Parenting An Autistic Child A literature map is a visual presentation

O R I G I N A L P A P E R

Parent and Family Outcomes of PEERS: A Social Skills Intervention for Adolescents with Autism Spectrum Disorder

Jeffrey S. Karst • Amy Vaughan Van Hecke •

Audrey M. Carson • Sheryl Stevens •

Kirsten Schohl • Bridget Dolan

Published online: 6 September 2014

� Springer Science+Business Media New York 2014

Abstract Raising a child with an Autism Spectrum Dis-

order (ASD) is associated with increased family chaos and

parent distress. Successful long-term treatment outcomes

are dependent on healthy systemic functioning, but the

family impact of treatment is rarely evaluated. The Pro-

gram for the Education and Enrichment of Relational Skills

(PEERS) is a social skills intervention designed for ado-

lescents with high-functioning ASD. This study assessed

the impact of PEERS on family chaos, parenting stress, and

parenting self-efficacy via a randomized, controlled trial.

Results suggested beneficial effects for the experimental

group in the domain of family chaos compared to the

waitlist control, while parents in the PEERS experimental

group also demonstrated increased parenting self-efficacy.

These findings highlight adjunctive family system benefits

of PEERS intervention and suggest the need for overall

better understanding of parent and family outcomes of

ASD interventions.

Keywords Autism � Parents � Caregivers � PEERS � Intervention

Introduction

Autism Spectrum Disorder (ASD) is a diagnosis charac-

terized by deficits in social communication and the pre-

sence of restricted, repetitive, and stereotyped interests and

behaviors (American Psychiatric Association 2013). Indi-

viduals with ASD demonstrate mild to severe impairment

early in development and continue to experience difficul-

ties throughout the lifespan. The increased rate of ASD

diagnoses (1 in 68 children: Center for Disease Control and

Prevention 2014) has contributed to a high level of demand

for effective services. However, there is great variability in

therapy options available for children and adolescents with

ASD, and marked discrepancy remains among the outcome

measures used to determine empirical support for these

interventions. The great majority of outcome studies to

date have focused directly on the child, ignoring the

broader family environmental context and leading to an

incomplete picture of the benefits and costs of any partic-

ular treatment (Karst and Van Hecke 2012). The limited

research on family and parent outcomes, which to date has

primarily stemmed from evaluation of parent training

programs, suggests a number of family and caregiver-level

benefits of intervention; including improved family rela-

tionships (Rogers 2000; Schertz and Odom 2007), reduced

J. S. Karst (&) � A. V. Van Hecke � A. M. Carson � S. Stevens � K. Schohl � B. Dolan Marquette University, 604 N 16th St., Cramer Hall #307,

Milwaukee, WI 53201, USA

e-mail: [email protected]

A. V. Van Hecke

e-mail: [email protected]

A. M. Carson

e-mail: [email protected]

S. Stevens

e-mail: [email protected]

K. Schohl

e-mail: [email protected]

B. Dolan

e-mail: [email protected]

Present Address:

J. S. Karst

Children’s Hospital of Wisconsin, Milwaukee, WI, USA

Present Address:

A. M. Carson

Texas Children’s Hospital, Houston, TX, USA

123

J Autism Dev Disord (2015) 45:752–765

DOI 10.1007/s10803-014-2231-6

levels of parenting stress and depression (McConachie and

Diggle 2007; Roberts and Pickering 2010) and greater

parenting self-efficacy (e.g., Sofronoff and Farbotko 2002).

It is likely that these positive environmental changes serve

to enhance, or at least maintain, gains made by a child or

adolescent in treatment.

The Program for the Education and Enrichment of

Relationship Skills (PEERS; Laugeson and Frankel 2010)

is an empirically supported social skills intervention for

adolescents with ASD that includes extensive parent

involvement throughout treatment. The PEERS interven-

tion has been offered through this midsized university’s

autism clinic beginning in the fall of 2010. This paper will

review the impact that having a child with an ASD can

have on families; followed by a brief review of social skills

interventions, including the PEERS program specifically,

and review the limited research on parent outcomes of such

treatments. Finally, the current investigation will be pre-

sented, which sought to determine whether families and

caregivers demonstrated benefit from participating in the

PEERS intervention.

