Rev J Autism Dev Disord (2018) 5:58–77
https://doi.org/10.1007/s40489-017-0123-3
REVIEW PAPER
Interventions to Promote Well-Being in Parents of Children
with Autism: a Systematic Review
Rebecca Frantz 1 & Sarah Grace Hansen 2 & Wendy Machalicek 3
Received: 25 September 2016 / Accepted: 27 October 2017 / Published online: 28 November 2017
# Springer Science+Business Media, LLC 2017
Abstract Parents of children with autism spectrum disorder
(ASD) experience unique challenges in performing their care-
giving roles, often experiencing greater levels of parental
stress than other parents. A systematic review of the literature
on interventions to improve parental well-being among par-
ents of children with ASD was conducted using three elec-
tronic databases (ERIC, PSYCHINFO, Medline) and a com-
bination of key terms. Forty-one of the included studies were
coded according to participant characteristics, intervention
characteristics, outcome measures, and study quality. The fol-
lowing research questions were examined: (1) What type and
format of interventions have been used to improve parental
outcomes among parents of children with ASD? (2) What
interventions have been most effective in improving parental
outcomes? (3) How strong is the evidence base for interven-
tions aimed at improving parental outcomes? Gaps in the lit-
erature, future directions for research, and implications for
practice will be considered.
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s40489-017-0123-3) contains supplementary
material, which is available to authorized users.
* Sarah Grace Hansen
shansen@gsu.edu
1
Department of Special Education, University of Illinois at
Urbana-Champaign, Champaign, IL 61820, USA
2
Department of Educational Psychology, Special Education and
Communication Disorders, Georgia State University, 852 CEHD, 30
Pryor St., Atlanta, GA 30303, USA
3
Department of Special Education and Clinical Sciences, University
of Oregon, Eugene, OR 97403, USA
Keywords Parental stress . Parental well-being . Caregiver
burden . Parental self-efficacy . Parental depression . Autism
spectrum disorder
Raising a child is uniquely rewarding and challenging for any
parent (Crnic and Greenberg 1990; Cameron et al. 1991). The
unique demands related to the parenting role can often lead to
parental stress (Deater-Deckard 1998; Plant and Sanders
2007). Stressed parents are less able to engage in positive
coping strategies to maintain adaptive family functioning
(Blackledge and Hayes 2006; Higgins et al. 2005). Parent
surveys indicate that the responsibility of caring for a child
may have an additive effect to any other stressors in an adult’s
life. In addition to balancing other social roles and obligations,
parents must cope with the economic and emotional require-
ments of being a parent (Abidin 1990; Deater-Deckard 1998).
Although parents of children with disability note positive
experiences related to raising a child with special needs, par-
ents of children with developmental disabilities experience
higher levels of child-related stress than parents of typically
developing children (Baker et al. 2002; Dumas et al. 1991;
Rodrigue et al. 1990; Tomanik et al. 2004). These parents may
experience additional stress due to unique demands such as
scheduling multiple appointments with various professionals,
having to commit time and energy to parent-implemented in-
tervention, and the economic burden of providing special re-
sources for their child (Lavelle et al. 2014; Sawyer et al. 2010;
Sharpe and Baker 2007).
Parents of children with significant disabilities such as au-
tism spectrum disorder (ASD) face additional challenges not
experienced by other parental groups (Falk et al. 2014). When
compared to parents of typically developing children and chil-
dren with other developmental delays, parents of children with
ASD often experience more parenting stress (Hayes and
Rev J Autism Dev Disord (2018) 5:58–77
Watson 2013; Hoffman et al. 2009; Eisenhower et al. 2005;
Estes et al. 2009; Pisula 2007), higher reported frequencies of
depression and anxiety (Dumas et al. 1991; Eisenhower et al.
2005; Olsson and Hwan 2001), reduced overall well-being
(Blacher and McIntyre 2006), and diminished perceived pa-
rental competency (Hastings and Taunt 2002; Giallo et al.
2013; Kuhn and Carter 2006). Additionally, increased parental
stress tends to be chronic (Dyson 1993; Rodrigue et al. 1990),
negatively impacting overall parental health and well-being.
Moreover, mothers and fathers may experience comparable
levels of stress (Hastings and Brown 2002; Noh et al. 1989),
suggesting that having a child with ASD may significantly
impact both parents.
Comorbid and associated behaviors of an ASD diagnosis
can intensify stress among parents. For example, severe chal-
lenging behaviors have been identified in numerous studies as a
risk factor for parental stress and mental health problems (e.g.,
Baker et al. 2002; Hastings et al. 2006; Lecavalier et al. 2006;
Tomanik et al. 2004; Wolf et al. 1989). Parents have also re-
ported social communication difficulties (Davis and Carter
2008) and restricted and repetitive behaviors (Gabriels et al.
2005) as characteristics contributing to their stress. Mothers
and fathers report elevated stress linked to an inability to relate
to their children (Dyson 1993; Koegel et al. 1992), suggesting
that the characteristic social deficits associated with autism sig-
nificantly impact parents. In addition, children with ASD are at
greater risk for anxiety and depression, especially as they get
older (Leyfer et al. 2006; Mayes et al. 2011; White et al. 2009).
This may be an additional stressor for parents.
The relationship between parental stress and child behavior
appears to be bidirectional (Hastings and Johnson 2001;
Hastings et al. 2006; Neece et al. 2012; Orsmond et al. 2003).
High levels of challenging behavior contribute to increases in
parenting stress over time and high levels of parenting stress
contribute to increases in challenging behavior, implying that
the two variables have a reciprocal effect on each other (Baker
et al. 2002; Hastings and Johnson 2001; Orsmond et al. 2003;
Neece et al. 2012). Parental stress has also been connected to
less positive and sensitive parenting behavior, which is associ-
ated with greater challenging behavior among children (Abidin
1990; Crnic et al. 2005; Deater-Deckard et al. 2006).
Parental stress among parents of children with ASD has
significant clinical and research implications, since it can con-
tribute to potential treatment outcomes (e.g., Davis and Carter
2008; Hastings and Brown 2002; Kuhn and Carter 2006;
Lecavalier et al. 2006; Osborne et al. 2008). In previous re-
search, stress among mothers has been associated with failure
to participate in services (Brinker et al. 1994; Gavidia-Payne
and Stoneman 1997) and fewer beneficial behavioral and de-
velopmental outcomes for children in early intervention pro-
grams (Osborne et al. 2008; Strauss et al. 2012). The relation-
ship between parental well-being and both treatment partici-
pation and adherence is critical to the success of parent-
59
mediated interventions and parent-delivered services (Strauss
et al. 2012).
For the aforementioned reasons, it is critical to target paren-
tal stress in behavioral interventions for children with ASD and
their families. Parents and caregivers are often the most consis-
tent presence in a child’s life and therefore may have the
greatest opportunity to influence the child’s development
(Bruder 2000). Family-centered practices that focus on family
outcomes in addition to child outcomes are associated with
greater engagement with services, family satisfaction with ser-
vices, family well-being, positive parenting practices, and im-
proved health and developmental outcomes for children
(Bailey et al. 2012). However, most behavioral interventions
for children with ASD focus primarily on child outcomes, with
minimal focus on parental outcomes such as stress and depres-
sion (Bailey et al. 1998; Mahoney et al. 1998). Although parent
training has become common practice for providing interven-
tion for children with ASD, the emphasis of this training is
often singularly focused on managing child challenging behav-
ior (Blackeledge and Hayes 2006). These services frequently
center on the child’s support needs, and parents are typically
taught specific strategies to support their child’s development
with emphasis on the core characteristics of the syndrome.
Parent training can lead to modest benefits in reducing parental
stress through support and advice (e.g., Pisterman et al. 1992;
Feldman and Werner 2002; however, most training programs
are not developed to directly target parental outcomes, such as
improved mental health (Dykens and Lambert 2013).
Fortunately, there is a growing body of evidence for inter-
ventions to reduce parental stress and enhance parental well-
being. Previous literature reviews (e.g., Hastings et al. 2006;
Singer et al. 2007) have examined the literature on psycholog-
ical interventions for parents of children with disabilities. For
example, Hastings et al. (2006) considered the evidence for
psychological interventions to remediate stress in parents of
children with disabilities and suggested that standard service
models (i.e., respite care, case management) contribute to de-
creased parental stress. In this selective review, the authors
found the strongest evidence base for cognitive behavioral
therapy (CBT), especially for the reduction of stress in
mothers. Reviewed studies also indicated the possible value
of parent-led support networks. Singer et al. (2007) conducted
a meta-analysis of group intervention research in an effort to
characterize the efficacy of treatments in reducing depressive
symptoms and other forms of psychological distress in parents
of children with developmental disabilities. The authors
suggested that CBT was consistently effective in reducing
parental stress in the six studies reviewed. In addition,
multicomponent interventions were found to be more
effective than behavioral parent training or CBT alone. In
another systematic literature review, Cachia et al. (2016) eval-
uated the efficacy of mindfulness-based interventions for re-
ducing stress and increasing psychological well-being in
60
parents of children with ASD but did not review the evidence
for other types of interventions. To the authors’ knowledge,
there are no current systematic reviews with a more compre-
hensive focus on psychological interventions for parents of
children with autism specifically. Therefore, the purpose of
the present review is to examine the evidence base for any
type of intervention that targets parental well-being as a pri-
