1 Autistic Disorders: Single case and group interventions Paul Probst, Department of Psychology...

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1 Autistic Disorders: Single case and group interventions Paul Probst, Department of Psychology University of Hamburg, Germany [email protected] Lectures at the Department of Psychology of the Sun Yat-Sen-University in Guangzhou (Kanton), the School of Psychology in Zhou Hai and the East China University in Shanghai Collaborators: Marlis Rossbach (Ph.D.), Tobias Leppert (Ph.D.) and a group of Psychology- Diploma (graduate ) students Scientists Exchange Program Between Germany & People‘s Republic of China (Supported by German Academic Exchange Agency, Bonn and Ministry of Education, China)

Transcript of 1 Autistic Disorders: Single case and group interventions Paul Probst, Department of Psychology...

Page 1: 1 Autistic Disorders: Single case and group interventions Paul Probst, Department of Psychology University of Hamburg, Germany probst@uni-hamburg.de probst@uni-hamburg.de.

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Autistic Disorders: Single case and group interventions

Paul Probst, Department of Psychology University of Hamburg, Germany

[email protected]

Lectures at the Department of Psychology of the Sun Yat-Sen-University in Guangzhou (Kanton), the School

of Psychology in Zhou Hai and the East China University in Shanghai

Collaborators: Marlis Rossbach (Ph.D.), Tobias Leppert (Ph.D.) and a group of Psychology-Diploma (graduate ) students

Scientists Exchange Program Between Germany & People‘s Republic of China (Supported by German Academic Exchange Agency, Bonn and Ministry of Education, China)

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Pervasive Developmental Disorders: Assessment and Interventions

Common historical roots between Chinese and German Psychology?

Assessment Methods

Intervention Methods Metaanalysis Group trainings Single case studies

Conclusions Theoretical validity Internal validity External validity

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COMMON HISTORICAL ROOTS

Ernst MEUMAN, 1862-1915

Psychologist and Philosopher

1911-1915: Chair of the first Philophical and Psychological Institute in Hamburg, Germany

1911: founded the Psychological Laboratory in Hamburg

Main field: Educational Psychology (transfer between theory to practice)

William STERN (1916-1933): Successor: Focus on interdependence between basic and applied psychology and philosophy (ethical issues). „Intelligent Quotient“ (critical view)

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COMMON HISTORICAL ROOTS AND IDEAS Ernst MEUMAN: Student of Wilhelm WUNDT, (University of Leipzig (Lipsy), Germany: Founder of first Psychological Laboratory in 1879)

Tsai YANPAI: First Psy. Lab. in Beijing, 1917 (Qicheng Jing, 2000, Wang, 1993)

Central ideas in Meuman‘s program

Better understanding of the „child‘s nature“ by „Experimental Pedagogy“ (educational measurement, devel. p.)

Close association between basic and applied research

Close association between research and teaching

Parallels to „Institutions of Psychology in China“ (2000) and current international psychology („Practitioner Scientist Model“)

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Pervasive Developmental Disorders: Assessment Methods

International Classification Systems: ICD-10 (WHO Multiaxial version for child disorders (similar to

DSM-4) Interviews and Questionnaires (with parents and significant others)

Autism Diagnostic Interview-Revised (ADI-R) / Questionnaire Checklist for Autism in Toddlers (CHAT) Child Behavior Checklist (CBCL, Parent Form, Teacher Form) Parent Stress Index (Abidin)

Behavioral Observational instruments Autism Observational Schedule-Generic (ADOS-G) Adolescent and Adult Psychoeducational Profile (AAPEP)

Cognitive and Language Development Wechsler Intelligence Test for Children (WISC) Progressive Matrices Test Peabody Picture Vocabulary Test Diverse Language Development Tests (Morphology, Syntax,

Semantics, Pragmatics) Chinese-Language Assessment Methods (ZHANG, Houcan, 2000)

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Pervasive Developmental Disorders: Assessment

Infantile Autism: International Classification of Diseases (ICD-10-Rev)( ICD- 10, F84): Deficits in Social Interaction

Gaze behavior, less play with children, less mutual emotion, less shared attention

Deficits in Communication & Language 50 percent: no expressive language, monotonous speech,

deficits in conversation Deficits in Interests and Behavior

Stereotyped behavior, rituals, less pretend play Early Beginning: 24-36 mo. Comorbidity and above-chance associated symptoms:

