a strategy during that six-month period they were also asked if
they found the strategy helpful. Fig. 2 illustrates those frequencies for the treatment group only
excluding the three participants who did not complete the follow-up (N = 26). For each of the
strategies the majority of participants who attempted the strategy reported that it was helpful.
5.3. Satisfaction ratings
The ratings of Client Satisfaction as measured by the Client Satisfaction Questionnaire (min = 13,
max = 91) were high with a mean rating of 74.25 (SD = 9.98) for the treatment group alone, and a mean
of 73.50 (SD = 10.15) collapsed across the treatment and the wait-list groups (after treatment
K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
707
Table 3
Strategies included in the Stepping Stones Triple P parenting program.
Strategy
Developing positive relationships
Spending quality time with children
Communicating with your children
Showing affection
Encouraging desirable behaviour
Using descriptive praise
Giving attention
Providing other rewards
Providing engaging activities
Setting up activity schedules
Teaching new skills and behaviours
Setting a good example
Description
Applications
Spending frequent, brief amounts of time
(as little as 1 or 2 min) involved in
child-preferred activities
Opportunities for parents to
become associated with
rewarding activities and events,
and also for children to share
experiences and practice
conversational skills
Promoting vocabulary,
conversational and social
skills
Opportunities for children
to become comfortable with
intimacy and physical affection
Having brief conversations or interactions
with children about an activity or
interest of the child
Providing physical affection (e.g., hugging,
touching, cuddling, tickling, patting)
Providing encouragement and approval
by describing the behaviour that
is appreciated
Providing positive non-verbal attention
(e.g., smile, wink, stroke on the cheek, pat
on the back, watching)
Providing tangibles desired by the
child (e.g., a toy, mirror, torch,
article of clothing, food) with praise
and attention
Arranging the child’s physical and
social environment to provide
interesting and engaging activities,
materials, and age-appropriate
toys (e.g., board games,
paints, tapes, books, construction toys)
Arranging a series of pictures or words
representing activities that children
can engage in
Demonstrating desirable behaviour
through parental modeling
Using physical guidance
Providing just enough pressure to gently
move a child’s arms or legs through the
motions of a task
Using incidental teaching
Using a series of questions and prompts
to respond to child-initiated interactions
and promote learning
Using verbal, gestural, and manual
prompts to teach new skills
Using ask, say, do
Teaching backwards
Using verbal, gestural, and manual
prompts to teach new skills beginning
with the last steps of the task
Encouraging appropriate
behaviour (e.g., speaking in a
pleasant voice, playing
cooperatively, sharing, drawing
pictures, reading, compliance)
As above
As above – particularly for
children who do not respond
to praise and attention
Encouraging independent play,
promoting appropriate
behaviour when in the
community (e.g., shopping,
travelling)
Prompting participation in the
daily routine of activities
Showing children how to behave
appropriately (e.g., speak calmly,
wash hands, tidy up, solve
problems)
Teaching self-care skills
(e.g., brushing teeth, making
bed) and other new skills
(e.g., playing with toys
appropriately). Also, ensuring
compliance with an instruction
(e.g., ‘‘put your hands down’’)
Promoting language, problem
solving, cognitive ability,
independent play
Teaching self-care skills
(e.g., brushing teeth, making bed)
and other new skills (e.g.,
tidying up)
As above
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K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
Table 3 (Continued )
Strategy
Using behaviour charts
Managing misbehaviour
Using diversion to another activity
Establishing ground rules
Description
Applications
Setting up a chart and providing social
attention and back-up rewards contingent
on the absence of a problem behaviour
or the presence of an appropriate
behaviour
Encouraging children for
appropriate behaviour
(e.g., playing cooperatively,
asking nicely) and for the
absence of problem behaviour
(e.g., tantrums, swearing, hitting)
Using instructions, questions,
and prompts to divert a child who
may soon misbehave
to another activity
Negotiating in advance a set of fair,
specific and enforceable rules
To prevent problem behaviours
(e.g., self-injurious behaviour,
damaging property, running
away)
Clarifying expectations
(e.g., for watching TV, shopping