mary outcome.
The present systematic literature review addresses the fol-
lowing a priori research questions: (1) What type/format of
interventions has been used to improve parental outcomes
among parents of children with ASD? (2) What interventions
have been most effective in improving parental outcomes
among parents of children with ASD? (3) How strong is the
evidence base for interventions aimed at improving parental
outcomes among parents of children with ASD?
Methods
Search Procedures
The first and second authors conducted systematic searches
using three electronic databases: PsychInfo, Education
Resources Information Center (ERIC), and Medline. First, ex-
ploratory searches were run to gather search terms. The
returned articles were reviewed for common terms, and these
terms were discussed with professionals working with families
with young children with special needs to create the final search
term list. The following search term combinations were en-
tered: (autism, autism spectrum disorder, PDDNOS,
Aspergers) AND (parental stress, parental self-efficacy, mater-
nal stress, paternal stress, maternal depression, paternal depres-
sion, burden). These searches yielded studies that addressed all
types of interventions targeting parental outcomes. The follow-
ing search terms were then added to the above combinations:
(acceptance and commitment therapy, cognitive behavior ther-
apy, mindfulness-based stress reduction, mindfulness, parent
education). These search terms were added to the initial search
terms in an effort to identify any studies that were potentially
missed in the initial search; they were chosen based on explor-
atory searches and discussions with professionals. The term
Bchallenging behavior^ was also added to the previous search
combinations to identify any further studies, since challenging
behavior is commonly associated with parental stress and sev-
eral studies measure both challenging behavior and parental
stress. However, studies did not have to measure challenging
behavior to be included in the present review. The authors did
not restrict the literature search by year to capture a range of
literature in a growing field.
The abstracts of 281 returned studies were read to deter-
mine the research method. Single-case studies, quasi-experi-
mental, and randomized group designs were retained for
Rev J Autism Dev Disord (2018) 5:58–77
further examination of the methods section for determination
of inclusion. Thirty-five studies were retained from the initial
281 studies. An ancestral search of the literature was conduct-
ed with each article to identify additional research for possible
inclusion. The references of all 35 included studies were read
to identify any additional studies. Six studies were identified
through an ancestral search of the literature. A total of 41
studies are included in the current review. Gray literature,
literature reviews, and descriptive studies were not included
in the analysis, but informed the discussion.
Inclusion Criteria
Requirements for inclusion in this review were as follows: (a)
publication in an English language peer-reviewed journal and
(b) included at least one parent of a child with autism spectrum
disorder (birth through 12). The age range of birth through 12
was used to capture the particular stress levels of parents of
young children. Inclusion of an ASD diagnosis or educational
classification was based on the diagnostic criterion outlined in
the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV-TR), which included children with
a diagnosis of Asperger’s syndrome, pervasive developmental
disorder-not otherwise specified (PDD-NOS), and autistic dis-
order, or the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-V). However, this review ex-
cluded participants with a diagnosis of Rett syndrome or
childhood disintegrative disorder (CDD); (c) investigated the
effects of an intervention that aimed to decrease parental stress
and parental depression or improve parental self-efficacy as a
primary outcome; and (d) utilized single-case, quasi-experi-
mental, or randomized group design to evaluate the impact of
the intervention on parent (and where relevant child) out-
comes. All interventions targeting parental outcomes were
included in the current review.
Exclusion Criteria
Studies were excluded based on the following criteria: (a)
reduced parental stress, and/or parental depression and/or pa-
rental self-efficacy were not primary outcome variables, or (b)
studies did not focus on results of an intervention (i.e., were
descriptive or correlational in nature). For example, Lecavalier
et al. (2006) examined the effects of child behavior on care-
giver stress in a sample of children with ASD, but caregiver
stress was examined as a secondary variable. In another study,
the authors examined how child characteristics influence par-
enting behavior and psychological stress among parents of
young children with ASD and other developmental disabil-
ities (Estes et al. 2009). Although maternal stress was mea-
sured as a primary outcome variable, this study did not focus
on the results of an intervention. A total of 246 studies were
Rev J Autism Dev Disord (2018) 5:58–77
excluded. A list of all studies excluded from the final review is
available from the first author upon request.
Coding and Data Extraction
Data was initially extracted by the first author through an
online form created for this review using Qualtrics survey
software. Qualtrics is a platform for survey and questionnaire
design available to students and faculty at REDACTED. The
following variables were extracted: (a) research methodology,
(b) child participant information (i.e., age and diagnosis), (c)
parent participant information (i.e., age, gender, marital status)
and family information (i.e., number of children in the house-
hold, ethnicity), (d) intervention (i.e., type, group or individ-
ual), (e) results (i.e., outcome measures, effect sizes), and (f)
design rigor.
Resulting articles were further categorized by targeted de-
pendent variable and intervention type. Dependent variables
were categorized as (a) parental stress, which included all
studies which measured parent stress or anxiety levels; (b)
parental depression; and (c) parental self-efficacy, which in-
cluded all studies which measured parental self-efficacy or
self-competence. Intervention types were categorized as (a)
behavioral interventions, or interventions using behavioral
teaching strategies (e.g., Early Start Denver Model; CBT);
(b) psychoeducational interventions, defined as interventions
that provide psychoeducational support around the child’s dis-
ability; (c) mindfulness-based interventions (e.g.,
mindfulness-based stress reduction); and (d) interventions that
did not fall under the preceding categories (e.g., massage
therapy).
Additionally, a coding sheet was developed by the first au-
thor to assess the quality and rigor of group (experimental and
quasi-experimental) studies according to What Works
Clearinghouse Design standards (What Works Clearinghouse
2008). No single-case studies were included in the current lit-
erature review. Group design studies were reviewed according
to the following criteria: (a) description of participants, (b) sam-
pling procedures, (c) use of control group, (d) random assign-
ment, (e) identifiable intervention components, (e) description
of treatment conditions, (f) fidelity procedures, (g) appropriate-
ness of measures, (h) appropriateness of data analysis tech-
niques, (i) and effect size. Studies were coded as high quality
if they met all required indicators, acceptable quality if they
met all but two of the required indicators, and does not meet
standards if they did not meet more than two of the required
indicators. A copy of coding procedures is available from the
first author upon request.
Interrater Reliability
The first and second authors independently completed 50% of
database searches previously carried out by the other to obtain a
61
measure of reliability. Reliability was also calculated for coding
surveys for 30% of the included studies resulting in 23 items
where the first and second authors could agree or disagree.
Reliability was calculated by dividing the total number of
agreements by the total number of coded items (agreements +
disagreements) and multiplying by 100 to obtain a percentage.
Reliability for literature searches was 89.4% and reliability for
coding was 93%. Any disagreements were discussed with the
third author and a consensus model was used to determine
inclusion of a study or recoding of extracted data.
Results
Participant Characteristics
The current review includes a total of 2147 parent participants
with 1622 (75.55%) mothers and 525 (24.45%) fathers. The
number of participating mother and father participants was
not reported for 5 of the 41 studies. Twenty-one (1.22%) of
the 41 studies did not report parent age. Of the studies that
reported marital status, 9.16% of parents were single parents.
Over half of the studies (28 studies) did not report information
on marital status. Of the studies that reported number of chil-
dren in the family, there was an average of 1.52 children (range
of 0–6). The number of children in the family was only reported
in 18 of the 41 studies. Participants came from diverse ethnic
backgrounds, with 77.31% white/Caucasian participants. Other
participants were Black/African American, Asian, Hispanic/
Latino, Native American, Hawaiian/Pacific Islander, Middle
Eastern, and East Indian. A few of the reviewed studies only
included participants from specific ethnic backgrounds. For
example, Chiang (2014) only included Chinese American par-
ticipants, Kucuker (2006) only included Turkish participants,
Leung et al. (2013) only included Chinese participants, Magaña
et al. (2015) only included Latino/Hispanic participants, and
Izadi-Mazidi et al. (2015) and McConkey and Samadi (2013)
only included Iranian participants. Race or ethnicity was not
reported in 20 of the 41 studies.
Child participant ages in the reviewed studies ranged from
21 months to 23 years, with a mean age of 5.17 years. Mean
child age or range was not reported in 1 of the 41 studies, but
the methods reported the study included preschool children.
Studies included 77.44% children with ASD. The number or
percentage of children with an ASD diagnosis was not report-
ed for 2 of the 41 studies, although both studies reported that
children with ASD were included. Child and parent character-
istics are reported in Table 1.
Outcome Measures
Data were extracted on the measurement tools used and results
for the following dependent variables: stress/anxiety,
62 Rev J Autism Dev Disord (2018) 5:58–77