Impact of ASD on Parents and Families

The impact of raising a child with ASD is extensive and

multifaceted. Families face significant demands on their time

due to the many needs of children with ASD, which fre-

quently includes participation in intensive therapy. Further,

families are often required to be flexible with their schedule

in order to accommodate the diagnosed child’s idiosyncratic

routines and behavior. In addition, families often deal with

significant financial demands secondary to the cost of ther-

apies, necessity of frequent travel for treatment, and limita-

tions on opportunities to work (Lord and Bishop 2010). The

extensive commitment required of families raising a child on

the autism spectrum often persists throughout the lifespan, as

approximately 85 % of individuals with ASD require life-

long family assistance in some fashion (Volkmar and Pauls

2003). Raising a child with ASD appears to negatively

impact the well-being of parents and families regardless of

symptom severity (Ekas et al. 2010; Pottie and Ingram 2008),

suggesting that even families of children with ‘‘higher-

functioning’’ ASD are negatively affected.

One of the most salient domains of impact caused by

ASD is the increase in chaos, or disorganization and lack of

order and routine, in the family system. Increased disorder

within the family has been attributed to numerous factors

associated with raising a child with ASD, including the

persistent time pressures and extensive financial burden

described earlier, as well as increased necessity for vigilant

parenting that is focused on one child in the family, con-

stant self- and child-advocacy (particularly with regards to

education) that takes time away from other family

necessities, fewer opportunities to work, and often the

presence of one or more therapists in the home (Lord and

Bishop 2010; Morrison et al. 2009; Pakenham et al. 2005;

Woodgate et al. 2008). Additionally, researchers have

found that families of children with ASD are more likely to

use maladaptive coping behaviors during times of crisis

(Sivberg 2002), exacerbating the disruptive nature of child

emotional or behavioral problems. Greater disruption

appears to contribute to a general decrease in family

quality of life (QOL) in families of children with ASD

when compared to the general population (Lee et al. 2008;

Mugno et al. 2007; Sivberg 2002).

Increased family chaos can cause reciprocal negative

effects on the child with ASD, as higher levels of family

chaos are associated with greater risk of child conduct

problems (Midouhas et al. 2013). The increased chaos seen

in families of children with ASD may also contribute to

increased parental conflict and decreased marital satisfac-

tion seen in these families (Brobst et al. 2009; Gau et al.

2011; Harper et al. 2013; Hartley et al. 2011). The presence

of emotional strain and relationship difficulties likely make

it more difficult for children with ASD to learn appropriate

social behaviors, as more maladaptive interactions are

modeled by caregivers who are frequently engaged in

conflict. An increase in family conflict may also create a

barrier to participating in enjoyable and potentially benefi-

cial activities, as families of children with ASD have been

found to limit involvement in community activities (Lam

et al. 2010). Notably, Kelly et al. (2008) noted that family

conflict was predictive of ASD symptom presentation and

found that negative family relationships influenced ASD

symptom manifestation more than positive family interac-

tions. These findings are understandable given the propen-

sity for most children with ASD to perform best in situations

with order, structure, and routine. Given this preference, it is

not surprising that children of ASD pick up on and are

negatively affected by familial chaos and distress.

In addition to systemic disorder within the family,

caregivers of children with ASD are affected at the indi-

vidual level. Parents of children with ASD experience

higher levels of parenting stress than parents of typically

developing children (e.g., Duarte et al. 2005; Hayes and

Watson 2012; Hoffman et al. 2009; Rao and Beidel 2009)

as well as parents of children with other developmental

disabilities (e.g., Estes et al. 2009, 2012; Schieve et al.