Mental Retardation (F7) (about 70%), Epilepsy (15-25%)Behavioral symptoms like self-injuring behavior, aggression Hyperactive behavior: inattention, hyperactivity, impulsivity

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Other Pervasive Developmental Disorders: Assessment ICD-10

Asperger-Syndrome Deficits in Social Interaction Deficits in Interests and Behavior No important delay in language and cognitive

development (however deviant speech: intonation, rhythm: prosodic features of language)

Atypical Autism Onset after 36 months OR Not all three key symptoms completely present

Rett-Syndrom Normal development during the first 5 months Loss of goal-directed hand movement skills Disturbance of cognitive, language and motoric abilities

Disintegrative Childhood Disorder Loss of already aquired language skills after second year Disturbance of social, cognitive, and motivational abilities

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Pervasive Developmental Disorders: Prevalence

Infantile Autism: 0.5 per 1000 Autism spectrum: 1 per 1000 or more Estimation of prevalence by Chinese Parent

Organization: Stars and Rain, founded by the parent Ms. Tian Huiping in 1993: 1.2 per 1000 (400 000 to 500 000 autistic children out of 380 Mio children) (Li Heng, 2002 http://www.guduzh.org.cn/english/index.htm)

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Autistic child: Christoph, 12 yrs.

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Autistic child: Maksim, 6 yrs.

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Pervasive Developmental Disorders: Assessment

Autism Diagnostic Interview (ADI-R): about 110 Items

General development of child; worries of parents Communication and Language Social Development and Play Interests and Behavior

Example from Part "Interest and Behavior" (Item 75: "Compulsions and Rituals"):

"Are there things which apparently have to be done by your child in some fixed serial order or in some specified manner (...), as for example, touching special objects or putting of objects in specified orde, before he / she will be able to start with a new activity?"

Coding: Rating: 0, 1, 2, 3. 3= one ore more activities which HAVE do be done in specified manner,- if interrupted extremely anxious and upset, - family life severely impaired

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Pervasive Developmental Disorders: Assessment Checklist for Autism in Toddlers (CHAT)

Parent Questionnaire: "Has your child ever used his/ her index finger to show you

something or to ask for somewhat"? Examiner Observations

Try to get the attention of the child. Then point to something in the room which is attractive and interesting and say: " Oh look, there is a teddy!"

Autism Diagnostic Observation Schedule- Generic (ADOS-G) Language and Communication Reciprocal Social Interaction Play and Phantasy Stereotyped Behavior and Restricted Behavior Other Deviant Behaviors

4 Modules: Module-1 = Non-speaking Children Module-2 = Children and Adults: Phrases and sentences with 3 or

more words Module-3 = Children and Youth, fluently speaking Module-4 = Youth and Adults, fluently speaking

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Pervasive Developmental Disorders: Assessment-ADOS-G

Child's reaction on the attempt to produce "Shared Attention" (Toy: remote-controlled dog) Coding on 4-point rating scale: 0-3

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Pervasive Developmental Disorders: Assessment: ADOS-G

Module 1

Module 2

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Pervasive Developmental Disorders: Assessment: ADOS-G

Module 3

Module 4

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Pervasive Developmental Disorders: Assessment Adolescent and Adult Psychoeducational Profile (AAPEP)

AAPEP: Assessment of developmental level of persons with autism and mental retardation: 3 Scales Direct observation: semi-standardized in the home environment Questionnaire for significant others in the areas of school and work

Six dimensions of development

Vocational skills Independence Leisure skills Professional skills Functional communication Interpersonal Behavior

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Pervasive Developmental Disorders: Assessment Adolescent and Adult Psychoeducational Profile (AAPEP): Examples

- Vocational/ professionall skills

- Leisure skills

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Pervasive Developmental Disorders: Assessment: Coloured and Progressive Matrices: Adapted to non-speaking persons

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Pervasive Developmental Disorders: Assessment : Peabody Picture Vocabulary Test: Adapted

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Aspects of program development and Evaluation (Rossi et al., 2004, "Evaluation" )

Assessment of social needs for intervention Program theory evaluation

Program elements based on scientific evidence?

