Journal of Autism and Developmental Disorders (2023) 53:390–404

https://doi.org/10.1007/s10803-022-05428-y

ORIGINAL PAPER

Parent–Child Interaction Therapy for Children with Disruptive

Behaviors and Autism: A Randomized Clinical Trial
Korrie Allen1 · John Harrington2,3 · Lauren B. Quetsch4 · Joshua Masse5,6 · Cathy Cooke3 · James F. Paulson7

Accepted: 5 January 2022 / Published online: 25 January 2022

© The Author(s) 2022

Abstract
A relatively large number of children with autism spectrum disorder (ASD) exhibit disruptive behavioral problems. While
accumulating data have shown behavioral parent training programs to be efficacious in reducing disruptive behaviors for
this population, there is a dearth of literature examining the impact of such programs across the range of ASD severity. To
evaluate the effectiveness of Parent–Child Interaction Therapy (PCIT), an evidence-based treatment for children with problem
behaviors and their families, in reducing disruptive behaviors among children (4–10 years) with ASD (without intellectual
disabilities). Fifty-five children (85.5% male, 7.15 years; SD 1.72) were enrolled from pediatric offices and educational set-
tings into a randomized clinical trial (PCIT: N = 30; Control: N = 25). PCIT families demonstrated a significant reduction in
child disruptive behaviors, increase in positive parent–child communication, improvement in child compliance, and reduction
in parental stress compared to the control group. Exploratory analyses revealed no differential treatment response based on
ASD severity, receptive language, and age. Results are promising for the use of PCIT with children demonstrating disruptive
behaviors across the autism spectrum.

Keywords Parent–child interaction therapy · Autism spectrum disorder · Randomized clinical trial

Introduction 150% leading ASD to become an urgent public health con-

cern (Maenner et al., 2021). Further, many of these children
Autism spectrum disorder (ASD), a continuum of neurode- engage in aggressive and other disruptive behaviors (e.g.,
velopmental disorders, is characterized by social deficits, tantrums, self-injury) toward themselves, family members,
communication impairments, and rigid, repetitive behaviors peers, and teachers (Kaat & Lecavalier, 2013; Kanne &
(APA, 2013). Over the past four decades, the estimated inci- Mazurek, 2011) representing one of the most common rea-
dence of ASD in the United States has continued to grow sons for referrals to mental health clinics and emergency
with the latest prevalence rates standing at 1 in every 44 departments (Pikard et al., 2018).
children (1 in 27 males, 1 in 116 females; Maenner et al., The presence of clinically significant behavioral prob-
2021). Since 2000, prevalence rates have increased by over lems among children with ASD is widely acknowledged
and cited; however, the exact prevalence varies greatly
* Lauren B. Quetsch due to the frequent use of clinical samples in studies (for a
[email protected] review, see Fitzpatrick et al., 2016; Hill et al., 2014; Solo-
mon et al., 2008) and inconsistent or ambiguous definitions
1
Present Address: University of Denver, Denver, CO, USA of behavior problems (see Hill et al., 2014; Tremblay et al.,
2
Children’s Hospital of the King’s Daughters, Norfolk, USA 2005). Some literature has reported that 50–70% of clini-
3
Eastern Virginia Medical School, Norfolk, USA cally-referred children and adolescents with ASD exhibited
4
Department of Psychological Science, University aggressive behavior to a caregiver, whereas other studies
of Arkansas, 480 Campus Drive, Memorial Hall, Fayetteville, concluded that approximately 90% of study participants
AR 72701, USA with ASD showed some form of challenging behavior (Jang
5
University of Massachusetts Dartmouth, Dartmouth, USA et al., 2011; Kanne & Mazurek, 2011; Mazurek et al., 2013;
6
The Boston Child Study Center, Boston, USA McTiernan et al., 2011). One literature review concluded
7 that approximately 25% of youth with ASD rise to the level
Present Address: Old Dominion University, Norfolk, USA

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Journal of Autism and Developmental Disorders (2023) 53:390–404 391

of meeting diagnostic criteria for a disruptive behavior dis- Psychosocial Treatments

order (i.e., oppositional defiant disorder, conduct disorder;
Kaat & Lecavalier, 2013). Comparatively, community sam- As an alternative to medication, the intervention literature
ples of neurotypical children have indicated rates of persis- has strong support for the effectiveness of comprehensive
tently aggressive behavior ranging from 0.5 to 10% (Broidy services for children with ASD. Established behavioral
et al., 2003; Lee et al., 2007). Even with the limitations in and educational treatments are available, including Learn-
the literature, there is a clear concern for the prevalence of ing Experiences and Alternative Program for Preschoolers
aggressive behaviors in the ASD population. and their Parents, Treatment and Education of Autistic and
Importantly, the presence of behavior problems can yield Communication Handicapped Children (TEACCH Method),
a myriad of other consequences impacting both the child and Early Start Denver Model, DIR/Floortime, Applied Behavio-
the family. Namely, disruptive and aggressive behaviors can ral Analysis (ABA), and ABA-derived models such as Early
present barriers to learning (Murray & Farrington, 2010), Intensive Behavioral Intervention (the UCLA Young Autism
assignment to residential or restrictive school placements Project), Pivotal Response Treatment, and Positive Behavior
(Dryden-Edwards & Combrinck-Graham, 2010), and further Support (PBS; Carroll & Kodak, 2019; Masse et al., 2007;
social impairment (Luiselli, 2009). Children with aggressive Smith & Iadarola, 2015). These focused therapies employ
behaviors are at an increased risk for physical harm/safety a number of techniques to increase socially-appropriate
concerns, reduced quality of life, increased familial financial behaviors; decrease challenging behaviors; and improve lan-
strain, limited access to supports and services, and both con- guage, social, and behavioral deficits in children with ASD
tribute to and are a consequence of parental stress (Hodgetts (Carroll & Kodak, 2019). However, these therapies do not
et al., 2013; Kanne & Mazurek, 2011; Krahé et al., 2015). always involve direct parent coaching and require coopera-
Failure to address behavioral problems in children with tive behavior from the child, which is problematic for chil-
ASD during early- to mid-childhood allows these behaviors dren exhibiting oppositional behavior (Masse et al., 2007).
to become established; and without intervention, problem Therefore, a behavioral intervention focused on reducing
behaviors are unlikely to ameliorate (Emerson et al., 2014; disruptive behaviors may act as a gateway treatment to more
Horner et al., 2002). The presence of behavioral problems intensive interventions, or alternatively, may fulfill particular
among children with ASD impedes developmental pro- needs of families unable to access or afford more intensive,
gress and the acquisition of key skills emphasized by early ABA-based treatments (McNeil et al., 2019; Williford et al.,
intensive behavioral interventions (Jang et al., 2011). When 2019). Due to many similarities between the behavioral
behavioral problems are addressed and decreased, children problems exhibited by children with ASD and those dis-
with ASD are more likely to comply with more intense and played by neurotypical peers with challenging behaviors, it
focused therapies to address other ASD-related concerns is appropriate to identify family-based evidence-supported
(Masse et al., 2007). treatments that could be translated to an ASD population to
reduce disruptive behaviors and aggression, increase compli-
Treatment for Children with ASD and Disruptive ance, and improve overall family functioning (McNeil et al.,
Behaviors 2019; Williford et al., 2019).