2007, 2011). This is concerning given that high levels of

parenting stress are associated with diminished child out-

comes over time following intervention (Osborne et al.

2008a, b). Additionally, parents of children with ASD

demonstrate decreased confidence in their parenting abili-

ties. This decrease in parenting self-efficacy (PSE) is

important to assess given the association between low PSE

and increased levels of parenting stress in parents of

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children with disabilities (Giallo et al. 2011). Sofronoff and

Farbotko (2002) noted that increased PSE post-intervention

was associated with fewer reported child behavior prob-

lems, suggesting that increases in PSE provides a direct

benefit to the child with ASD.

Social Skills Interventions for ASD

Given the significant strain associated with raising a child

diagnosed with ASD, it is important to understand how

specific treatments impact parents and families. The majority

of interventions for high-functioning adolescents with ASD

focus on addressing social deficits, which are important to

address given the negative outcomes associated with ostra-

cism in adolescents with ASD (Sebastian et al. 2009). Such

interventions available for pre-teens and teenagers with ASD

have demonstrated empirical evidence for improving social

deficits (Reichow and Volkmar 2010). Unfortunately, White

et al. (2007) noted that many of the gains made during

treatment appear to diminish after treatment has concluded.

One of the primary factors necessary for social skill main-

tenance is to help children with ASD generalize the skills

learned in treatment to broader contexts (Rao et al. 2008).

Increased generalization of skills is likely more difficult

without systemic changes made during treatment at both the

family and parent level. Many of the social skills programs

which include higher levels of parental involvement have

demonstrated evidence of long-term benefit, including the

Program for the Education and Enrichment of Relationship

Skills (PEERS; Laugeson et al. 2009).

The PEERS treatment curriculum is a 14-week manu-

alized intervention (Laugeson and Frankel 2010) that was

developed as an extension of Children’s Friendship

Training (CFT; Frankel and Myatt 2003). The PEERS

program uses a variety of cognitive-behavioral principles

to help enhance the social functioning of adolescents with

ASD (see Table 1). Preliminary research on PEERS has

identified significant social skills and friendship improve-

ments in adolescents with ASD immediately following

intervention and at 14-week follow-up (Laugeson et al.

2011), as well as up to 5 years post-treatment (Mandelberg

et al. 2014). Mandelberg et al. noted in their long-term

outcome study that parent involvement in this intervention

likely plays a large role in the maintenance of treatment

gains from PEERS. Specifically, Laugeson and Park (2014)

suggested that the ‘‘social coaching’’ (p. 93) role of parents

during and after PEERS is imperative for generalizing

skills learned during treatment.

Summary and Objectives

Raising a child with ASD is associated with family disrup-

tion and parent distress. There appears to be a transactional

relationship among the well-being of families and the

overall functioning of children with ASD (e.g., Mandell

et al. 2011; Osborne et al. 2008a, b; Siller and Sigman 2002).

However, comprehensive evaluation of parent and family

outcomes is limited in ASD intervention research, and

practically non-existent in research of social skills programs.

This limitation has led to incomplete understanding of fac-

tors associated with positive treatment outcomes, particu-

larly over the long term (Karst and Van Hecke 2012).