Table 1 Parent and child characteristics

Study Child demographics Parent demographics

Intervention Ages % N Role Age

with
ASD

Anclair and Hiltunen, 2014) CBT 12 years 100 1 1 mother 47

Al-Khalaf et al. (2014) Psychoeducational Preschool age 100 10 10 mothers NR
Barlow et al. (2008) Other M = 6.5 years 20 188 165 M = 38
mothers
23 fathers
Barlow et al. (2006) Other M = 6.5 years 17 95 84 mothers M = 38
11 fathers
Bendixen et al. (2011) Behavioral M = 4.41 years 100 38 19 fathers M = 34.75
19 mothers
Benn et al. (2012) MBSR 5–23 years 75 25 23 mothers M = 47
2 fathers
Braiden et al. (2012) Behavioral M = 3 years 100 31 18 mothers NR
13 fathers
Bristol et al. (1993) Behavioral M = 3.82 years 50 28 28 mothers M = 30.47
Budd et al. (2011) Behavioral 5 years 100 1 1 mother NR
Chiang (2014) Psychoeducational 3–11 years 100 11 9 mothers NR
2 fathers
Cullen and Barlow (2004) Other M = 6 years 61.7 79 70 mothers M = 37
9 fathers
Dababnah and Parish (2016) Behavioral M = 3.7 years 100 17 16 mothers NR
1 father
D’Elia et al. (2014) Behavioral M = 4.1 years 100 30 NR NR
Dunn et al. (2012) Other M = 6.5 years 100 20 19 mothers NR
1 father
Dykens et al. (2014) MBSR vs other M = 10.85 years 94 243 243 M = 40.87
mothers
Estes et al. (2014) Behavioral M = 1.75 years 86 82 77 mothers M = 33.8
5 fathers
Farmer and Reupert (2013) Psychoeducational 2 years and older 100 98 63 mothers NR
35 fathers
Ferraioli and Harris (2013) Behavioral vs MBSR 3–18 years 100 15 10 mothers NR
5 fathers
Gika et al. (2012) Other 4.5–17 years 100 11 11 mothers M = 44
Hodgetts and McConnell Behavioral 4–12 years 100 15 10 mothers NR
(2013) 5 fathers
Izadi-Mazidi et al. (2015) CBT M = 7.5 years 100 16 16 mothers M = 37.7
Keen et al. (2007) Behavioral M = 3.05 years 100 76 39 mothers NR
37 fathers
Kirkham et al. (1986) Other 7–9 years NR 4 4 mothers NR
Kucuker (2006) Behavioral M = 3.88 years NR 57 29 mothers M = 31.45
28 fathers
Leung et al. (2013) Behavioral M = 4.17 years 61.7 74 66 mothers NR
8 fathers
Magana et al. (2015) Psychoeducational and M = 5.78 years 100 19 19 mothers M = 33.16
behavioral
McAleese et al. (2014) Psychoeducational and other Majority of children 100 55 NR NR
5–11 years
McAleese et al. (2014) Psychoeducational 3–17 years 100 28 17 mothers Majority of parents
11 fathers 31–50 years
Minjarez et al. (2012) Behavioral M = 3.11 years 94 24 15 mothers NR
9 fathers
Neece (2014) MBSR 2.5–5 years 86 46 33 mothers M = 34.5
13 fathers
Patra et al. (2015) Psychoeducational M = 5.92 years 100 10 NR NR
Samadi et al. (2012) Psychoeducational M = 8.2 years 100 37 24 mothers 54% (30–39)
Rev J Autism Dev Disord (2018) 5:58–77 63

Table 1 (continued)

Study Child demographics Parent demographics

Intervention Ages % N Role Age

with
ASD

13 fathers
Sorfronoff and Farbotko Behavioral M = 8 years 100 89 45 mothers NR
(2002) 44 fathers
Suzuki et al. (2014) Psychoeducational M = 4.4 years 100 72 72 mothers M = 35.14
Tellegan and Sanders (2014) Behavioral M = 6.7 years 100 64 61 mothers M = 38.35
3 fathers
Todd et al. (2010) Other M = 7 years NR 22 19 mothers NR
3 fathers
Tonge et al. (2006) Behavioral and other M = 3.88 years 100 105 NR NR
Williams et al. (2005) Other M = 7 years 18.3 80 76 mothers M = 38
4 fathers
Whitney and Smith, 2015 Other Majority 3–18 years 52.2 156 156 M=1
mothers
Whittingham et al. (2009) Behavioral M = 5.9 years 100 58 54 mothers NR
4 fathers
Wong and Kwan (2010) Behavioral M = 2.21 years 100 17 NR NR

depression, and self-efficacy. The dependent variables for
each individual study are reported in Table 2.
Stress Thirty-two studies examined parent stress. Eleven differ-
ent measurement tools were used across studies. The Parental
Stress Index-Short Form (PSI-SF; Abidin 1990) was the most
commonly used measure (52.38% of studies). The PSI-SF is a
screener for dysfunctional parent-child stress or relationship fac-
tors, including parent behavior problems and child adjustment
problems. One study (i.e., Dykens et al. 2014) used this measure
to assess outcomes of a randomized control trial comparing a
mindfulness-based stress reduction (MBSR) program to a posi-
tive psychology-based practice. Five studies (i.e., Barlow et al.
2006; Barlow et al. 2008; Cullen and Barlow 2004; Todd et al.
2010; Williams et al. 2005) used the Hospital Anxiety and
Depression Scale (HADS; Zigmond and Snaith 1983), a 14-
item questionnaire used to determine the levels of anxiety and
depression. For example, Barlow et al. (2006) used the HADS to
assess the outcomes of a randomized control trial evaluating
massage therapy.
depressive symptoms designed for use by the general popula-
tion. For example, Magana et al. (2015) used the CES-D in a
quasi-experimental design to evaluate the effects of a
psychoeducational and behavioral intervention.
Parental Self-Efficacy Studies that measured self-efficacy (or
self-competence) measured parents’ perceived ability to deal
with the everyday challenges of parenting, as well as their
perceptions of competence in the delivery of specific interven-
tions. Fifteen of the included studies examined parental self-
efficacy, all using a range of tools. One tool, the Parental
Sense of Competence Scale (PSOC; Gibaud-Wallston and
Wandersmann 1978) was used in three studies (i.e., Dunn
et al. 2012; Estes et al. 2014; Keen et al. 2007). The PSOC
looks at two dimensions of parenting, satisfaction and effica-
cy. One study (i.e., Estes et al., 2014) used this scale to exam-
ine changes in perceptions of self-efficacy after intervention
with a parent-implemented ESDM intervention.
Interventions

Depression Seventeen of the included studies measured par-
ent depression as a dependent variable. Eight different mea-
sures were used across studies. Three studies used the HADS
(i.e., Barlow et al. 2006, 2008; Todd et al. 2010), previously
described above. For example, Todd et al. (2010) used the
HADS in a quasi-experimental design to evaluate the effects
of CBT and behavioral intervention. Three of the studies (i.e.,
Brinker et al., 1994; Magana et al. 2015; Neece 2014) used the
Center for Epidemiological Studies Depression scale (CES-D;
Radloff 1977). The CES-D is a short self-assessment for
Interventions were delivered through various formats.
Individual format interventions were delivered to one or both
parents at a time, and group format interventions were deliv-
ered to a larger group of parents. Some interventions used both
a group and individual format, usually consisting of group
sessions followed by individual sessions. Of the interventions
included in this review, 47.60% used an individual format,
35.71% used a group format, and 16.69% used both a group
and individual format. One study (i.e., Bristol et al. 1993) did
not specify the type of intervention format used. A variety of
64 Rev J Autism Dev Disord (2018) 5:58–77