Medication Parent–Child Interaction Therapy (PCIT) Parent–Child

Interaction Therapy is a two-phase, empirically-supported
Approximately two thirds of youth and adults with autism treatment designed for children ages 2–7 with disruptive
take psychotropic medication (Houghton et al., 2017). behaviors (McNeil & Hembree-Kigin, 2010). Based on the
Although medication options for this population are limited, attachment theory and social learning theory, PCIT places
antipsychotics approved by the Food and Drug Administra- emphasis on improving the quality of the parent–child
tion (i.e., risperidone, aripiprazole) are frequently prescribed relationship and parent–child interactions. During the first
by providers to reduce irritability commonly associated with phase, Child-Directed Interaction (CDI), parents are taught
autism (Houghton et al., 2017). Studies have found as many specific skills to enhance the parent–child relationship and
as 50% of children with ASD are on at least one psycho- increase positive parenting. During the second phase, Par-
tropic medication (with rates often increasing with age) to ent-Directed Interaction (PDI), parents are taught how to
treat non-core ASD symptoms including oppositional behav- give effective commands and use consistent discipline tech-
iors or aggression (Jobski et al., 2017; Ziskind et al., 2020). niques.
Although some studies have shown promising results when PCIT has demonstrated clinically significant improve-
using these psychotropic drugs, adverse side effects are com- ments for families of children with disruptive behaviors and
mon and significant (e.g., exhaustion, rapid weight gain, ASD. Specifically, positive outcomes have demonstrated
anxiety, increased aggression; Larry & Erickson, 2018). enhanced interaction style of parents, decreased child

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392 Journal of Autism and Developmental Disorders (2023) 53:390–404

behavior problems, improved child adaptability, increased Language Individuals with ASD can experience commu-
child vocalizations, and higher child compliance (for a nication deficits in both receptive and expressive language
review, see Owen et al., 2019; Scudder et al., 2019). Moreo- (Özyurt & Eliküçük, 2018). Due to the high demand for
ver, similar outcomes on externalizing behavior, parenting verbal comprehension inherent in PCIT, studies with PCIT
skills, and parental stress have been found when matched- have frequently limited the enrollment to children who have
cases for children with and without ASD were compared receptive language skills of at least 24 months (Beverly &
(Parladé et al., 2019). Previous studies of PCIT with ASD Zlomke, 2019; Owen et al., 2019). Improvements in lan-
have rarely explored children with more severe levels of guage for children with ASD have been demonstrated in
autism, children’s medication use, or children outside the previous PCIT studies (see Beverly & Zlomke, 2019). How-
typical PCIT age range (older than 7 years; e.g., Scudder ever, few studies in PCIT have explored how language may
et al., 2019; see Owen et al., 2019 for a review). impact treatment outcomes, thus warranting further inves-
PCIT is a unique treatment model for children with ASD tigation.
and problem behaviors. Importantly, many of the therapies
available to families of children with ASD and behavior Age Children with ASD may present with disruptive and
problems are therapist-led intensive interventions whereas aggressive behaviors but fall outside of the standard age
PCIT is a cost-effective time limited intervention designed to range of PCIT. Given that more than half of children with
help parents address behavior problems. PCIT could possi- ASD may demonstrate cognitive capabilities lower than
bly serve as a gateway therapy for more intensive treatments their chronological age, expanding PCIT’s age range may
and be used in conjunction as a first-line treatment to pre- help address the children who are developmentally delayed
pare children with ASD for other comprehensive therapies but who may have otherwise aged-out of early interven-
(McNeil et al., 2019). tion services to target problem behaviors (Charman et al.,
2011; Maenner et al., 2021). Only a few PCIT studies have
Additional Factors Impacting Treatment Effectiveness expanded the age range up for exactly this reason (e.g.,
8-year-olds: Zlomke et al., 2017; 12-year-olds: Solomon
ASD Severity Although a strong research base is being built et al., 2008). Understanding the impact of PCIT on children
for conducting PCIT with children on the autism spectrum with differing profiles and a broader age range will help
(see McNeil et al., 2019), most of the more methodologi- inform future studies conducted with this population.
cally rigorous studies for PCIT have been implemented with
children with Level 1 severity (formerly Asperger syndrome; Purpose and Hypotheses
APA, 2013) or have only implemented components of the
treatment (i.e., only CDI; see Owen et al., 2019). While The purpose of this study was to evaluate the effectiveness
some case studies have demonstrated PCIT’s success for of PCIT in reducing oppositional behaviors and increasing
children with more significant delays, there is a paucity of positive parenting behavior among children (4 to 10 years)
literature for determining the effectiveness of PCIT for chil- with ASD (without intellectual disabilities). This study
dren with lower levels of ASD functioning. More research expands the PCIT effectiveness research by including chil-
is needed to determine the effectiveness of the entire PCIT dren with varying levels of ASD and who may fall outside
protocol (i.e., both CDI and PDI phases) across the autism the standard age-range for PCIT. The study included three
spectrum (McNeil & Quetsch, 2019). hypotheses: (1) PCIT will result in a significant decrease in
parent-reported disruptive behaviors; (2) parent and child
Medication Use Few PCIT studies with children with ASD interactions (child compliance rates and parenting skills)
have reported on or measured child medication use (Scud- will significantly improve over the course of PCIT; and, (3)
der et al., 2019). Yet, antipsychotic medications are pre- PCIT will result in significant improvements in parent effi-
scribed at high rates to children with ASD (Ziskind et al., cacy and parent mental health (stress and depression). The
2020). While the literature is limited, previous explorations second goal of the study was to perform exploratory analyses
of intensive behavioral interventions have shown improve- to assess the differential impact of the full PCIT protocol by
ments regardless of medication status; although, children autism severity, medication use, and language level on the
taking antipsychotic medications may require fewer ses- disruptive behaviors of children across the autism spectrum.
sions to achieve behavioral goals (Frazier et al., 2010). A Finally, this study assessed parental satisfaction with PCIT.
study controlling for medication use could further clarify
the effectiveness of medication and/or PCIT on child behav- Research Design
ioral outcomes.
The study design followed a step-wise model for conducting
psychosocial interventions for ASD, as outlined by Smith