Thus, the primary aim of this study was to understand

the impact of the PEERS program, which includes exten-

sive family involvement, on family chaos, parenting stress,

and parenting self-efficacy. The PEERS program appears

likely to reduce household chaos by providing increased

structure and order for families, particularly in the domain

of their teen’s social interactions, via the presentation of

rote rules for initiating and maintaining friendships as well

as for dealing with negative events. Further, it was

expected that PEERS would reduce parenting stress by

providing parents education on trouble-shooting their

teen’s social difficulties (via the PEERS curriculum and

providers. It was also expected that the guidelines provided

throughout PEERS would help increase parenting self-

efficacy by providing parents with concrete methods for

addressing problematic situations such as peer ostracism,

conflict, teasing, and bullying. Thus, it was predicted that,

following 14 weeks of PEERS intervention: (1) Families in

the experimental group would demonstrate decreased lev-

els of family chaos compared to those in the waitlist control

group, as measured by the Confusion, Hubbub, and Order

Scale (CHAOS; Matheny et al. 1995); (2) Parents in the

experimental group would demonstrate significantly

decreased levels of total parenting stress compared to

parents in the waitlist control group, as measured by the

Table 1 PEERS sessions and content

Session Didactic

1 Introduction and conversational skills I: trading information

2 Conversational skills II: Two-way conversations

3 Conversational skills III: Electronic communication

4 Choosing appropriate friends

5 Appropriate use of humor

6 Peer entry I: entering a conversation

7 Peer entry II: exiting a conversation

8 Get-togethers

9 Good sportsmanship

10 Rejection 1: teasing and embarrassing feedback

11 Rejection II: bullying and bad reputations

12 Handling disagreements

13 Rumors and gossip

14 Graduation and termination

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Stress Index for Parents of Adolescents (SIPA; Sheras et al.

1998); and (3) Parents in the experimental group would

demonstrate significantly increased levels of parenting self-

efficacy compared to parents in the waitlist control group,

as measured by the parenting self-efficacy subscale of the

Parenting Sense of Competence Scale (PSOC; Gibaud and

Wandersman 1978, as cited in Johnston and Mash 1989).

Methods

Participants

The study was part of a larger randomized, controlled trial

evaluating several domains of PEERS outcomes and was

approved through the university Institutional Review

Board. The PEERS intervention was offered free of charge

to families participating in this study. Incentive for par-

ticipation limited to a small prize (i.e., approximately 25

dollars in value) provided at the end of PEERS for teens

who successfully completed the program.

The final sample for this study consisted of 64 parent–

child dyads (32 from both the experimental and waitlist

control group; see Fig. 1 for recruitment details). The

experimental group included 22 female caregivers and 10

male caregivers along with 26 male adolescents and 6

female adolescents, while the waitlist group consisted of 25

female caregivers and 7 male caregivers along with 27

male adolescents and 5 female adolescents. Data analyses

were conducted using SPSS statistics, version 19 (IBM

2010). Statistical analyses suggested no significant differ-

ences on key demographic variables between parents who

completed parenting measures and families who did not

complete the intervention, those with missing or incom-

plete data, or families in which a different parent com-

pleted pre- and post-measures. Primary analyses were also

conducted with male caregivers removed from both groups,

with no major differences emerging in the outcomes

reported in this paper. Parents in the final sample ranged

from 32 to 56 years of age with an average of 46.3 years of

age; teens ranged from 11 to 16 years of age with an

average of 13.8 years of age at the time of intake. There

were no significant differences on parent age or teen age

between the experimental and waitlist groups. In addition,

Fig. 1 PEERS recruitment CONSORT

Table 2 Demographic means and standard deviations

EXP (n = 32) WL (n = 32)

Parent age 46.1 (4.6) 46.6 (5.6)

Child age 14.1 (1.3) 13.4 (1.5)

# of Siblings 1.3 (1.0) 1.5 (0.9)

Verbal SS 100.65 (18.75) 95.60 (18.29)

Non-verbal SS 102.00 (18.38) 101.56 (15.85)

Full scale IQ 101.94 (18.32) 98.63 (18.00)

ADOS communication 3.91 (1.60) 3.56 (1.52)

ADOS social interaction 7.38 (2.03) 7.66 (2.32)

ADOS total score 11.34 (3.19) 11.12 (3.42)

Vineland 75.13 (11.21) 78.82 (12.84)

EXP experimental group, WL waitlist control group, SS standard

score, Vineland vineland total adaptive behavior composite

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no significant differences between groups were found for

teen intellectual functioning (as measured on the KBIT-2)

or ASD symptom severity (as measured on the ADOS-G,

Module 4). For additional demographic information, please

see Tables 2 and 3.