Table 2 Intervention characteristics and outcome measures

Study Intervention type Format Dosage Measures Outcomes

Anclair and CBT Individual 18 (1-h) sessions Shirom-Melamed Burnout Reduced symptoms of depression
Hiltunen Questionnaire (SMBQ)
(2014)
Al-Khalaf Psychoeducational Group 4 (4-h) sessions Parenting Stress Index (PSI) Statistically significant reductions
et al. Coping Strategy Indicator in parental stress
(2014) (CSI) Statistically significant increases in
parents’ coping skills
Barlow et al. Other/massage therapy Individual 8 (1-h) sessions Hospital Anxiety and Significant improvements in
(2006) Depression Scale (HADS) anxiety and depressive
symptoms
Barlow et al. Other/massage therapy Individual 8 (1-h) sessions HADS No significant improvements in
(2008) Generalized Self-Efficacy anxiety and depressive
Scale (GSES) symptoms
Parent’s Self-Efficacy Scale Significant improvements in
(PSES) parental self-efficacy
Bendixen Behavioral Individual 2 sessions Parenting Stress Index-Short No statistically significant
et al. Form (PSI-SF) improvements in parental stress
(2011) Significant decreases in stress at
follow-up
Benn et al. Mindfulness Group 10 sessions PSS State Subscale of the Significant decreases in anxiety
(2012) State-Trait Anxiety postintervention and follow-up
Inventory for Adults Significant decreases in depression
(STAI) Everyday Parenting postintervention but not
Scale follow-up
Braiden et al. Behavioral Individual 10 (2–3-h) sessions PSI No significant increases in parent
(2012) self-efficacy
Significant decreases in parental
stress
Bristol et al. Behavioral Individual NR Community Epidemiologic Significant reduction in depressive
(1993) Depression Scale (CES-D) symptoms
Budd et al. Behavioral Individual 13 (90-min) sessions PSI-SF Significant decreases in parental
(2011) stress
Chiang Psychoeducational Group 10 (120-min) sessions World Health Organization Significant improvements in
(2014) Quality of Life parental stress and depression
Questionnaire (WHOQOL)
Cullen and Other/massage therapy Individual 8 (1-h) sessions HADS Significant improvement in parental
Barlow anxiety and depression
(2004)
Dababnah Behavioral Individual 12 (2-h) sessions PSI Significant decreases in parental
and Parish stress
(2016)
D’Elia et al. Behavioral Individual 3 sessions (duration NR) PSI Significant decreases in parental
(2014) stress
Dunn et al. Other/occupational Individual 10 (1 h) sessions PSI-SF Significant decreases in parental
(2012) therapy Parenting Sense of stress
Competence Scale (PSOC) Significant increases in parental
self-efficacy
Dykens et al. Mindfulness vs Group 6 (1.5 h) sessions Beck Depression Inventory Significant reduction in depression
(2014) psychotherapy (BDI) and anxiety for both groups
Beck Anxiety Inventory(BAI) following intervention and
PSI follow-up
Mothers participating in
psychotherapy had greater
improvements in depressive
symptoms than mothers
participating in MBSR
Estes et al. Behavioral Individual 13 (1-h) sessions Questionnaire on Resource Significant decreases in parental
(2014) and Stress (QRS-F) PSOC stress
No significant improvements in
self-efficacy
Farmer and Psychoeducational Group 6 (2-h) sessions Self-constructed Significant reduction in parental
Reupert questionnaire/Likert scale anxiety
(2013) Significant increase in parental
confidence
Group 8 (2-h) session PSI-SF
Rev J Autism Dev Disord (2018) 5:58–77 65

Table 2 (continued)

Study Intervention type Format Dosage Measures Outcomes

Ferraioli and Behavioral vs Significant decrease in parental

Harris mindfulness stress among participants in
(2013) MBSR group
Gika et al. Other/progressive Individual 4 sessions PSI-SF Significant decrease in parental
(2012) muscle relaxation stress
Hodgetts and Behavioral Individual 10 (1-h) sessions Depression-Anxiety Stress Significant improvement in parental
McConne- Scale (DASS) well-being
ll (2013) Parental Self-Efficacy Significant increase in parental
Questionnaire self-efficacy
Izadi-Mazidi CBT Group 7 (90-min) PSI-SF Significant decrease in parental
et al. sessions stress
(2015)
Keen et al. Behavioral Group/individual 2-day group PSI Significant decrease in parental
(2007) vs individual workshop and 10 home-based PSOC stress
consultations vs 6 weeks Increase in self-efficacy among
individual use of instruc- parents in professional supported
tional DVD and workbook intervention compared to
self-directed video-based inter-
vention
Kirkham Other Group 8 (2-h) sessions QRS-F Decreased stress for 3 of 4
et al. participants
(1986)
Kucuker Behavioral Individual 2 h/week for 4 weeks QRS-F No significant decrease in parental
(2006) BDI stress for mothers or fathers
Significant decrease in depression
for both mothers and fathers
Leung et al. Behavioral Group 8 (2-h) sessions and 2 PSS Significant decrease in parental
(2013) follow-up phone sessions stress
Magana et al. Psychoeducational and Individual 8 (2-h) sessions Caregiver burden, satisfaction, No significant improvement in
(2015) behavioral and efficacy scale (i.e., depression and caregiver burden
Likert scale w/ 20 items) Significant improvement in parental
from Heller et al. (1999) self-efficacy
and
CES-D
McAleese Psychoeducational and Group 3 (3-h) sessions Wright and Williams Significant increase in parental
et al. other/psychotherapy Questionnaire (2007) self-efficacy
(2014)
McConkey Psychoeducational Group 3 (60–90-min) sessions PSI Significant decrease in parental
and stress immediately following
Samadi intervention but not at 3 months
(2013) follow-up
Minjarez Behavioral Group 10 (90-min) sessions PSI Significant decrease in parental
et al. Family Empowerment stress
(2012) Scale Significant decrease in parental
self-efficacy
Neece (2014) Mindfulness Group 8 (2-h) sessions CES-D Significant decrease in depressive
PSI symptoms
Significant decrease in parental
stress
Patra et al. Psychoeducational Group 12 (2-h) sessions Family interview for stress Significant decrease in parental
(2015) and coping in mental stress
retardation (Likert scale)
developed for study
Samadi et al. Psychoeducational Group and 7 (60–90-min) sessions GHQ Significant improvement in parental
(2012) individual stress with maintenance at
follow-up
Sorfronoff Behavioral Group vs 1-day group workshop vs 6 Self-constructed, 15-item Significant increase in self-efficacy
and individual individual sessions BParental Self-Efficacy in for both group and individual
Farbotko Management of Asperger participants
(2002) Syndrome Questionnaire^
Suzukiet al. Psychoeducational Group 4 (120-min) sessions GHQ-28 No significant improvement in
(2014) depressive and anxiety
symptoms
Behavioral Individual 4 (15–105-min) sessions
66 Rev J Autism Dev Disord (2018) 5:58–77

Table 2 (continued)