Process evaluation Are participants satisfied with the program services

Outcome (impact) evaluation Positive („desired“) outcomes? Unintended side effects?

Efficiency evaluation: cost benefit analysis

Pervasive Developmental Disorders: Interventions

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Social need for parent and teacher programs? Broad evidence from international research

literature for elevated stress profiles in families and classrooms with autistic and hyperactive children. : Specific symptom pattern which are disruptive in

social group life (e. g. compulsive, ritualistic behaviors)

Parent and teacher ask for more professional support and education (e. g. Haeussler, 2000, Three-nation-study)

Pervasive Developmental Disorders: Interventions: Social needs assessment

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• * 85% of parents report: My child lives in his/her own world sometimes or frequently, 61% of these parents say that this child behavior is very stressful. * Similarly, impairment in verbal communication, tantrum behavior, self-injuring behaviors, and strange behaviors in the public put high stresses on parents as well. * All parents from the present study report permanent demands caused by dependent behaviors of their child.

• Causes for stress reactions: (a) Specific child symptom pattern; (b) Fundamental attribution errors in former (and present!!) science: biased psychogenic theories blaming parents and other significant others for having caused autism tec.)

Pervasive Developmental Disorders: Interventions: - Social needs assessment

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Autistic child: Christoph, 12 yrs.

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Autistic child: Maksim, 6 yrs.

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Conceptual Framework: Program Theory Assessment

1. Etiology and Nature: Autism and ADHD are caused by genetic and medical factors; Autism: mostly permanent disability; Autistic persons have specific needs: "Need for sameness"

(Kanner, 1943), "visual learners", "need for visual structure" and "daily life routines" (Schopler, Schreibman; Howlin& Rutter);

2. Evidence-based psychological interventions can influence course and shape of autism and ADHD positively. They include:

3. Broad Spectrum Cognitive-Behavioral interventions Consequential interventions: focus on consequences following

behavior; Antecedent interventions: focus on stimulus (environment)

preceding behavior („Developmental perspective“); Broad spectrum parent, teacher and community interventions

(„Social systems perspective“); 4. Creating a trustful Expert –Mediator(= parent ... ) relationship. 5. „Client-centered“ perspective (Carl Rogers).

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Antecedent and Consequential Interventions

• S-O-R-C-K

Antecendent = preceding

interventions

Consequential interventions

S= Stimulus/ Situation: social and physical environment; O= Organism

(Individuum, Personality); R= Response (behavior, action);

C= Consequence (e. g. encouragement, reward, reproach,reprimand, admonition, withdrawal of privileges),

K= Contingency: reinforcement schedule: (e. g. continuous or intermittent)

Modification of child‘s environment accor-ding to develop-mental level + needs

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Evidence from metaanalysis: autism intervention studies

Scientist groups/

Functions

Schopler TEACCH

(USA), Struct.T.

+PT

Lovaas

(USA)ABA+PT

Koegel+Schreib-

mann

(USA), ABA+PT

Broad-SpectrumBehavior Th+PT

(USA)

HowlinRutter(UK), BS-

BT+PT

BS-BT +PT + TT

(Germany.)

Language - 1.08 D S 0.42 -

Cild Behavior

S 0.75 S S 0.60 S

Parent-Child

Interaction.

S - 1.17 S 0.75 S, D

Family adaptation

0.54 0.51 D D 1.03 D

Classroom behavior

D D D D - S

S= significant Outcome in One-Group-Pre-Post-Study; D= Descriptive Statistics= positive; Numbers in cells: Post-Post-Effect sizes from 2-group-controlled studies

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Main Research Objectives:

Are psychoeducational group training programs effective in: Parents of autistic (mostly mentally retarded

children) Special Education Teachers of autistic and

mentally retarded students (School councelors for serving students with

attention deficit/ hyperactivity disorder (AD/HD), who councel and supervise classroom teachers in regular schools)

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Methods of Evaluation-1

Specifications Autism Parent Group Training

Autism Teacher Group Training

ADHD Teacher Group Training

Child Sample 23 children (mostly mentally retarded), M-age= 9 yrs.

10 special school students; M-age= 10 yrs.

11 regular school students, M-age= 9 yrs.