Procedure

Recruitment

Families were recruited for participation in PEERS through

local ASD support, service, and diagnostic agencies,

advertisements in the local Autism Society newsletter, and

through word of mouth from families with previous partic-

ipation. Upon calling to express interest in PEERS, families

were provided with a brief synopsis of the program and, if

interested, participated in a telephone screening process to

ensure that teens met criteria for initial inclusion in PEERS.

This screener is included in the PEERS manual and provided

a brief assessment of teen interest in the program and

intellectual functioning as well as family willingness to

participate in treatment. At this point, all families meeting

criteria for potential enrollment were placed on a call list for

the next available round of intake appointments, which were

held twice annually in August and January. A maximum

number of 20 children were accepted for each round of

intakes, allowing for a maximum of 10 adolescents in each

intervention group, the highest number recommended for

PEERS groups by Laugeson and Frankel (2010)

Randomization and Inclusion Criteria

Following initial enrollment in PEERS via the phone

screener, families were randomly assigned to either the

‘‘experimental’’ or ‘‘control’’ group (see Fig. 1 for CON-

SORT diagram detailing process of enrollment). Random

assignment was completed for each set of intakes, which

comprised of between 14 and 20 families each (i.e., 7–10

adolescents per group), and was done by alternating

assignment per subject number. The only contingency to

random assignment was that no PEERS group could con-

tain only one child of either gender. Inclusion for enroll-

ment in PEERS and this study included meeting several

criteria. First, the adolescent had to clearly state interest in

participating in the group via administration of a PEERS-

specific mental status checklist (Laugeson and Frankel

2010). Second, the teen and his or her parent(s) needed to

be willing to attend PEERS regularly, with a maximum of

two absences allowed. In addition, the child needed to

obtain a verbal and full scale IQ score on the Kaufman

Brief Intelligence Test-Second Edition (Kaufman and Ka-

ufman 2004) of greater than or equal to 70. Further, teens

needed to be between the ages of 11 and 16 years old at the

time of their intake, and be enrolled in either middle school

or high school. Finally, the child had to meet criteria for a

diagnosis of either Autism or Autism Spectrum Disorder on

the Autism Diagnostic Observation Schedule-General

(ADOS-G; Lord et al. 2002), Module 4. The ADOS-G is a

gold standard of ASD evaluation (Ozonoff et al. 2005), and

trained members of the PEERS team who had established

ADOS coding reliability completed administration of the

ADOS-G. Of note, given that this study was commenced

prior the publication of the DSM-5, it is not clear whether

all participants would meet new criteria for an ASD diag-

nosis given the required presence of restricted or repetitive

interest and behaviors. An additional requirement was that

teens not have comorbid severe mental health disorders

(e.g., psychotic disorders). However, no potential partici-

pants were excluded due to this criterion.

Pre-assessment

Prior to the first intake appointment, the parent or parents

who planned on attending PEERS sessions were asked to

Table 3 Demographic frequency statistics

EXP experimental group, WL

waitlist control group

Marital status Education level Income Parent race/ethnicity

EXP

Married = 24 High school = 1 Under 25K = 2 Black non-Hispanic = 1

Divorced = 7 Some college = 6 25–50k = 4 White non-Hispanic = 30

Unmarried = 1 College degree = 19 50–75k = 7 White Hispanic = 1

Advanced degree = 3 75–100k = 3

100k? = 15

WL

Married = 25 High school = 3 Under 25k = 1 Black non-Hispanic = 2

Divorced = 4 Some college = 2 25–50k = 5 White non-Hispanic = 29

Separated = 1 College degree = 19 50–75k = 4 White Hispanic = 1

Unmarried = 2 Advanced degree = 8 75–100k = 5

100k? = 15

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attend this appointment with their teen. For both groups,

the intake process consisted of the following: First, parent

consent and teen assent for participation in PEERS and the

research associated with PEERS were reviewed and signed.