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Journal of Autism and Developmental Disorders (2023) 53:390–404 393

et al. (2007) and in accordance with the guidelines adopted Table 1  Demographic composition of sample
by the National Institute of Mental Health (NIMH). This Treatment ­groupa Control ­groupb
research design adheres to the recommendation that when M(SD) or N(%) M(SD) or N(%)
applying PCIT to a new population, it should first be empiri-
Child sex
cally tested in its standard form to determine its efficacy
Male 26 (86.7%) 21 (84.0%)
before any modifications are made to the model (Masse
Female 4 (13.3%) 4 (16.0%)
et al., 2007; McCabe et al., 2005). Thus, our study evalu-
Child age 7.03 (1.6) 7.26 (1.4)
ated the efficacy of PCIT in its manualized form (Eyberg &
Child ethnicity
Funderburk, 2011) for children with ASD and behavioral
White 17 (56.7%) 19 (76.0%)
problems.
Black 7 (23.3%) 2 (8.0%)
Latinx 4 (13.3%) 1 (4.0%)
Other 2 (6.7%) 3 (12.0%)
Method
Family financial status
Less than $25,000 2 (6.7%) 3 (12.0%)
Participants
$25,000–$49,999 7 (23.3%) 5 (20.0%)
$50,000–$99,000 16 (53.3%) 13 (52.0%)
Families were recruited from the eastern United States.
Over $100,000 5 (16.7%) 4 (16.0%)
The region included 10 cities and 6 counties in two states
BASC T-score
located in socio-economically and culturally diverse areas
Externalizing 74.8 (11.1) 73.2 (11.5)
that ranged from rural to urban and suburban settings. The
CARS-2 T-score 49.9 (9.5) 48.3 (8.9)
region consisted of 61% White, 31% Black, and 8% other
PPVT standard score 90.3 (8.7) 94.7 (7.2)
ethnic groups. Fifty-five female and eight male caregivers
Psych Rx 16 (53.3%) 15 (60.0%)
(N = 55 families) and their 4- to 10-year-old children par-
ticipated in the present study. All adult caregivers living in Na = 30, Nb = 25
the home were encouraged to participate in this treatment as BASC behavior assessment system for children, CARS Childhood
research suggests that dual-parent involvement (e.g., mother, Autism Rating Scale, PPVT peabody picture vocabulary test, Psych
father) leads to better maintenance of treatment gains (Bag- Rx psychological prescription/medication
ner & Eyberg, 2003). Although eight fathers participated in
treatment, the primary caregivers in each household were No parents endorsed concerns which was confirmed through
identified as the participating mothers. Therefore, data for a check of the children’s medical records. However, no cog-
this study only include information from the primary car- nitive data was collected in the present study.
egivers (i.e., mothers, in this case). Overall, 181 interested families responded to study
Children who participated in the study (Table 1) were recruitment. Please see Fig. 1 for an overview of the screen-
mostly boys (85.5%) with a mean age of 7.15 years (SD ing and recruitment process. Recruitment took place over
1.72). Their racial/ethnic composition was 65.5% White, 10 months, and assessment and treatment completion took
16.4% Black, 9.1% Latinx, 9.1% other ethnicity. Most 18 months. In total, 163 phone screens were conducted and
children (80%) were referred by pediatric health care pro- 92 families qualified and were scheduled for a clinical intake
fessionals, 12% were referred by teachers, and 8% were assessment. Of those families that completed the intake pro-
self-referred. At the time of intake, 56.4% were prescribed cess, 55 met criteria for inclusion. Families were excluded
medication to address behavioral issues. Most children came if based on the screening measures the child (a) had lim-
from families with total household incomes between $50,000 ited receptive language (n = 8), (b) lacked severe behavior
and $99,000 (n = 29; 52.7%). To be included in the study, problems (n = 10), (c) were not previously diagnosed with
children had to demonstrate at-risk or clinically significant ASD by a health professional (n = 4), or (d) the family did
externalizing behaviors (Behavior Assessment Scale for not complete the intake process (n = 9). There were three
Children [BASC]; Reynolds & Kamphaus, 1992), be diag- families screened as eligible for the study that cancelled their
nosed with ASD by a health professional prior to the study participation from the original group. Families not meet-
(confirmed and assessed for severity using the Child Autism ing the inclusion criteria (n = 37) were given feedback and
Rating Scale [CARS]; Schopler et al., 1980), and obtain a appropriate recommendations for services. Upon complet-
receptive language age equivalent of 2 years or higher (Pea- ing the clinical intake, children were stratified based on the
body Picture Vocabulary Test [PPVT]; Dunn & Dunn, 2007) dichotomized variable of psychiatric medication use (yes/
to ensure the child was able to follow basic parental com- no), then matched using the continuous variables of exter-
mands. Parents were asked to report if the child had been nalizing behaviors (BASC), severity of autism (as measured
previously diagnosed with an intellectual disability (yes/no). using the CARS), and age. Families were assigned using

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394 Journal of Autism and Developmental Disorders (2023) 53:390–404

Fig. 1  CONSORT diagram

Assessed for Eligibility by Phone Screen (N = 163)

Excluded (n = 71)
Did not meet inclusion criteria (n = 68)
Other (n = 2)
Withdrew (n = 1)

Enrollment
Assessed for Eligibility by Clinical Intake (N = 92)

Excluded (n = 37)
Did not meet inclusion criteria (n = 22)
Did not complete intake (n = 9)
Did not match for randomization (n = 2)
Other (n = 1)
Withdrew after intake (n = 3)