Study Intervention type Format Dosage Measures Outcomes

Tellegan and Depression, Anxiety and Significant improvement in parental

Sanders Stress Scales-21 anxiety and stress
(2014) (DASS-21) Parenting Scale No significant improvement in
parental depression
Significant increase in parenting
confidence
Todd et al. CBT and behavioral Group 9 or 10 (2-h) sessions HADS Significant reduction in parental
(2010) Behavior Management depression
Questionnaire (BMQ) Significant reduction in parental
anxiety
Significant improvement in parental
self-efficacy
Tonge et al. Behavioral vs Individual and 20 (90-min small group) ses- GHQ-28 No significant difference in parental
(2006) other/psychotherapy group sions and 10 (60-min) depression between groups
family sessions immediately following treatment
Significant improvement in parental
depression for both groups at
follow-up
Greater improvement in anxiety for
the psychotherapy group in
comparison to the behavioral
group
Williams Other/massage therapy Individual 8 (2-h) sessions HADS Significant improvement in
et al. PSES depressive symptoms and parental
(2005) stress
Significant improvement in parental
self-efficacy
Whitney and Other/online journal Group 8 (15-min) sessions PSI Significant increase in parental
Smith writing self-efficacy
(2015)
Whittingham Behavioral Individual and 9 sessions Being a Parent Scale Significant increases in parental
et al. group self-efficacy
(2009)
Wong and Behavioral Individual 10 (30-min) sessions PSI-SF Significant reductions in parental
Kwan stress
(2010)