Next, in a separate room from their teen, parents completed

questionnaires for this study as well as measures pertaining

to their child’s social skills, emotional and adaptive func-

tioning, and behavior. Concurrently, teens were adminis-

tered the ADOS-G and KBIT-2 to ensure that they met

criteria for enrollment in PEERS. Parents were informed

immediately regarding their teen’s eligibility for partici-

pation. The teens were then provided with a variety of

questionnaires regarding their social skills, experiences,

and self-perception. Following administration of these

questionnaires, teens participated in other components of

the broader investigation of PEERS. At the conclusion of

the intake process, families were notified of their assign-

ment to either the experimental or waitlist group to ensure

that responses were not biased by group assignment.

PEERS Intervention

Following completion of the intake process, parents and

teens in the Experimental group attended 14 weekly ses-

sions of PEERS spaced out over a 16-week period to allow

time for holiday and school breaks. Parent and teen ses-

sions consisted of concurrent but separate, weekly, 90-min,

didactic sessions that strictly adhered to the treatment

outline in the PEERS manual (Laugeson and Frankel

2010).

The PEERS intervention focused on numerous impor-

tant topics related to initiating and maintaining friendships

in adolescence (see Table 1). Major themes presented to

teens during PEERS included identifying appropriate

friends, trading information and establishing common

interests with others, improving conversational skills,

hosting get-togethers with friends, and dealing with nega-

tive events such as teasing, bullying, and arguments. In

addition to these topics, Laugeson et al. (2009) identified

three core features of PEERS intervention. The first pri-

mary feature is the small group format of PEERS, which is

recommended to include between 5 and 10 teenagers.

Secondly, Laugeson et al. noted that parent involvement is

crucial and allows for direct instruction of social skills,

supervision and practice throughout intervention, and

support of the child’s attempts to develop appropriate

friendship networks. Finally, the lessons presented in

PEERS are founded on social etiquette rules consistent

with modern-day adolescent relationships. These skills are

presented in concrete, directed lessons in accordance with

the optimal learning style of children with ASD (Laugeson

and Frankel 2010). Regular fidelity checks were conducted

by trained undergraduate assistants to ensure treatment

remained adherent to the PEERS manual and was equiva-

lent between groups.

Teen PEERS sessions were led by Master’s level stu-

dents in the Clinical Psychology doctoral program, under

the supervision of a certified PEERS provider who had

participated in formal on-site training from the developers

of the PEERS treatment manual. Teen group leaders were

assisted by trained undergraduate psychology students,

who acted as ‘‘coaches’’ during behavioral rehearsal of

skills learned in PEERS and assisted in role-play presen-

tations of rules. Parent sessions were led by advanced

graduate students in the Clinical Psychology Doctoral

Program, again under the supervision of the trained PEERS

provider, who provided weekly hour-long supervision

sessions for both graduate students and coaches.

The treatment sessions were held in two separate rooms

within the Psychology Department’s mental health clinic.

The teen sessions followed a regular format beginning with

homework review (e.g., discussion of each teen’s get-

together), followed by presentation of the new didactic

lesson, therapist and coach ‘‘role play,’’ behavioral

rehearsal, review of new homework, and re-unification

with parents (which includes a review of the lesson and

homework assignment). Didactic lessons focused on pre-

sentation of social guidelines, which were written in

numerical sequence on a whiteboard at the front of the

room, while teens were asked to participate in discussion of

why these rules helped build and maintain friendships. For

example, the session on ‘‘handling disagreements’’ outlined

a multi-step method for resolving conflict with friends,

after which teens participated in a mock disagreement with

the PEERS leader or coach in which they were asked fol-

low these steps in sequence. Behavioral rehearsals were

carried out through indoor or outdoor activity period to

help generalize the skills learned in group, with therapist

and coaches providing in vivo feedback. For example,

following the lesson on good sportsmanship, teens were

asked to play a game amongst a small group (2–3 other

participants) while utilizing the rules they had just learned.