Randomized (N = 55)
Allocation

Allocated to Treatment Group (n = 30) Allocated to Control Group (n = 25)

Assessment

Pre-Test Assessment Completed (n = 30) Pre-Test Assessment Completed [n = 23

Pretest

(paper assessments not complete for n = 1)]

Dropped (n = 2)
Assessment
Interim

Interim Assessment Completed (n = 28) Interim Assessment Completed (n = 20)

Dropped (n = 2) Dropped (n = 3)
Assessment
Posttest

Post-Test Assessment Completed (n = 25) Post-Test Assessment Completed (n = 19)

Dropped (n = 3) Not Completed (n = 1)

stratified randomization to the control or treatment (PCIT) Enrolled families completed a baseline assessment (Time 1:
group using a research randomizer program. Randomization pre-treatment) that included parental report questionnaires
was determined by the lead researchers (first and second and parent–child observations which were videotaped and
authors). Two children did not match and were not included coded by research personnel. Approximately 8 weeks after
in the randomization process, yielding a total of 30 treatment the Time 1 assessment, all TG and CG families were sched-
group (TG) families and 25 control group (CG) families. uled to complete an interim-treatment assessment (Time 2).
Treatment for children with ASD in the study location was This interim assessment marked the transition from CDI to
limited. Many families were on a wait-list of 12–18 months PDI for treatment families. The Time 3 assessment occurred
for ABA. Families in both the TG and CG continued rou- post-treatment (upon graduation for TG), 8 weeks after Time
tine community care throughout the study, which primarily 2. All families were compensated for study participation
consisted of speech therapy services (TG = 38%, CG = 40%). at Time 1 and Time 3 assessment visits. Data collection
and treatment delivery was conducted in a medical center.
Procedure Enrollment, assessments, and treatment delivery were con-
ducted by the research team.
The study was approved by the Eastern Virginia Medical
School and the Children's Hospital of the King's Daugh- Screening Measures and Inclusion Measure
ters Institutional Review Boards. Children were recruited
by providing study information packets to pediatric offices, Behavior Assessment Scale for Children‑Second Edition
the Tidewater Autism Society of America, Community Ser- (BASC‑2)
vice Boards, and school systems. Children were screened
prior to enrollment on level of disruptive behavior (BASC), The BASC-2 (Reynolds & Kamphaus, 1992) was used in
autism severity (CARS), and receptive language (PPVT). the identification and differential diagnosis of emotional/

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Journal of Autism and Developmental Disorders (2023) 53:390–404 395

behavioral disorders in children. Child participants had to 7-point Likert-type scale (1 = never to 7 = always). The
receive an at-risk score (T ≥ 60) or higher on externalizing Problem Scale includes “yes” or “no” responses and meas-
behavior problems to meet eligibility criteria for the pre- ures how problematic the child’s behavior is for the parent.
sent study. The Externalizing subscale of the measure was The Intensity and Problem scales yield test–retest reliability
also used to determine if any changes in child behavior were coefficients of .80 and .85 across 12 weeks, respectively, and
detected over time. .75 across 10 months. The ECBI has been normed for chil-
dren with ASD (ages 2–12 years) with cutoff scores on the
Childhood Autism Rating Scale, Second Edition (CARS‑2) Intensity (x = 169) and Problem Scales (x = 23) being signifi-
cantly higher than neurotypical comparisons (i.e., x = 132,
The CARS-2 (Schopler et al., 1980) was used on the child 15, respectively; Jeter et al., 2017). The ECBI was adminis-
sample to identify and confirm a diagnosis of autism while tered to both groups at each assessment period (Times 1–3)
distinguishing them from children with other developmental and weekly to the TG families.
disabilities. The measure is empirically validated and pro-
vides concise, objective, and quantifiable ratings based on Dyadic Parent–Child Interaction Coding System (DPICS)
direct behavioral observation. Only children with an existing
diagnosis of ASD were included in the present study. Out- The DPICS (Eyberg et al., 2004) is a behavioral observa-
comes of the CARS-2 produce a cutoff score (indicative of tion coding system that measures parental verbalizations
autism > 28) with scores above this being further identified (i.e., labeled and unlabeled praise, behavior descriptions,
as either “mild to moderate” (T scores between 29 and 49) reflections, imitation, neutral talk, questions, direct and indi-
or “severe” (scores at or above a T-score of 50). None of the rect commands, criticism) and child compliance. It acts as
children in the sample had intellectual disabilities; there- a measure of the quality of parent–child interaction during
fore, the CARS-2 Standard Form was delivered for children three 5-min standard situations (i.e., Child-led Play, Parent-
6 years of age and younger unless the child 7 or older had led Play, Clean-up) that vary in the degree of parental con-
a notable communication impairment. The CARS-2 High trol. While Child-led Play (CLP) assesses parents’ use of
Functioning was delivered to youth 7 years of age or older skills that allow the child to lead an interaction, Parent-led
in the sample. Children’s CARS-2 T scores ranged from 32 Play (PLP) instructs the parent to lead and have the child fol-
to 65, with the mean score of 48.3 (SD 8.3). low, while Clean-up (CU) requires the child to put away all
the toys without assistance from the parent. Compliance in
Peabody Picture Vocabulary Test, Fourth Edition (PPVT‑IV) this study represents the average compliance rate of PLP and
CU at each assessment point. The DPICS was administered
The PPVT-IV (Dunn & Dunn, 2007) is an individually weekly to the TG families. Frequency counts of each of the
administered, untimed, norm-referenced, wide-range test “Do” (i.e., labeled praises, behavior descriptions, reflections)
designed for children and adults ages 2.6 to 90 + years and “Don’t” (i.e., questions, direct and indirect commands,
that assesses receptive vocabulary and verbal ability. The criticism) skills were gathered in a 5-min observation period
PPVT-IV has measures of reliability in the 0.90’s and valid- at the outset of each session. Competency was reached when
ity studies indicate it is sensitive enough to identify lan- a parent attained 10 labeled praises, 10 behavioral descrip-
guage-delayed students. Children met participation criteria tions, 10 reflections, with 3 or less “Don’t” skills combined
if their receptive language score was at or above a 2-year-old during the 5-min coding period.
equivalent. Researchers received extensive (40 h) DPICS training
to ensure reliability. Coders were considered reliable after
Outcome Measures of Child and Parent Functioning attaining a .75 kappa for each of the “Do” and “Don’t” skills
on five consecutive observations. Throughout the study,
Primary outcome measures included measures of external- two researchers blinded to group assignment independently
izing behavior and observational measures. Secondary out- observed the same individuals for 50% of all sessions and
come measures included assessments of parenting stress, maintained a .85 inter-rater reliability.
depression, and locus of control.
Parent Stress Index‑Short Form (PSI‑SF)
Eyberg Child Behavior Inventory (ECBI)
The PSI-SF (Abidin, 1995) is a 36-item parent self-report
The ECBI (Eyberg & Boggs, 1989) is a 36-item parent- measure of stress as it relates to in the parent–child dyad
report scale of disruptive behavior and includes two scales: with strong reliability and validity indices. The Total Stress
Intensity and Problem. The Intensity Scale measures the score was the only scale utilized in the present study.
frequency with which disruptive behavior occurs using a