trips, visiting relatives, going
out in the car)
Correcting occasional rule breaking
(e.g., leaving school bag on floor
in kitchen, running through
the house)
Ignoring attention seeking
behaviour (e.g., answering back,
protesting after a consequence,
whining, pulling faces)
Initiating an activity (e.g., getting
ready to go out, coming to the
dinner table), or terminating a
problem behaviour (e.g., fighting
over toys, pulling hair) and saying
what to do instead (e.g., share,
keep your hands to yourself)
Dealing with noncompliance,
temper outbursts, self-injurious
behaviour, pica
Dealing with noncompliance,
mild problem behaviours that
do not occur often (e.g., not
taking turns)
Dealing with dangerous
behaviour (e.g., reaching for
an iron, running out onto the
road, attempting to hit
themselves) or terminating
a problem behaviour
(e.g., hitting another person)
Dealing with self-injurious
behaviour, repetitive
behaviour, or struggling
during physical guidance
Dealing with noncompliance,
children repeating a problem
behaviour after a logical
consequence
Dealing with children not sitting
quietly in quiet time, temper
outbursts, serious misbehaviour
(e.g., hurting others)
To prevent out-of-home
disruptions (e.g., on shopping
trips, visiting, travelling in a
car, bus, train)
Using directed discussion for
rule breaking
The identification and rehearsal of the
correct behaviour following rule breaking
Using planned ignoring for minor
problem behaviour
The withdrawal of attention whilst the
problem behaviour continues
Giving clear calm instructions
Giving a specific instruction to start a
new task, or to stop a problem behaviour
and start a correct alternative behaviour
Teaching children to communicate
what they want
Teaching a functionally equivalent way
of making needs known or met
Backing up instructions with
logical consequences
The provision of a specific consequence
which involves the removal of an activity
or privilege from the child or the child
from an activity for a set time
Catching or blocking hands, legs to
prevent the completion of a behaviour
Blocking
Using brief interruption
Having a child sit quietly were a problem
has occurred for a set time
Using quiet time for misbehaviour
Removing a child from an activity in
which a problem has occurred and having
them sit on the edge of the activity for
a set time
The removal of a child to an area away
from others for a set time
Using time-out for serious
misbehaviour
Planned activities
Providing engaging activities in specific
high-risk situations
K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
709
Table 3 (Continued )
Strategy
Additional strategies
Social stories
Comic strip conversations
Description
Applications
Facilitation of social
understanding through
the creation of a short
story about a
particular situation
Using simple drawings as
visual supports
to aid conversation
Facilitation of social
understanding
Promoting conversational
and social skills
received). Additionally, the ratings of satisfaction with the partial group format as measured by the
Strategies Questionnaire (min = 5, max = 25) were high with a mean rating of 19.52 (SD = 3.58) for the
treatment group alone and a mean of 19.13 (SD = 3.41) collapsed across the treatment and wait-list
groups.
5.4. Qualitative findings
The Client Satisfaction Questionnaire and the follow-up Questionnaire offered opportunities for
qualitative feedback and this was analysed from the combined group (N = 56). The majority of the
Fig. 1. The number of participants who attempted each of the strategies during the program, grouped according to those who
found the strategy helpful, sometimes helpful and not helpful. Key to strategies utilised:
Number
Strategy
Number
Strategy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Quality time
Communicating with children
Showing affection
Praise
Giving attention
Other rewards
Providing engaging activities
Activity schedules
Setting a good example
Physical guidance
Incidental teaching
Ask, say, do
Teaching backwards
Behaviour charts
15
16
17
18
19
20
21
22
23
24
25
26
27
Diversion
Establishing clear ground rules
Directed discussion
Planned ignoring
Giving clear, calm instructions
Teaching to communicate
Logical consequences
Blocking
Brief interruption
Quiet time
Time out
Comic strip conversations
Social stories
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K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
Fig. 2. The number of participants who attempted each of the strategies at follow-up, grouped according to those who found the
strategy helpful, sometimes helpful and not helpful. For ‘Key to strategies utilised’ see Fig. 1.
feedback was of a positive nature (66.07%). The positive feedback fell into four key themes.