High-Intensity-Group: n= 6, Low-Intensity-Group: n= 5

Training participants sample

24 parents (80% mothers)

10 special school teachers for mentally retarded children

6 school councelor teachers, who supervised 10 classroom teachers, who taught 11 children

Training setting variables

3-full-day-group training (in 3 groups) + sporadic single parent consultation

3-full-day group training + single teacher consultation and training (3h)

3-half-day-group training + parent and classroom teacher consultation (6h) + classroom teacher Contingency Management Training (8h: this module only in High-Intensity-group)

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Methods of Evaluation-2

Aspects Autism Parent Group Training

Autism Teacher Group Training

ADHD Teacher Group Training

Study design One-Group-Pre-Post (6 mo.)-Design

One-Group-Pre Post (9-mo.)-Design

Quasi-experimental Two-Group-Pre-Post (4 mo.)-Follow-Up (6 mo.)-Design :“High“- and „Low-Intensity“ Group

Curriculum (manualized)

(1) Theoretical Instruction: Causes, nature, and treatment of disorder

(2) Family and school issues (3) Practical instruction (by role play, exercises, video modelling ...)

(3a) How to shape child‘s environment by visual structure in space, time and action (schedules, visual guides, social stories)

(3b) How to change behaviors and teach new behaviors by behavioral consequences (e g. reward by tokens)

Process Assessment

- Parent Rating Scales - Teacher Rating Scales

- Teacher Rating Scales

Outcome Variables

- Parent Training Effect Evaluation Q.

- Symptom & Behavior Rating-Teacher Stress Q.

- Symptom Rating- School Situation Questionnaire

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Effect size

• Effect size statistics characterizes the magnitude of a program effect in a standardized form that makes it comparable across measures that use different units or scales (Rossi).

• Effect size-Post-Post: The standardized mean difference: the mean outcome difference between an experimental group and a control/ comparison group in standard deviation units:

– ES-Post-Post= (M-Post-Experimental minus M-Post-Control)/ pooled standard deviation (sd-post-post-pooled)

– ES-Post-Post-corrected-for-Pre-Pre-difference:

[ES-Post-Post= (M-Post-Experimental minus M-Post-Control)/ pooled standard deviation-post (sd-post-post)] minus [(M-Pre-Experimental minus M-Pre-Control)/ pooled standard deviation-pre (sd-post-post

• ES-Pre-Post= (M-Pre minus M-Post)/standard deviations of individual differences (s-diff): ES-Pre-Post= M-diff/s-diff

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Methods of Evaluation: Autism Parent Training Curriculum: practical instruction: Visual Structure

Daily Schedule (for Christoph, 12 yrs.)

What to do next?- Lunch

- Sleeping break

- Leisure activities with educator Holger

- Guided work with educator

- Independent work on table

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Methods of Evaluation: Autism Parent Training Curriculum: practical instruction

Visual structure in the bath-room: How to brush my teeth

Visual structure in the classroom: No kicking other children !!!

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Example: Autism Parent Training Curriculum: Practical instruction: parent discussion on dressing/ undressing problems in children: how

to implement visual structure

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Autism-Parent-Training: Parental Evaluation of Training Questionnaire

Percentage (%) of moderate or strong agreements to the statements on 4-point unipolar rating-scale

On the whole, parent training has been effective in improving my child's daily management

89%

Parent training enhanced our family atmosphere

68%

Parent training reduced the daily demands and stresses of parents

74%

The other parents in the parent training group were significant teachers to me

95%

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Autism-Parent-Training: Parent homework: Implementation of visual structure

Visual structure in the kitchen: Susanne's (16 yrs.) working schedule for setting the table:

- First to find plate

- then cup

- then glass

- then knive, fork and spoon

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Autism-Teacher-Training: Child Behavior Symptom Scale (Teacher Rating:

48 Item-Questionnaire)

97

98

99

100

101

102

103

104

105

106

Symptom Behavior Score

Pre

Post

Pre-Post-Effect size d= 0.66

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Autism-Teacher-Training: Child Behavior Symptom Scale (Teacher Rating): Most

improved symptoms

Symptom behavior (selection) Pre-Post-effect size (d)

“Child is disobedient, does not accept rules"

1.28

“ ... is not motivated to explore and to do new things" (.69), "

0.69

“ ... is frequently manipulating light switches"

0.63

“ … does not react on calling his/her name"

0.55

“ ... appears indifferent and non-responsive"

0.52

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Autism-Teacher-Training: Implementation of "Structured Teaching Strategies"

• Implementation: 9 of 10 (90%) teachers implemented at least one “structured teaching” strategy in the classroom. On the average, the teachers implemented 2 (out of 5 trained) strategies.