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396 Journal of Autism and Developmental Disorders (2023) 53:390–404

Parenting Locus of Control‑Short Form (PLOC‑SF) Data Analysis

The PLOC-SF (Campis et al., 1986) is a 25-item self-report Mean scores on parent-report questionnaires as well as
questionnaire that measures the degree to which parents feel behavioral observation counts and ratios derived from the
in control of their child’s behavior. DPICS were primarily analyzed using Repeated Measures
MANOVAs. This is a suitable technique given the uniform-
Beck Depression Inventory (BDI‑II) ity of the assessment schedule. Additionally, it is preferable
to the alternative of multiple univariate tests as it detects
The BDI-II (Beck et al., 1961) is a 21-item self-report meas- patterns between multiple dependent variables which may
ure assessing the intensity of depression. Respondents are not otherwise arise in univariate tests. Additional univariate
asked to consider how they have been feeling over the last comparisons are presented as follow-ups to the MANOVAs,
two weeks and respond to specific items about depression- as are graphical displays of observed effects.
related symptoms on a scale from 0 to 3. Higher scores on
the BDI-II indicate greater severity of depression.
Results
Measure of Treatment Satisfaction
Among the 30 TG families and 25 CG families that were
Therapy Attitude Inventory (TAI) initially enrolled in study, 25 TG and 19 CG families com-
pleted all three assessment time points (Time 1–3) in the
The TAI (Eyberg, 1993) is a 10-question measure contain- study (see Fig. 1). Forty-four families completed the study
ing items on a 5-point Likert scale. Higher scores repre- yielding an attrition rate of 19 percent. The primary reason
sent higher levels of caregiver satisfaction. The measure for dropout was relocation to a new city. Overall, the dropout
addresses the impact of parent training skills on such areas rate is significantly lower than would be expected consider-
as confidence in discipline skills, quality of parent–child ing that attrition rates from child psychotherapy range from
interaction, the child’s behavior, and overall family adjust- 40 to 60% (Wierzbicki & Pekarik, 1993). Significant differ-
ment. The TAI was administered at Time 2 and Time 3 ences were found between groups on all primary outcome
assessments to TG families only. measures from Time 1 to Time 3 (see Table 2).

Treatment Change in Child Disruptive Behavior

PCIT sessions were conducted by a clinical psychologist The two parent-report measures that were used to assess
once a week and lasted between 60 and 90 min. Families in disruptive and oppositional behavior observed by the par-
the TG condition received the entire protocol of PCIT (i.e., ent in the home included the ECBI (Table 2; Fig. 2) and
both CDI and PDI phases) unless families terminated before the BASC (Table 2). On the ECBI Intensity scale, a sig-
treatment completion. In both phases of treatment (CDI, nificant Time X Group interaction was observed, such that
PDI), therapists actively coached parents toward understand- children in the TG demonstrated a much steeper decline in
ing of the therapeutic interaction skills as assessed during a behavioral intensity (Wilk’s λ (2, 39) = 47.28, p < .001; Par-
5-min parent–child observation (DPICS) at the start of the tial η2 = .48). Univariate tests reveal that children receiv-
session. On average, families achieved CDI skills compe- ing PCIT demonstrated lower intensity of behavior prob-
tencies in 6.2 sessions and PDI in 5.9 sessions. Throughout lems at Time 2 (F(1,39) = 8.21, p = .006) and significantly
treatment, parents were asked to practice the skills at home increased that difference (F(1,39) = 30.76, p < .001) at Time
daily in 5–10 min sessions, initially focusing on CDI skills 3 (see Fig. 2) compared to CG families. A similar interac-
and then incorporating PDI skills at times when a command tion was observed for the ECBI Problems scale (Wilk’s λ (2,
was necessary. The therapists included a licensed clinical 37) = 5.77, p = .007; Partial η2 = .238), revealing that chil-
psychologist and a supervised post-doctoral clinical psychol- dren in the TG demonstrated significantly fewer problems at
ogy fellow, each of whom attended a 40-h PCIT training Time 3 (F(1,37) = 8.41, p = .006), but not at Time 2. Overall,
conducted by a PCIT Global Trainer. All therapy sessions each child in the treatment group scored in the non-clinical
were videotaped, and 50% of the session tapes from each level of the ECBI on both the Problems and Intensity scale
family were randomly selected and checked independently at the conclusion of the treatment.
by two coders for integrity using the PCIT treatment manual When measured with the BASC Externalizing Problems
checklist. Accuracy was 95% with the treatment protocol. subscale (Table 2), a similar Time X Group interaction
In addition, supervision from a PCIT Global Trainer was was observed, such that children in the TG demonstrated
received regularly. continued decline in externalizing problems at Times 2

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Journal of Autism and Developmental Disorders (2023) 53:390–404 397

Table 2  Outcome measures

Measure Group Pretreatment Interim Posttreatment Pre-to-post Δ |d*| df F(p)
N (44) M (SD) M (SD) M (SD) M (SD)