different interventions were used to target parent outcomes,
including psychoeducational programs, CBT, mindfulness-
based stress reduction, behaviorally based programs, and
others. Intervention type and format for each individual study
is reported in Table 2.
Psychoeducational Programs Psychoeducational programs
were defined as any programs that provide parents with
psychoeducational information, support, and problem solving
specifically around the child’s disability. For example, a
psychoeducational intervention might educate parents on the
symptoms of ASD (e.g., social communication difficulties) and
provide suggestions for parents on responding to child symptoms.
Nine of the included studies, representing 340 parents, mea-
sured the effectiveness of psychoeducational programs on im-
proving parental outcomes (i.e., Al-Khalaf et al. 2014; Chiang
2014; Farmer and Reupert 2013; Magana et al. 2015; McAleese
et al. 2014; McConkey and Samadi 2013; Patra et al. 2015;
Samadi et al. 2012; Tonge et al. 2006). For example, Al-
Khalaf et al. (2014) examined the effects of a psychoeducational
program on decreasing parental stress and improving coping
skills among mothers of children with ASD in Jordan. The
psychoeducational program included 4-h sessions each week
for 4 weeks delivered by a licensed psychologist at a private
center for children with disabilities. The program was designed
to help mothers understand their child’s behaviors (e.g., rigid
and repetitive behaviors and communication difficulties) and
focused on generating strategies to cope with typical daily
events specific to raising a child with ASD. Chiang (2014) ex-
amined the effects of a psychoeducational program on decreas-
ing parenting stress and increasing parental confidence and qual-
ity of life among parents of Chinese American children with
ASD. The psychoeducational program involved ten weekly
group sessions. During each 120-min session, the first author
lectured on one of ten topics chosen based on parents’ interests
and facilitated group discussions and role plays connected to
weekly topics. Farmer and Reupert (2013) examined the effects
of a group psychoeducational program on parental stress and
self-efficacy among parents of children with ASD in rural
Australia. The 6-week program included 2-h weekly sessions
Rev J Autism Dev Disord (2018) 5:58–77
focused on information about ASD, behavioral differences and
practical strategies for raising a child with ASD. Program infor-
mation was presented using multiple media and a 72-page man-
ual. Participants were encouraged to share their stories, listen to
others, and provide mutual support.
Findings from studies evaluating the outcomes of
psychoeducational interventions reflect promising results for
remediating parental stress and improving self-efficacy. Seven
studies evaluated the impact of psychoeducational interven-
tions on parental stress (i.e., Al-Khalaf et al. 2014; Chiang
2014; McConkey and Samadi 2013; Patra et al. 2015;
Samadi et al. 2012; Suzuki et al. 2014). Six (85.71%) of these
studies reported significant decreases in parental stress. Four
studies evaluated the impact of psychoeducational interven-
tions on parental self-efficacy (i.e., Chiang 2014; Farmer and
Reupert 2013; Magaña et al., 2015; McAleese et al. 2014) and
all four studies reported significant increases in parental self-
efficacy. Only two studies examined the impact of a
psychoeducational intervention on depression among parents
(i.e., Magaña et al., 2015; Suzuki et al. 2014). Both studies
reported no significant decreases in parental depression.
Cognitive Behavioral Therapy Cognitive behavioral inter-
ventions were defined as interventions that include behavior
analytic perspectives on thought processes, with a focus on
understanding the relationship between thoughts, behaviors,
and feelings. CBT is designed to teach individuals to modify
dysfunctional patterns of thinking in order to improve coping
skills (National Association of Mental Illness [NAMI], n.d.).
For example, a psychologist employing CBT would teach a
parent to distinguish between different emotions, identify au-
tomatic thoughts (i.e., thoughts and feelings that enter the
mind automatically in response to external events), and link
thoughts to emotions and behavior. The psychologist would
teach parents how to engage in more adaptive and positive
alternatives to negative thoughts and modify problematic core
beliefs about themselves or the world (e.g., challenging the
belief, BI am a bad mother^).
Three of the reviewed studies, representing 17 parents,
used CBT to improve parental well-being in parents of chil-
dren with ASD (i.e., Anclair and Hiltunen 2014; Izadi-Mazidi
et al. 2015; Todd et al. 2010). For example, Anclair and
Hiltunen (2014) examined the use of CBT for remediating
stress-related problems in a mother of a 12-year-old child with
ASD. The treatment included eighteen 1-h sessions and treat-
ment targets were individualized based on presenting prob-
lems and assessment, with a focus on exhaustion, depression,
and sleeping difficulties. Izadi-Mazidi et al. (2015) examined
the effects of group CBT on parenting stress in mothers of
children with ASD. The intervention consisted of seven 90-
min sessions with individual and group activities. Educational
techniques such as role playing, group discussion, and home-
work assignments were used. In another study, Todd et al.
67
(2010) examined the effects of a group-based intervention
on depression, anxiety, and self-efficacy in parents of children
with disabilities. The program consisted of nine or ten 2-h
sessions co-facilitated by a clinical psychologist and commu-
nity nurses or specialist teachers. The program incorporated
CBT and behavioral techniques. In addition to learning strat-
egies for managing child behavior and facilitating child com-
munication, parents learned CBT strategies for managing pa-
rental stress. Parents were taught through modeling, home
practice, problem-solving, and role play.
Findings from studies evaluating the effects of participating
in CBT indicate promising findings regarding decreases in
stress and depressive symptoms and increases in self-
efficacy among parents of children with ASD. Two studies
(Izadi-Mazidi et al. 2015) evaluated the impact of CBT on
parental stress and both studies reported significant decreases
in parental stress. Two studies examined the impact of CBT on
parental depression (Anclair and Hiltunen 2014; Todd et al.
2010) and both studies reported significant decreases in de-
pression. Only one study (Todd et al. 2010) examined the
impact of CBT on parental self-efficacy and reported signifi-
cant increases in parental self-efficacy.
Mindfulness-Based Interventions Mindfulness-based inter-
ventions teach and promote the practice of Bmindfulness,^ or
Bpaying attention in a particular way: on purpose, in the pres-
ent moment, and nonjudgmentally^ (Kabat-Zinn 1994, p. 4)
throughout daily activities and routines. In application to par-
ents of children with ASD, mindful parenting involves paying
attention in an intentional and nonjudgmental way to one’s
own parenting behavior (Beer et al. 2013). Mindfulness-
based interventions teach parents to adjust negative thought
patterns related to how they organize and interpret their expe-
riences, while engaging in a compassionate approach to self-
reflection and parenting (Cachia et al. 2016).
Three of the 41 studies, representing 329 parents, examined
the effects of mindfulness-based interventions on parent out-
comes (i.e., Benn et al. 2012; Dykens et al. 2014; Ferraoli and
Harris 2013; Neece 2014). For example, Benn et al. (2012)
examined the effects of mindfulness training on anxiety and
depression among parents and educators of children with spe-
cial needs. They used a manualized instructional curriculum
(SMART-in-Education) developed by the Impact Foundation
(Cullen and Wallace 2010). The curriculum includes practices
from the MBSR program developed by Kabat-Zinn and
Santorelli (1999) and includes additional content focused on
emotion theory and regulation, forgiveness, kindness and
compassion, and application of mindfulness to parenting and
teaching. The program included ten 2.5-h group sessions and
home practice. Mindfulness practices included mental training
exercises, daily sitting practice, and monitoring emotional and
behavioral responses. Parents experienced significant de-
creases in anxiety immediately following intervention and at
68
later follow-up. Parents also experienced significant decreases
in depression immediately following intervention, but not at
later follow-up. Dykens et al. (2014) compared the effects of a
MBSR program to a positive adult development program
(PAD; positive psychology practice) on parent stress, depres-
sion, anxiety, sleep, and well-being. There were a total of six-
weekly group sessions. Each 1.5-h session, led by peer men-
tors, focused on teaching specific breathing, meditation, and
movement techniques. Parents in both intervention groups
experienced significant decreases in depression and anxiety
immediately following intervention and at later follow-up. In
another study, Neece (2014) examined the effects of a group
MBSR program on parent depression and stress. The program
consisted of eight 2-h sessions. The intervention followed the
manual outlined by Kabat-Zinn and Santorelli (1999). It
consisted of didactic material, group and individual mindful-
ness exercises, and group discussion or discussion in pairs.
Parents experienced significant decreases in depressive symp-
toms and parental stress following intervention.
Findings from studies evaluating the effects of participating
in mindfulness-based interventions indicate promising find-
ings regarding decreases in parental stress and depression.
Four studies (i.e., Benn et al. 2012; Dykens et al. 2014;
Ferraoli and Harris 2013; Neece 2014) examined the impact
of mindfulness-based interventions on parental stress. All four
studies reported significant decreases in parental stress. Three
studies (i.e., Benn et al. 2012; Dykens et al. 2014; Neece
2014) examined the impact of mindfulness-based interven-
tions on depression. All three studies reported significant de-
creases in depressive symptoms among parents. There are no
studies included in this review that examined the impact of
mindfulness-based interventions on parental self-efficacy.
Behaviorally Based Programs Behaviorally based programs
included interventions that trained parents to use behavior
analytic teaching strategies to manage their child’s behavior.
Behaviorally based interventions included unpackaged behav-
ioral parent training programs (i.e., Bendixen et al. 2011;
Ferraoli and Harris 2013; Keen et al. 2007; Magaña et al.,
2015; Sorfronoff and Farbotko 2002) and packaged interven-
tions including the TEACHH Autism Program (i.e., D’Elia
et al. 2014), Parent Child Interaction Therapy (i.e., Budd
et al. 2011), the Early Start Denver Model (i.e., Estes et al.
2014), the Stepping Stones Triple P Program (i.e., Hodgetts
and McConnell 2013; Whittingam et al. 2009), the Small
Steps Early Intervention Program (i.e., Kucuker 2006), the
Triple P Positive Parenting Program (i.e., Leung et al. 2013),
the Primary Care Stepping Stones Triple P Program (i.e.,
Tellegan and Sanders 2014), and pivotal response training
(i.e., Minjarez et al. 2012).
Nineteen of the 41 studies, representing 840 parents, eval-
uated the effects of behaviorally based interventions on paren-
tal outcomes (i.e., Bendixen et al. 2011; Braiden et al. 2012;
Rev J Autism Dev Disord (2018) 5:58–77
Bristol et al. 1993; Budd et al. 2011; Dababnah and Parish
2016; D’Elia et al. 2014; Estes et al. 2014; Ferraoli and Harris
2013; Hodgetts and McConnell 2013; Keen et al. 2007;
Kucuker 2006; Leung et al. 2013; Magaña et al. 2015;
Sorfronoff and Farbatko 2002; Tellegan and Sanders 2014;
Todd et al. 2010; Tonge et al. 2006; Whittingham et al.
2009; Wong and Kwan 2010). In one study, Braiden et al.
(2012) examined the effects of a TEACCH-based Early
Intervention Program on parental stress and self-efficacy
among parents of children with ASD. The intervention was
a 10-week program consisting of one-to-one support sessions
with an accredited TEACCH facilitator. Sessions focused on
teaching parents to understand their child’s autism and imple-
ment behaviorally based methods to support their child’s self-
help and independence, play, and early social skills. Estes
et al. (2014) examined the effects of parent-implemented
Early Start Denver Model (ESDM) on parental stress and
self-efficacy in parents of young children with ASD. Parents
participated in thirteen 1-h individual, center-based sessions
and were taught principles associated with ESDM (i.e.,
Dawson et al. 2010), including gaining the child’s attention,
principles of behavior change, and language facilitation
strategies within daily activities and routines. In another
study, Whittingham et al. (2009) examined the effects of the
Stepping Stones Triple P program (SSTP) on stress and de-
pressive symptoms among parents of children with ASD.