The PEERS parent sessions included homework review

and troubleshooting, discussion of that week’s didactic

lesson, and review of homework for the upcoming week

prior to re-unification. Per the PEERS manual, parents

were discouraged from using the meeting as a support

group, but were free to provide instrumental support by

offering advice for how they had overcome specific barri-

ers to implementing lessons and completing PEERS

homework. The final week of PEERS consisted of a

graduation ceremony and party, where parents reviewed

major concepts of the group and discussed plans for

moving forward after PEERS, while teens were rewarded

with prizes and games dependent on the level of individual

and group participation.

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During the treatment period, the waitlist control group

was free to access community services and resources as

needed. Parents were asked to report on the use of such

services for themselves, their family, or their child at the

time of their follow-up appointment with the administra-

tion of a brief survey.

Post-assessment

After the experimental group had completed the PEERS

program, both the waitlist and experimental groups com-

pleted the same measures and procedures as during the

intake session. The outtake sessions were mostly similar to

the intake sessions; though consent and assent procedures

and administration of the ADOS-G and KBIT-2 did not

take place. Teens were again asked to complete their forms

in a separate room from their caregiver and had a graduate

or undergraduate research assistant available to answer

questions about any items.

Measures

Confusion, Hubbub, and Order Scale (CHAOS)

The CHAOS (Matheny et al. 1995) is a 15-item, parent-

report measure assessing environmental confusion in the

home. Items are presented on a 6-point Likert scale from

‘‘Strongly Agree’’ to ‘‘Strongly Disagree,’’ with higher

scores indicating greater reported family chaos. Examples

of items include ‘‘Your family almost always seems to be

rushed’’ and ‘‘The atmosphere in your home is calm.’’

Matheny et al. (1995) reported good internal consistency

(0.79) among items. Further, Coldwell et al. (2006) con-

firmed significant bivariate correlations between household

chaos, as measured by the CHAOS, and parenting factors

such as warmth, enjoyment, anger, hostility, and parent–

child positivity and negativity. Additionally, Coldwell

et al. found that household chaos, as measured by the

CHAOS, predicted problem behavior in children over and

above parenting factors, suggesting strong construct

validity of the CHAOS. Assessment of scale reliability via

Cronbach’s alpha suggested good internal consistency (.87

and .81) at pre and post intervention in this study.

Stress Index for Parents of Adolescents (SIPA)

The SIPA (Sheras et al. 1998) is a screening and diagnostic

instrument that identifies areas of stress in parent-adoles-

cent interactions and is appropriate for parents of adoles-

cents ranging in age from 11 to 19 years. The SIPA

consists of 90 items assessing the amount of stress expe-

rienced by a parent as a function of specific characteristics

of his/her adolescent life (i.e. Adolescent Domain), func-

tioning that relates to a parent’s distress as he/she interacts

with the adolescent (i.e. Parent Domain), and the perceived

quality of the relationship that the parent has with the

adolescent (i.e., Adolescent-Parent Relationship Domain).

These scales combine to form a Total Parenting Stress

score. There is also a 22-item scale that measures the

number of stressful life events the parent has experienced

in the past year. The majority of subscale coefficient alphas

range from the high .80 s to .90, and test–retest reliability

estimates for a 4-week interval range from .74 to .93 for

SIPA subscales (Sheras et al. 1998). Parenting stress as

assessed by the SIPA has been found to relate to the quality

of parents’ perceptions of their parenting alliance, other

psychological measures of adolescent and parent func-

tioning, and the quality of the marital relationship and

family system (Sheras et al. 1998). Ozonoff et al. (2005)

identified the SIPA as a psychometrically sound measure

for use with parents of adolescents with ASD. Within this

study, Cronbach’s alpha suggested strong internal consis-

tency (.95) at pre and post intervention.