Primary measures
ECBI—intensity CG 153.6 (22.7) 142.6 (27.94) 139.0 (25.5) − 16.2 (18.8) 2.04 40 38.18 (< .001)
TG 158.7 (25.8) 114.5 (33.3) 91.1 (27.8) − 68.5 (32.1)
ECBI—problems CG 19.6 (4.96) 17.4 (7.79) 14.6 (8.20) − 4.27 (4.62) 1.09 40 10.51 (.002)
TG 20.2 (7.18) 12.2 (8.25) 7.81 (8.60) − 12.91 (10.27)
BASC- externalizing problems CG 73.2 (11.5) 65.2 (11.0) 65.6 (11.7) − 5.42 (6.28) 1.52 39 22.88 (< .001)
TG 74.8 (11.1) 63.9 (10.2) 60.2 (8.14) − 16.86 (8.63)
DPICS “Do” Behaviors CG 3.59 (3.02) 4.56 (3.48) 4.68 (3.47) 1.35 (3.59) 3.30 40 94.31 (< .001)
TG 5.20 (3.95) 26.88 (12.29) 35.52 (12.35) 30.32 (11.89)
DPICS “Don’t” Behaviors CG 19.47 (15.55) 21.22 (9.25) 21.53 (12.56) 2.82 (9.46) 2.17 40 47.20 (< .001)
TG 19.8 (9.29) 4.25 (7.81) 1.56 (2.52) − 18.24 (9.94)
DPICS PDP compliance CG .474 (.270) .384 (.286) .471 (.230) − .021 (.169) 1.87 39 32.25 (< .001)
TG .335 (.195) .332 (.238) .727 (.209) .393 (.264)
DPICS cleanup compliance CG .555 (.245) .594 (.249) .505 (.135) − .054 (.224) .98 40 8.85 (.005)
TG .465 (.285) .390 (.236) .731 (.315) .266 (.403)
Secondary measures
Parenting stress total CG 114.4 (21.6) 114.5 (19.1) 109.7 (22.1) − 8.81 (15.59) .82 39 5.95 (.019)
TG 122.7 (23.1) 109.3 (23.2) 96.6 (28.2) − 27.7 (28.22)
Beck depression inventory CG 11.0 (5.39) 9.11 (8.00) 7.00 (6.63) − 4.33 (3.91) .42 41 1.64 (.208)
TG 15.3 (7.57) 11.8 (9.46) 8.16 (8.19) − 7.16 (8.74)
Parenting locus of control CG 49.5 (10.3) 48.1 (10.4) 47.2 (11.6) − 4.00 (8.70) .57 41 3.40 (.072)
TG 52.3 (7.78) 48.0 (10.0) 44.2 (8.98) − 8.92 (8.59)

CG control group, TG treatment group, ECBI eyberg child behavior inventory, BASC behavior assessment system for children, DPICS dyadic
parent–child interaction coding system, DPICS “Do” Behaviors behavior descriptions, reflections, labeled praises. DPICS “Don’t” Behaviors
questions, commands, criticism
*
Effect sizes of d > .80 are considered large

Fig. 2  Change in ECBI intensity 180

160

140
ECBI Intensity Score

120

100
Control Group
80 Treatment Group
60

40

20

0
Time 1 Time 2 Time 3

and 3, whereas the CG leveled off after Time 2 (Wilk’s λ Externalizing Problems at Time 3 (F(1,37) = 6.61, p = .014)
(2, 36) = 11.79, p < .001; Partial η2 = .40). Univariate tests but not at Time 2.
revealed that children in the TG demonstrated lower levels of

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398 Journal of Autism and Developmental Disorders (2023) 53:390–404

Change in Parent–Child Interactions scale, a significant Time X Group interaction was observed,
such that parents in the TG demonstrated a steeper decline in
In terms of PCIT “Do” skills (measured by DPICS labeled parenting stress over the course of the study (Fig. 4; Wilk’s
praises, behavior descriptions, reflections), parents in the TG λ (2, 37) = 4.67, p = .016; Partial η2 = .20). No significant
showed significant increases over the three assessment peri- difference were found between the TG and the CG on the
ods (Wilk’s λ (2,37) = 49.81, p < .001; Partial η2 = .73). Uni- PLOC-SF (p = .072) or BDI-II (p = .208; Table 2).
variate tests indicated no statistically significant differences
between groups at baseline with TG parents showing sig- Exploratory Analyses
nificantly more “Do” behaviors at Time 2 (F(1,38) = 49.07,
p < .001) and maintaining this change (F(1,48) = 299.19, Autism Severity
p < .001) through Time 3 (See Fig. 3).
PCIT “Don’t” skills (DPICS commands, questions, criti- All TG children were divided into ASD severity groups
cism) showed a similar but inverse pattern over time. Parents according to CARS-2 scores at or above a T-score of 50. In
in the TG showed significant decreases in “Don’t” behaviors terms of ECBI Intensity scores, the most sensitive indica-
over the three assessment periods (Wilk’s λ (2, 37) = 21.33, tor of behavior change in this study, there was not an ASD
p = .001; Partial η2 = .54). Univariate tests indicated no sta- Severity X Time effect. This appears to indicate children
tistically significant differences between groups at Time 1, with varying severity of ASD responded similarly to the
with TG parents showing significantly fewer “Don’t” behav- treatment over time (NS, Partial η2 = .25, p = .16).
iors at Time 2 (F(1,38) = 36.68, p < .001), and maintaining
this change (F(1,38) = 63.53, p < .001) through Time 3 Medication Use
(Fig. 3).
Parents and children were observed for compliance/com- On the ECBI Intensity scale, no significant differences were
mand ratio during the PLP and CU periods of the DPICS found between children on psychiatric medications and those
(Table 2). Treatment families showed a statistically sig- not on psychiatric medications, regardless of whether they
nificant Time X Compliance ratio change during the PLP were in the TG or CG. Medication X Group X Time was not
activity (Wilk’s λ (2, 36) = 15.85, p < .001; Partial η2 = .47) significant (NS, Partial η2 = .08, p = .076).
with significant relative improvement occurring at Time
3 (F(1,37) = 21.22, p < .001). A very similar pattern was Receptive Language and Age
observed during the CU activity with the Time X Compli-
ance being significant (Wilk’s λ (2, 37) = 7.99, p = .001; Par- Pearson’s r correlations were conducted for the TG to deter-
tial η2 = .30) and the major improvement being observed for mine if children’s receptive language (PPVT-IV) or age
Time 3 (F(1, 38) = 10.07, p = .003). impacted change in child behavior (post-treatment ECBI
Intensity—pre-treatment ECBI Intensity). The findings were
Change in Parenting Stress and Psychopathology not significant.