SSTP focuses on teaching parents to provide their child with
positive attention and consider the function of the child’s be-
havior to appropriately adapt parenting practices. The inter-
vention included a group format of six sessions that involved
teaching parenting strategies and an individual format of three
sessions involving observation practice and direct feedback.
Behaviorally based interventions show promising findings
for remediating parent stress and depression, as well as
remediating parental self-efficacy. Eighteen of the included
studies examined the impact of behaviorally based interven-
tions on parental stress and 89.47% of those studies found
significant reductions in parental stress. Fourteen of the in-
cluded studies examined the impact of behaviorally based
interventions on parental depression and 92.85% of those
studies found significant decreases in parental depression.
Eighteen studies examined the impact of behaviorally based
interventions on parental self-efficacy and all 18 studies found
significant increases in parental self-efficacy.
Other Interventions Other interventions were categorized as
any interventions that did not fit into any of the previously
described categories. Several other types of interventions were
used to promote positive parental outcomes, including parent
training in massage therapy (i.e., Barlow et al. 2006, 2008;
Cullen and Barlow 2004), contextual intervention based in
occupational therapy (i.e., Dunn et al. 2012), progressive mus-
cle relaxation (i.e., Gika et al. 2012), psychotherapeutic
Rev J Autism Dev Disord (2018) 5:58–77
intervention (Dykens et al. 2014; Kirkham et al. 1986;
McAleese et al. 2014; Tonge et al. 2006), and online journal
writing (Whitney and Smith 2015). Eleven studies,
representing 815 parents, examined the effects of other inter-
ventions on parental outcomes.
Participation in psychotherapy has promising outcomes
among parents of children developmental disabilities, including
reduced stress and depression and increased self-efficacy. Four
studies examined in this review examined the impact of various
types of psychotherapy on parental outcomes (Dykens et al.
2014; Kirkham et al. 1986; McAleese et al. 2014; Tonge et al.
2006). All four studies examined the impact of psychotherapy on
parental stress and reported significant decreases in parental
stress. One study (i.e., Tonge et al. 2006) compared psychother-
apy with behavioral parent management training and reported
greater decreases in parental stress among parents participating
in psychotherapy compared to behavioral parent management
training. Two studies (i.e., Dykens et al. 2014; McAleese et al.
2014) examined the impact of psychotherapy on depressive
symptoms among parents and both studies reported significant
decreases in depressive symptoms. In addition, (Dykens et al.
2014) reported greater decreases in depressive symptoms among
parents participating in psychotherapy based in positive psychol-
ogy compared to parents participating in MBSR. Two studies
(Kirkham et al. 1986; McAleese et al. 2014) examined the impact
of psychotherapy on parental self-efficacy and reported signifi-
cant increases in parental self-efficacy.
Studies included in this review suggest promising out-
comes for parents that have participated in massage therapy,
including reduced parental stress and depression and in-
creased self-efficacy. Four studies examined the influence of
massage therapy on parental outcomes (i.e., Barlow et al.
2006, 2008; Cullen and Barlow 2004; Williams et al. 2005)
among 442 parents of children with developmental disabil-
ities. All four studies examined the effects of massage training
on parental stress and depression. Three studies (75%) report-
ed positive outcomes and one study (i.e., Barlow et al. 2008)
did not report significant improvements in parental stress or
depression. Two studies examined the effects of massage
training on self-efficacy (i.e., Cullen and Barlow 2004;
Barlow et al. 2008) and both studies reported significant im-
provements in self-efficacy.
Only one study included in this review examined the out-
comes of training parents in an intervention based on occupa-
tional therapy (i.e., Dunn et al. 2012). This study examined the
effects of participation in the intervention on parental stress
and self-efficacy among 20 parents of children with ASD. The
authors reported significant reduction in parental stress and
significant increases in self-efficacy.
Only one study in this review examined the impact of pro-
gressive muscle relaxation training on parent outcomes (i.e.,
Gika et al. 2012). This study evaluated the effects of progres-
sive muscle relaxation training on parental stress among 11
69
parents of children with ASD. The authors reported significant
decreases in parental stress.
Only one study in this review examined the impact of on-
line journal writing (i.e., Whitney and Smith 2015) on parents
of children with developmental disability. This study exam-
ined the impact of online journal writing on parental self-
efficacy among 156 mothers of children with developmental
disabilities. The authors reported significant increases in pa-
rental self-efficacy.
Study Rigor and Effect Size Reporting
Since over half (71.43%) of the included studies used a quasi-
experimental research method, few studies met quality stan-
dards. Only one of the included studies (2.45%) received a
rating of high quality, seven studies (17.07%) were found to
be of acceptable quality, and the remaining 33 studies (80.5%)
were rated does not meet standards. A small number (19.51%)
of the included studies reported effect size. Using Cohen’s stan-
dards for effect size calculation, a small effect is 0.2, a medium
effect is 0.5, and a large effect is 0.8 or higher (Cohen 1977).
Three of these studies (19.04%) reported a small effect size, one
study (12.50%) reported a medium effect size, two studies
(25%) reported large effect sizes, and two studies (25%) report-
ed medium to large effect sizes. Most studies measured multiple
dependent variables and, so in some cases, reported different
effect sizes within the same study.
Regarding the effectiveness of psychoeducational interven-
tions, only one study (Chiang 2014) reported effect sizes. The
mean effect size was 0.91, indicating a large effect size.
Regarding the effectiveness of behavioral interventions, four
studies reported effect sizes (i.e., Braiden et al. 2012; Dababnah
and Parish 2016; Leung et al. 2013; Tellegan and Sanders 2014).
The mean effect size for behavioral interventions is 0.54, indicat-
ing a medium effect. Regarding the effectiveness of CBT, none
of the included studies reported effect sizes. Regarding the effec-
tiveness of mindfulness-based interventions, two studies reported
effect sizes (i.e., Neece 2014; Dykens et al. 2014). The mean
effect size for mindfulness-based interventions was 0.84, indicat-
ing a large effect. Regarding the effectiveness of other interven-
tions, effect sizes were reported for one study examining the
effects of massage therapy (i.e., Barlow et al. 2006). The mean
effect size for massage therapy was 0.21, indicting a small effect.
Reported effect sizes, rigor of research, and design of studies are
available in Table 3.
Overall, studies examining the effects of behaviorally
based interventions and mindfulness-based interventions on
parental outcomes were of the highest quality. With regard
to studies examining the effects of psychoeducational inter-
ventions on parental outcomes, 100% of studies did not meet
standards. With regard to studies examining the effects of
CBT on parental outcomes, 100% of studies did not meet
standards. With regard to studies examining the effects of
70
Table 3 Study, design, and
quality and effect sizes Study
Anclair and Hiltunen (2014)
Al-Khalaf et al. (2014)
Barlow et al. (2006)
Barlow et al. (2008)
Bendixen et al. (2011)
Benn et al. (2012)
Braiden et al. (2012)
Bristol et al. (1993)
Budd et al. (2011)
Chiang (2014)
Cullen and Barlow (2004)
Dababnah and Parish (2016)
D’Elia et al. (2014)
Dunn et al. (2012)
Dykens et al. (2014)
Estes et al. (2014)
Farmer and Reupert (2013)
Ferraioli and Harris (2013)
Gika et al. (2012)
Hodgetts and McConnell (2013)
Izadi-Mazidi et al. (2015)
Keen et al. (2007)
Kirkham et al. (1986)
Kucuker (2006)
Leung et al. (2013)
Magana and Lopez (2015)
McAleese et al. (2014)
McConkey and Samidi (2013)
Minjarez et al. (2012)
Neece (2014)
Patra et al. (2015)
Reed et al. (2013)
Samadi et al. (2012)
Sorfronoff and Farbotko (2002)
Suzuki et al. (2014)
Tellegan and Sanders (2014)
Todd et al. (2010)
Tonge et al. (2006)
Williams et al. (2005)
Whitney and Smith (2015)
Whittingham et al. (2009)
Wong and Kwan (2010)
mindfulness-based interventions on parental outcomes, 50%
of studies did not meet standards and 50% of studies were of
acceptable quality. With regard to studies examined the effects
of behaviorally based interventions on parental outcomes,
63.15% of studies did not meet standards, 31.58% of studies
were of acceptable quality, and 5.27% were of high quality.
With regard to studies examining the effects of other interven-
tions on parental outcomes, 90% of studies did not meet stan-
dards and 10% were of acceptable quality.
Discussion
The current literature review provides a comprehensive and
critical examination of the existing research on all types of
Rev J Autism Dev Disord (2018) 5:58–77
Design Tau-u/effect sizes d Quality
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Randomized group design 0.12–0.30 Acceptable quality
Randomized group design Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Randomized group design Not reported Acceptable quality
Quasi-experimental 2 = 0.41 Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental 0.88–1.0 Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental 0.79 Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Randomized group design 0.81–0.98 Does not meet standards
Randomized group design Not reported Acceptable quality
Quasi-experimental Not reported Does not meet standards
Randomized group design Not reported Acceptable quality
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Randomized group design 0.43 Acceptable quality
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental 0.70–0.87 Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Quasi-experimental Not reported Does not meet standards
Randomized group design 0.16–0.91 High quality
Quasi-experimental Not reported Does not meet standards
Randomized group design Not reported Acceptable quality
Quasi-experimental Not reported Does not meet standards
Randomized group design Not reported Does not meet standards
Randomized group design Not reported Acceptable quality
Randomized group design Not reported Acceptable quality
interventions targeting the improvement of parental outcomes
in parents of children with ASD, including depression, paren-
tal stress, and parental self-efficacy. Due to the increased like-
lihood of experiencing stress among parents of children with
ASD and the bidirectional relationship between parent and
child outcomes, it is vital to target parental well-being of par-
ents of children with ASD. This review identified 41 studies
evaluating different types of interventions for remediating pa-
rental stress and/or depression and/or improving parental self-
efficacy. Our findings suggest a variety of future research
questions related to our a priori research questions: (a) What
type/format of interventions has been used to improve parental
outcomes among parents of children with autism spectrum
disorder (ASD)? (b) What interventions have been effective
in improving parental outcomes among parents of children
Rev J Autism Dev Disord (2018) 5:58–77
with autism spectrum disorder (ASD)? (c) How strong is the
evidence base for interventions aimed at improving parental
outcomes among parents of children with ASD? (d) What are
the gaps in the literature, future directions for research, and
implications for clinical practice?
Several different interventions were represented in the cur-
rent review, including psychoeducational programs, CBT,
mindfulness-based interventions, behaviorally based interven-
tions, and other interventions including massage therapy, psy-
chotherapeutic intervention, occupational therapy-based inter-
vention, online journal writing, and progressive muscle relax-
ation therapy. Behaviorally based interventions were the most
commonly evaluated (19 studies), followed by psycho edu-
cational interventions (nine studies) and mindfulness-based
interventions (five studies). Interventions included both indi-
vidual and group formats, with a majority of studies examin-
ing the effects of interventions delivered to a group of parents.
Many of the studies included in this review found positive
effects on parental outcomes, including depression, parental
stress, and parental self-efficacy. Some studies (i.e., eight stud-
ies) did not find positive effects for some parental outcomes
(i.e., Barlow et al. 2008; Bendixen et al. 2011; Braiden et al.
2012; Estes et al. 2014; Kucuker 2006; Magana et al. 2015;