Participants felt that the program was sound, participants reported noticing an improvement in their
child’s behaviour, participants reported improvements in their own parenting skills and confidence
and, finally, participants felt they had established rapport with their therapists. Areas where
participants offered suggestions for improvement included the program having more specific
information about ASD, the program containing more information about promoting emotional
regulation in their children and changes to the format of the program (particularly longer breaks in
between sessions and longer group sessions).
The Client Satisfaction Questionnaire offered participants the opportunity to report other problems
with their child that they felt might be related to the original difficulty. The majority of the
participants (73.21%) answered ‘no’ or left this question blank. The responses were found to contain
three themes: Autistic traits (8.93%), emotional management (7.14%) and continued behaviour
management difficulties (12.5%).
The Strategies Questionnaire offered the participants the opportunity to comment on the partial
group format. The majority of the feedback was positive (87.1%). The positive feedback contained four
key themes. Participants reported desiring more group time, finding the groups supportive,
participants appreciated the opportunity to share ideas with other parents and, finally, participants
reported that they felt understood and that the experience normalised their own difficulties. The only
negative feedback came from a small percentage (6.78%) of parents who were uncomfortable in their
group or with working in groups generally.
6. Discussion
6.1. Strategies used
Participants reported attempting the majority of the strategies during the course of the program
and for each strategy the majority of the parents who attempted a strategy found it to be helpful.
From clinical experience parents of children with ASD frequently report concern about using the
parenting strategy ‘timeout’ with their children. It is thus noteworthy that 75% of parents reported
that they had tried timeout during the program and found it to be helpful. In addition, 68.2% of parents
reported that they had used timeout in the six months following the program and found it to be
helpful. This indicates that the majority of parents of children with ASD can expect to experience
success with the strategy timeout if it is applied correctly and for appropriate behaviours.
Pilot research on the acceptability of Stepping Stones Triple P for parents of children with ASD
indicated that the parents were concerned about the physical contact involved in the strategies of
K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
711
physical guidance and blocking (Whittingham et al., 2006). However, 81.8% of the parents involved in
this study indicated that they had used physical guidance through out the program and found it to be
helpful and 84.5% reported that they had used physical guidance and found it to be helpful by followup. In addition, 64.3% of parents reported that they had used blocking through out the program and
found it to be helpful and 69.2% reported that they had used blocking and found it to be helpful by
follow-up. These results show that, for the majority of parents, concerns about the physical contact
involved in these strategies are unfounded.
Comic Strip Conversations and Social Stories (Gray, 1998) were added to the Stepping Stones Triple
P program as part of Planned Activities Training on the basis of the focus group research (Whittingham
et al., 2006). The majority of parents reported attempting Social Stories in the course of the program
(65.4%) and over half of the parents were using Social Stories at follow-up six months later (53.8%).
Additionally, of the parents who used Social Stories the majority found it to be helpful. Comic Strip
Conversations was attempted by 23.3% of parents during the course of the program and this rose to
38.4% of parents at follow-up six months later. Again, the majority of parents who used Comic Strip
Conversations found it to be helpful. Thus, there appears to be a significant number of parents of
children with ASD who appreciate the opportunity to learn Comic Strip Conversations and Social
Stories and find such strategies useful when implemented. Further use of Comic Strip Conversations
and Social Stories with the ASD population may address the desire of some parents for ASD specific
strategies.
6.2. Parent satisfaction
Overall, the level of participant satisfaction was high and this was demonstrated in the qualitative
feedback. Participants felt that the program was sound, they reported noticing an improvement in
their child’s behaviour, reported that they were now more skilled and confident as parents and finally,
participants wrote notes of thanks and appreciation to their own therapists.