The parent-level variables revealed a large variation, with

only parental stress demonstrating a statistically significant
change between the TG and CG. On the PSI-SF Total Stress

Fig. 3  Average DPICS skill 40

frequency
35
DPICS Skill Frequency

30 Control Group "Do"

Behaviors
25
Control Group "Don't"
20 Behaviors

15 Treatment Group "Do"

Behaviors
10 Treatment Group "Don't"
5 Behaviors

0
Time 1 Time 2 Time 3

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Journal of Autism and Developmental Disorders (2023) 53:390–404 399

Fig. 4  Change in parent stress 125

total score
120

PSI-SF Total Stress Score

115
110
105
Control Group
100
Treatment Group
95
90
85
80
Time 1 Time 2 Time 3

Treatment Satisfaction to their children’s behaviors through describing their chil-

dren’s actions, reflecting their words, and giving them
Findings on the TAI show that TG parents found the tech- labeled praises for appropriate behaviors. Parents in the TG
niques helpful in regards to disciplining their child (91%) also demonstrated a significant reduction in the use of com-
and teaching their child new skills (93%). All parents of mands, questions, and criticisms when interacting with their
children in the TG felt their relationship with their child was children. Importantly, parents progressed in issuing effective
better than before the program and that their child’s behav- commands to their children and following through appro-
ior problems and compliance with parental commands and priately, resulting in improvements in child compliance and
requests had improved. Ninety-three percent of the parents decreases in parent–child conflict.
reported satisfaction with the progress their child had made Secondary analyses were conducted examining paren-
in regards to their general behavior and many (86%) felt that tal stress and psychopathology. The TG demonstrated sig-
the program helped with other general personal and family nificant change in parenting stress over the course of the
problems. These findings suggest that families of children study, but treatment did not change parental perceptions of
with a range of ASD presentations were highly satisfied with control or ratings of depression. It is well-established that
PCIT. there is significant parental stress associated with parenting
a developmentally delayed child (e.g., Lichtlé et al., 2020;
Padden & James, 2017); yet, prior PCIT research examin-
Discussion ing parental stress with the ASD population has been mixed
(Agazzi et al., 2017; Solomon et al., 2008). As such, given
This study further demonstrates the efficacy of PCIT among the varying levels of ASD severity in this study, this finding
children with ASD and co-occurring behavior problems. is promising.
The treatment was provided to children with ASD (with- In addition, due to the limited availability of services for
out intellectual disabilities) and the results demonstrated children with ASD in the study region, children between
similar behavioral changes to children without ASD who 4 to 10 years of age with varying levels of ASD severity
received PCIT. Specifically, based on both parent-report and were included in the study. The results indicate that despite
observation data, children in the TG demonstrated a signifi- the slightly higher age range (M = 7.18 years) and range of
cant reduction in challenging behavior at the completion of ASD severity, the TG responded to PCIT in similar ways to
CDI, and this reduction continued through the completion children without ASD (Boggs et al., 2004). Children were
of PDI. Furthermore, from Time 1 to Time 3, TG families also stratified by psychiatric medication status before being
used significantly more relationship-building skills and randomly assigned to the TG or the CG. Medication use had
obtained more compliance from their children when giving no significant impact on child disruptive behaviors while
them commands, compared to the CG. This finding is similar PCIT did have a clear and significant impact on reducing
to other PCIT literature conducted with children with ASD disruptive behaviors for children in the TG. Additionally,
(Ginn et al., 2015; Masse et al., 2016; Parladé et al., 2019; associations of disruptive behavior change with receptive
Scudder et al., 2019; Zlomke et al., 2017). language functioning and with child age were explored for
The overall quality of the parent–child relationship sig- the TG. Outcome indicated that age and language differ-
nificantly improved as well. Parents completing PCIT dem- ences were not associated with difference in behavior change
onstrated a significant improvement in differential attention

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400 Journal of Autism and Developmental Disorders (2023) 53:390–404

signifying that PCIT resulted in similar changes regardless to 4; by age 5, the treatment options begin to significantly
of age and receptive language. decrease. However, the majority of children with ASD con-
Families also reported that PCIT was an effective and tinue to experience language, social, and behavioral difficul-
satisfactory treatment for their children’s behavior problems: ties throughout their school years (Marsh et al., 2017; McK-
90% of the TG families reported satisfaction with the pro- ean et al., 2017). Additionally, for families receiving later
cess and outcome of treatment, and over 85% felt it improved diagnoses or who are limited by accessibility of resources
their parenting skills, their child’s behavior, and the overall (Godon-Lipkin et al., 2016), PCIT may be a gateway to
family functioning. Although attrition in child therapy has reduce disruptive behaviors, improve the effectiveness of
been identified as a substantial problem (NIMH, 2001), few other interventions, and increase accessibility due to wide
in this study dropped out of treatment. availability of PCIT providers in the United States (Scudder
PCIT was used in its original form with only tailoring, et al., 2017; Soke et al., 2018). A research review (Solo-
as suggested by the creator of PCIT, Sheila Eyberg, to meet mon et al., 2008) concluded that children with autism are
the needs of individual families (2005). The theoretical and significantly at-risk for problematic behaviors which, with-
empirical foundation of PCIT was maintained, along with its out intervention, are more likely to worsen than improve.
core defining features. Outcomes from the present study are Despite this problem, our understanding of effective behav-
in line with previous research claims positing that PCIT can ioral treatment of children with ASD is limited. PCIT may
be effective without significant modifications for children be one answer.
with developmental delays, including children in the older
range of typical PCIT research (ages 7–10 years; McDiarmid Limitations
& Bagner, 2005).
Future studies may strive to overcome the present study’s
Implications for Research, Policy, and Practice limitations. For example, the study did not include an alter-
native treatment control; therefore, the results must still
Previous studies evaluating the impact of autism treatment be considered provisional. Additionally, future research
approaches have been conducted with middle- to upper-mid- on PCIT may benefit from further analyses regarding how
dle-class families with an estimated annual treatment cost treatment may differentially impact children at various
ranging from $25,000 to $60,000 per child and requiring up levels of autism functioning. Researchers should focus on
to 25 h per week (Solomon et al., 2007). For many families, PCIT adaptations for children at lower levels of function-
there is a lack of both treatment availability and financial ing. Moreover, while the present study was unique in that
resources (Mackintosh et al., 2012). This study demonstrates it included youth classified as severely autistic, it excluded
that PCIT offers an innovative, more cost-effective approach youth with a comorbid intellectual disability. Future studies
to delivering an evidence-based therapy to a diverse popula- may also benefit from measuring, reporting, and controlling
tion. Specific benefits of this model of treatment include: (a) for youth’s cognitive functioning (e.g., IQ) to lend insight in
a family-based approach that addresses caregivers’ capacity PCIT’s effectiveness of youth with ASD and diverse intel-
to manage ASD-related behaviors; (b) direct-coaching to lectual levels.
maximize parental learning and retention; (c) a time-limited Although this study did not measure non-disruptive
model; and (d) a treatment model that can be wildly dis- behaviors of autism, such as self-stimulation, eye contact,
seminated. Historically, few studies of behavioral treatment language, and social engagement, positive changes in these
of ASD employed an experimental design (2 of 68 studies behaviors were both observed by therapists and reported
per a 2001 meta-analysis; Lord & McGee, 2001); however, by parents and teachers. Next steps include assessing
even though recent studies for various early interventions are these behaviors in the context of other child characteristics
utilizing randomized controlled trials, only a few of these are including autism severity, language level, and cognitive
behaviorally-based treatments. Additionally, many studies functioning.
have substantial bias and limitations preventing robust find- As PCIT did not significantly decrease parent depression,
ings for this population (French & Kennedy, 2018; Tachi- future studies should explore ways to improve these meas-
bana et al., 2017). Therefore, the use of a controlled rand- ures of parent-functioning, possibly through the addition
omized design for this study addresses a significant gap in of a parent psycho-education/treatment module or referral
the research for this treatment and population. for individual parental therapy. A larger sample size would
Treatment research for children with ASD has primarily allow for more thorough analyses of other possible corre-
focused on the benefits of early intensive behavioral inter- lates, such as age and gender.
vention (e.g., Remington et al., 2007; Rogers & Vismara, In families with typically-developing children, PCIT has
2008). Many children receive some form of intensive behav- been found to provide treatment effects lasting up to two
ioral training after being diagnosed between the ages of 3 years (Boggs et al., 2004). In order to determine whether