Suzuki et al. 2014; Tellegan and Sanders 2014; Tonge et al.
2006). For example, Estes et al. (2014) found significant im-
provements in parental stress, but no significant improve-
ments in parental self-efficacy, and Suzuki et al. (2014) did
not find any significant improvements in depression or
anxiety.
Only eight studies reported effect size. In a previous meta-
analysis on interventions targeting parental stress as a primary
or secondary variable (Singer et al. 2007), the weighted effect
size of included interventions was 0.29, indicating small effects,
reflecting the overall efficacy of interventions. In regard to the
current review, effect sizes reported for psychoeducational in-
terventions were large, effect sizes reported for behavioral in-
terventions were medium, effect sizes reported for mindfulness-
based interventions were large, and effect sizes reported for
massage therapy were small. However, not enough studies re-
ported effect sizes to adequately compare the effectiveness of
intervention types.
Overall, the results of this review indicate that there are
promising interventions to support parents of children with
ASD. However, researchers and clinicians should interpret
these findings with caution. The majority of studies included
in this review used a quasi-experimental research design;
therefore, inferences about the functional relation between
the intervention and the dependent variables cannot be defin-
itively made. Over half of the included studies (76.19%) did
not meet standards of rigor as coded according to What Works
Clearinghouse Standards (2008); therefore, the strength of the
findings is compromised. For example, many of the included
studies lacked important demographic data and information
71
about intervention components, weakening their rigor. Of fur-
ther importance, only three of the studies (i.e., Estes et al.
2014; Magana et al. 2015; Tellegan and Sanders 2014) mea-
sured and reported adequate treatment fidelity. Without strong
treatment fidelity, it is unclear whether changes in outcomes
were the result of the intervention or some other variable, such
as increased time for a parent to emotionally process an ASD
diagnosis or make positive adaptations to family functioning.
Few intervention studies have targeted parent outcomes and
even fewer studies have evaluated specific interventions such
as MBSR or CBT. The narrow breadth of extant research
limits the findings. Nevertheless, a majority of the research
included in this review was published within the last ten years
(i.e., 2006–2016). This may reflect a promising shift in focus
toward emphasizing parent outcomes among families of chil-
dren with ASD.
Limitations
The present literature review has several limitations. The in-
cluded studies evaluated several different types of interven-
tions, but due to the limited available research on similar in-
terventions, the authors are unable to compare the effective-
ness of the various types of interventions. For example, there
is not enough evidence to determine whether CBT or MBSR is
more effective at improving parental well-being. Additionally,
the authors included articles that met specific inclusion
criteria, including children birth–12 years with a diagnosis of
ASD. Although all of the included studies included partici-
pants that met this criteria, several of the studies also included
participants that did not meet the aforementioned criteria. The
authors were unable to extract data for individual participants,
and overall data may not accurately reflect data for the spec-
ified population of interest. However, most of the participants
from the included studies met the inclusion criteria, with
77.44% of participants with an ASD diagnosis and a mean
age of 5.7 years.
Future Directions for Research
Although this review included 2147 parents across 41 studies,
few studies met criteria for rigorous experimental research.
Therefore, more research is clearly needed to determine the
effectiveness of interventions to promote parental well-being
among parents of children with ASD. Future studies should
utilize randomized control group designs and incorporate
measurement of treatment fidelity to improve rigor, thereby
strengthening the available evidence for the effectiveness of
interventions on improving parental outcomes. Additionally,
the reporting of essential demographic data will assist in de-
termining which programs are most effective for individual
families and their specific needs. Researchers should also
72
provide greater detail about intervention components for rep-
licability in future studies.
An important future direction for research is examining the
relationship between parent and child outcomes. Previous re-
search (e.g., Hastings and Johnson 2001; Hastings and Brown
2002; Hastings et al. 2006; Neece et al. 2012; Orsmond et al.
2003) has suggested that there is a bidirectional relationship
between parent and child outcomes. However, most of this
research is correlational or descriptive in nature and does not
evaluate the experimental effects of an intervention on parent
and child variables. Some previous studies have measured
both parent and child outcomes (e.g., Braiden et al. 2012;
Budd et al. 2011; D’Elia et al. 2014; Gika et al. 2012; Wong
and Kwan 2010), although many of these studies used a quasi-
experimental design. One of the aims of this review was to
evaluate research where reduction of stress improved overall
family outcomes. However, there is currently insufficient re-
search to establish a functional relation between decreases in
parental stress and child outcomes. Future research should
examine the covariance between parent and child outcomes.
It may also be of benefit to measure the relationship be-
tween treatment adherence and parental well-being. Although
there is a strong evidence base for the effectiveness of parent-
implemented behavioral interventions for children with ASD
(e.g., McConachie and Diggle 2007; Warren et al. 2011), treat-
ment adherence has been cited as a barrier to parent-
implemented intervention (Allen and Warzak 2000).
Previous research indicates that parents of children with
ASD have less treatment adherence to behavioral treatment
recommendations than medical treatment recommendations
(Moore and Symons 2009). The effectiveness of behavioral
interventions is dependent upon consistent implementation of
essential features (Albin et al. 1996; Detrich 1999; Moore and
Symons 2009). Parents who experience less stress and depres-
sion and greater self-efficacy may be better able to deliver
behavioral interventions with greater treatment adherence, al-
though this relationship has not been explored.
Moreover, a limitation of the current literature is that it
relies on parent report data to measure parent outcomes.
Participation in an intervention alone can lead to better ratings
on self-report measures (e.g., Fisher and Katz 2008; Howard
1980; Van de Mortal 2008), leading to potential type II errors.
Measuring the biomarkers of stress, such as cortisol levels,
heart rate, or blood pressure, in addition to self-report may
provide more comprehensive data on parental outcomes. For
example, cortisol dysregulation has been associated with pa-
rental stress and depression in previous research (e.g., Dykens
and Lambert 2013; Seltzer et al. 2010) and may provide an
additional measure of improvement in parental stress symp-
toms following intervention.
Finally, the current review evaluated the effectiveness of
various interventions. It is still unclear which interventions are
most effective in improving parental well-being. Future
Rev J Autism Dev Disord (2018) 5:58–77
research should compare the effectiveness of different types
of interventions. It is also worthwhile to compare the effects of
group interventions versus individual interventions on parent
outcomes. Participating in group interventions may provide
parents with the necessary social support needed to enhance
parental well-being. Parents of children with ASD may expe-
rience social isolation due to the high demands of raising a
child with a disability and limited opportunities to participate
in social events because of their child’s challenging behavior.
Research indicates that socially isolated mothers may experi-
ence greater stress and have fewer socially satisfying interac-
tions with their children (e.g., Lee et al. 2008; Heiman and
Berger 2008). In addition, Bromley et al. (2004) identified
unmet needs among mothers of children with disabilities such
as having someone to talk to (85% of mothers) and meeting
other parents in socially satisfying situations (69% of
mothers). If social isolation and lack of social support is an
issue, participating in group interventions may be beneficial
for parents of children with ASD because it provides them
with an opportunity to connect with other parents who are
having similar experiences. Some parents, however, may dif-
ferentially benefit from or prefer more targeted, intensive, and
individualized supports.
Practical and Clinical Implications
The current literature review provides several clinical impli-
cations for working with families of children with ASD. For
example, due to the bidirectional relationship between parent-
child outcomes, it is important to concurrently target parent
outcomes such as stress, depression, and self-efficacy while
teaching parents skills they can use to support their child’s
development and manage challenging behavior. It may be
especially constructive to provide wraparound services for
families, in which resources and supports are provided (i.e.,
parent training, therapeutic services, respite care, social ser-
vices, family counseling) in addition to developmental and
behavioral services for the child. For example, early interven-
tion agencies should collaborate with mental health profes-
sionals to provide concurrent referrals upon diagnosis in order
to address both parent and child outcomes. It may also be
beneficial for early intervention professionals to receive train-
ing in the use of assessments (e.g., PSI-SF; PSES; HADS) at
intake that directly assess parental well-being prior to inter-
vention in order to inform the appropriate delivery of services
for each family.
Of particular interest is the relatively large proportion of
culturally diverse participants included in this review.
Research on the cultural adaptation of interventions indicates
that it is important not only to identify evidence-based prac-
tices but also to identify which practices work for whom and
how to adapt evidence-based practices across diverse cultural,
ethnic, and socioeconomic groups (Bernal 2006; Bernal and
Rev J Autism Dev Disord (2018) 5:58–77
Saez-Santiago 2006; Lau 2006). Although parental stress is a
common experience across various cultures (e.g., McConkey
et al. 2008; Shin et al. 2006; Wang and Day 2011), psycho-
logical experiences like stress, depression, and well-being
may be especially specific to culture (e.g., Asner-Self et al.
2006; Kirameyer 2001; Ryder et al. 2008; Yen et al. 2000). In
addition, parenting practices greatly vary across cultural, eth-
nic, and socioeconomic groups (e.g., Bradley and Corwyn
2002; Kelley and Tseng 1992; Kotchick and Forehand 2002;
Julian and McKelvey 1994; Varela et al. 2004), possibly re-
quiring cultural adaptations to interventions related to parent-
ing. Further research is needed that examines the effects of
parent-stress interventions for targeted cultural and ethnic
groups.
Conclusion
The importance of supporting parental well-being among par-
ents of children with ASD cannot be overemphasized. Parents
of children with ASD often experience increased stress, due to
the unique challenges of raising a child with ASD. Parental
stress may be further exacerbated by specific characteristics
associated with ASD, such as poor social communication
skills and often high levels of challenging behavior. Parents
who experience increased stress or depression or low levels of
self-efficacy may be less effective in managing their child’s
challenging behavior and implementing interventions to sup-
port their child’s development. This review of the literature
suggests several promising interventions for improving paren-
tal well-being in parents of children with ASD. Overall, the
included studies suggest that parent participation in
psychoeducational programs, behaviorally based programs,
CBT, mindfulness-based programs, and a variety of other in-
terventions may benefit from reduced parental stress and de-
pression and increased self-efficacy. However, there is very
little research meeting quality standards that examine on the
effectiveness of interventions to support parental well-being in
this population. Although there appears to be a shift in focus
toward supporting parent outcomes, more research in this area
is greatly needed and should be a priority for researchers.
Compliance with Ethical Standards This research did not involve
any human subjects.
Conflict of Interest The authors declare that they have no conflicts of
interest.
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