The areas that the parents believed could be improved fell into three areas. Firstly, parents would
like to have a program that was specialised for ASD. Some were concerned that it focussed too much
upon ‘‘normal tendencies’’ of children and expressed a desire to spend more time in session on comic
strip conversations and social stories. One implication of this feedback is that it emphasises the
importance of psychoeducation to enable the parents to understand the relevance of behavioural
management techniques to the ASD child.
Another area raised by parents was their continued concern about the emotional regulation skills
of their child, particularly the role that their child’s anxiety and anger plays in their behaviour. Many of
the Stepping Stones Triple P strategies can be used to foster emotional regulation skills in children
(e.g., rewards for ‘brave’ behaviour). However, this concern demonstrates that some parents may need
particular assistance to understand how the Stepping Stones strategies may be used to improve
emotional regulation skills. It also suggests that some parents may benefit from specific information
about how to foster emotional regulation skills in their child as part of the parenting program. Further
investigation is necessary but Acceptance and Commitment Therapy may provide a promising adjunct
to parenting interventions if this is the case. Lastly, some parents made suggestions for changing the
format of the program. Mostly, this consisted of requesting longer group sessions and/or longer time in
between sessions. It may be that some parents from this population need longer to process the
information and make the parenting changes. Of course, in a normal clinical context this adaptation
could have been made more easily than was possible in a controlled trial. It is also possible that a
better outcome may be achieved by spending more time addressing general parent concerns prior to
commencing the parenting program. This could be achieved by training parents in mindfulness based
strategies via an Acceptance and Commitment Therapy workshop.
6.3. Group format
Overall, the level of satisfaction with the group format was high. Qualitatively, participants
reported several advantages of the group sessions including the ability to share ideas with each other,
increased support, understanding from the other parents and the normalisation of their own
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K. Whittingham et al. / Research in Autism Spectrum Disorders 3 (2009) 702–713
difficulties. However, a minority of parents reported a negative experience of the partial group format.
This negative experience consisted of either discomfort in group situations or a dislike of the particular
group in which they were placed. Participants who reported disliking their group commented that
their group found it difficult to ‘‘remain focussed in their discussions’’ and one participant simply
commented, ‘‘a strange group’’. Thus, whilst we can conclude that a partial group format is beneficial
to many parents of children with ASD, there is a caveat that practitioners ensure that the group
remains focussed during the session.
Additionally, it may be the case that the presence of autistic traits in some of the parents also
contributed to these less positive experiences. Practitioners working with parents of children with
ASD should be aware that some parents may have autistic traits themselves. This may contribute to
feelings of discomfort or other difficulties in a group situation.
6.4. Limitations and future directions
The parents within this study were highly satisfied with the partial group format. In addition, many
parents used the additional strategies of Comic Strip Conversations and Social Stories and of those that
did use these strategies the majority found them to be helpful. However, it remains to be tested
whether the partial group format and the additional strategies of Comic Strip Conversations and Social
Stories added anything above and beyond the effect of standard Stepping Stones Triple P. Some
parents also desired specific information about how to foster emotional regulation skills in their child.
Future research could explore this further with an Acceptance and Commitment Therapy adjunct to
parent training being one potential way to address this.
6.5. General conclusions
Overall, participants reported a high level of satisfaction with the Stepping Stones Triple P program
and for each strategy the majority of parents who attempted it found it to be helpful, including
timeout and strategies involving physical contact. In addition, it is suggested that some parents may
benefit from learning Comic Strip Conversations and Social Stories. The partial group format was
popular, contributing to feelings of support and normalisation as well as the sharing of ideas, however,
it should be noted that a minority of the parents did not feel comfortable in groups. In addition, parents
of children with ASD may require particular direction about the use of the parenting strategies in
fostering emotional regulation skills in their children.
Acknowledgements
The study was supported by a small grant from the School of Psychology, The University of
Queensland. We would like to acknowledge the participation of the parents who took part in the study
and the clinical interns who helped to conduct the program.
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