13
Journal of Autism and Developmental Disorders (2023) 53:390–404 401

the treatment gains demonstrated by families completing Agazzi, H., Tan, S. Y., Ogg, J., Armstrong, K., & Kirby, R. S. (2017).
PCIT will be maintained, follow up data has been collected Does Parent-Child Interaction Therapy reduce maternal stress,
anxiety, and depression among mothers of children with autism
three months after treatment completion. The results of these spectrum disorder? Child & Family Behavior Therapy, 39(4),
data will be reported in future publications. Furthermore, in- 283–303. https://​doi.​org/​10.​1080/​07317​107.​2017.​13756​22
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ered a viable treatment for children with ASD and behavioral Bagner, D. M., & Eyberg, S. M. (2003). Father involvement in treat-
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therapeutic process. Parents were satisfied with their expe- for children with autism spectrum disorders. In C. B. McNeil, L.
rience with PCIT and reported significant improvement in B. Quetsch, & C. Anderson (Eds.), Handbook on Parent-Child
child behavior, compliance, and parent–child interactions. Interaction Therapy for children on the autism spectrum. Springer.
This study also expands the limited research on PCIT among https://​doi.​org/​10.​1007/​978-3-​030-​03213-5
Boggs, S. R., Eyberg, S. M., Edwards, D., Rayfield, A., Jacobs, J., Bag-
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Acknowledgment This work was supported by the Commonwealth 26, 1–22. https://​doi.​org/​10.​1300/​J019v​26n04_​01
Health Research Board Grant awarded to John W. Harrington. Broidy, L. M., Nagin, D. S., Tremblay, R. E., Bates, J. E., Brame, B.,
Dodge, K. A., Fergusson, D., Horwood, J. L., Loeber, R., Laird,
Author contribution Korrie Allen and John Harrington developed R., Lynam, D. R., Moffitt, T. E., Pettit, G. S., & Vitaro, F. (2003).
the study concept and design, received funding to conduct the study Developmental trajectories of childhood disruptive behaviors and
and oversaw all aspects of the study implementation, data collection, adolescent delinquency: A six-site, cross-national study. Devel-
analysis and interpretation, and led manuscript preparation. Lauren opmental Psychology, 39(2), 222–245. https://​doi.​org/​10.​1037//​
Quetsch and Joshua Masse contributed to the expertise of PCIT and 0012-​1649.​39.2.​222
significantly assisted with manuscript preparation and interpretation of Campis, L. K., Lyman, R. D., & Prentice-Dunn, S. (1986). The parental
results; Cathy Cooke assisted with program management and manu- locus of control scale: Development and validation. Journal of
script preparation; and James Paulson led the analysis and interpreta- Clinical Child & Adolescent Psychology, 15(3), 260–267. https://​
tion of the results. All authors reviewed the results and approved the doi.​org/​10.​1207/​s1537​4424j​ccp15​03_​10
final version of the manuscript. Carroll, R. A., & Kodak, T. (2019). Evidence-based treatment models
for autism spectrum disorder. In C. B. McNeil, L. B. Quetsch,
& C. Anderson (Eds.), Handbook on Parent-Child Interaction
Declarations Therapy for children on the autism spectrum. Springer. https://​
doi.​org/​10.​1007/​978-3-​030-​03213-5
Conflict of Interest The authors report no conflicts of interest. Charman, T., Pickles, A., Simonoff, E., Chandler, S., Loucas, T., &
Baird, G. (2011). IQ in children with autism spectrum disorders:
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bution 4.0 International License, which permits use, sharing, adapta- logical Medicine, 41(3), 619–627. https://​doi.​org/​10.​1017/​S0033​
tion, distribution and reproduction in any medium or format, as long 29171​00009​91
as you give appropriate credit to the original author(s) and the source, Dryden-Edwards, R. C., & Combrinck-Graham, L. (2010). Develop-
provide a link to the Creative Commons licence, and indicate if changes mental disabilities from childhood to adulthood: What works for
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included in the article's Creative Commons licence, unless indicated Dunn, D. M., & Dunn, L. M. (2007). Peabody Picture Vocabulary Test,
otherwise in a credit line to the material. If material is not included in Fourth Edition, manual. NCS Pearson, Inc.
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