• Example: a 10-year old boy with mild mental retardation, severe language deficits, disruptive hyperactive and noisy behaviours got the opportunity to separate from the group for some time by sitting on a working place in a small room close to the classroom. After a few weeks the boy tolerated the group situation in the classroom better than before.

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ADHD-Teacher-Training: AD/ HS Symptom-Score (DSM-IV)

Teacher Rating: Number of symptoms (Max.= 18)

0,00

2,00

4,00

6,00

8,00

10,00

12,00

14,00

Pre Follow-Up

Intensive-G

Standard-G.

ES-Follow-Up-Follow-Up= 1.14

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ADHD-Teacher-Training: : Child Behavior Checklist (CBCL): Teachers‘s Report Form (TRF):

“How happy or satisfied is he/she?“

4,00

4,20

4,40

4,60

4,80

5,00

5,20

Pre Post FollowUp

Intensive-G

Standard-G.

4= average, 5= somewhat less, 6= clearly less

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Autism Intervention Methods: Single Case Study

• Computer-assisted training of purchasing skills: A single case study of a 15-year-old boy with early infantile autism

• Abstract. The aim of the present exploratory single case study is to examine the effectiveness of a computer-assisted training of purchasing skills in a 15-year-old boy with early infantile autism. The purchasing behavior was systematically observed under baseline, training, and post-training conditions. The systematic observation of the training process included variables of trainee's learning and tutor's teaching behavior. The video-based behavioral observations are analyzed by the partial time sampling and the event sampling method..

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Autism Intervention Methods: Single Case Study

Take (buy) it Now!

Anthony,

WISC:

Verbal-IQ= 57,

Non-Verbal-IQ= 48,

Total-IQ= 57

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Autism Intervention Methods: Single Case Study

- Example for training task: „You have 10 Euro, select 5 or more products ......

A. goes shopping: Left column: Count your money; Right column: Select products, fill in prizes; Add by pocket calculator, Middle column: compare both numbers : Enough money? If YES, go to the cashier

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Autism Intervention Methods: Single Case Study

0,00

5,00

10,00

15,00

20,00

25,00

30,00

Baseline-1 Training Baseline-2

Attention to pricelabels: Percentage(%) of intervals

Condi-tions

BL-1 TR BL-2

N of trials

3 35 3

N of inter-vals

41 591 51

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Autism Intervention Methods: Single Case Study

0,0010,0020,0030,0040,0050,0060,0070,0080,0090,00

100,00

Baseline-1 Training Baseline-2

Percentage (%) ofsuccessfulshopping trials

- Event sampling method: successful shopping trials

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Autism Intervention Methods: Single Case Study

The results indicate that the purchasing skills of the autistic adolescent could be improved significantly by the training.

There are restraints of internal and external validity.

The findings give evidence to the assumption that daily living skills such as shopping behavior in autistic persons can be improved significantly by computer-based interventions.

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ConclusionsConclusions

Threats of Experimental Validity

* Internal validity: no control group in autism parent & teacher trainings; quasi-experimental design in ADHD-Training); small samples, focus on verbal report outcomes (sources: parents teachers) * External validity („commodity“ samples“)

Effect Evaluation

Effectivity was evaluated positively by the majority of parents and teachers. They reported consistently substantial transfer from training to daily family and school life. – Several program effect sizes were in the medium to higher range

Program Evaluation

Programs include theory- and evidence-based elements, which are consistent with „normal science“;

Process Evaluation

Curriculum, trainer performance, group setting and

social climate were rated positively by great majority;

Efficiency Assessment

Group training can be considered as as "Low-Cost"-interventions. Li Heng (2002): "parents need to be educators", parent training programs offered.

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ConclusionsConclusions

• Overall ConclusionsOverall Conclusions• Given some methodological constraints, the

investigated parent and teacher training approaches have revealed some substantial degree of educational & clinical validity

• The findings are consistent with the results of a large body of international studies

• The findings suggest cross-cultural validity in terms of culture-specific adaptability of training concepts and interventions