Parenting Sense of Competence Scale (PSOC)

The Parenting Efficacy subscale of the PSOC (Gibaud-

Wallston and Wandersman 1978, as cited in Johnston and

Mash 1989) is a 7-item, parent-report measure of parenting

self-efficacy, defined as the ‘‘degree to which the parent

feels competent, capable of problem solving, and familiar

with parenting (Johnston and Mash 1989, p. 173) The

measure includes a six-point Likert-scale ranging from

‘‘Strongly Disagree’’ (6) to Strongly Agree (1) on state-

ments such as ‘‘I meet my own personal expectations for

expertise in caring for my child’’ and ‘‘If anyone can find

the answer to what is troubling my child, I am the

one’’(Johnston and Mash 1989, p. 171). Reverse scoring is

used such that higher scores indicate greater levels of

parenting self-efficacy. Johnston and Mash (1989) reported

good internal consistency within the parenting efficacy

subscale (alpha = 0.76) and as well as good divergent

construct validity from the other subscale of the PSOC

(Parenting Satisfaction). Cronbach’s alpha suggested

excellent internal consistency at pre (.90) and post (.92)

intervention for this study.

Results

Exploratory Analyses

Exploratory bivariate correlational analyses were con-

ducted to assess for linear relationships among variables of

758 J Autism Dev Disord (2015) 45:752–765

123

interest for the total sample. This allowed for better

understanding of the overlap among parent and family

constructs as well as determination of whether child factors

such as cognitive ability and ASD symptomology were

related to parent and family functioning. (See Table 4 for

summary). When assessing parent report across both

groups, Pearson’s r correlations suggested a significant

inverse relationship between parenting self-efficacy

(PSOC) and total parenting stress (SIPA), r (62) = -.47,

p \ .001, as well as between parenting self-efficacy and family chaos (CHAOS), r (62) = -.50, p \ .001. Parent- ing stress and family chaos were also inversely related,

r (62) = .30, p = .017. None of the primary variables of

interest were significantly correlated with full scale IQ on

the KBIT-2 or total score on the ADOS-G.

Primary Analyses

To assess hypotheses regarding significant change in the

experimental group versus the waitlist control group from

pre to post-intervention, five mixed between-within sub-

jects analysis of variance (ANOVA) were conducted (see

Table 5 for scale means and standard deviations and

Table 6 for ANOVA results).

Family Chaos

In assessing overall family disruption from the CHAOS,

there was not a significant main effect for time or group.

However, there was a significant interaction effect between

time and group, Wilks Lambda = .936, F (1, 62) = 4.26,

p = .04, partial eta squared = .06, suggesting a significant

difference between groups over time in the domain of

family disruption and distress, with the experimental group

showing a significant decrease in family chaos over time in

comparison to the waitlist control group (see Fig. 2). Fol-

low-up of this interaction via simple effects paired t tests

suggested marginally significant reduction in family chaos

in the experimental group (p = .07), with a non-significant

increase in the waitlist control group (p = .18).

Parenting Stress

In assessing the impact of PEERS on total parenting stress

T-scores from the SIPA, there was not a significant main

effect for time or group. There also was not a significant

interaction effect between time and group (p = .23, partial

eta squared = .03), suggesting no significant difference

Table 4 Significant bivariate correlations among variables of interest prior to intervention (n = 64)

SIPA-TS PSE (PSOC) CHAOS

SIPA-TS – -.474** .298*

PSE (PSOC) – – -.502**

Parent age -.108 -.078 -.092

Teen age -.017 -.125 .062

# of siblings -.009 -.002 -.002

FSIQ (KBIT-2) .099 -.081 .047

ADOS-G total score .152 -.097 .033

* p \ .05 ** p \ .01 SIPA–TS stress index for parents of adolescents–total parenting stress,

PSE parenting self-efficacy, PSOC parenting sense of competence

scale, CHAOS confusion, hubbub, and order scale, KBIT-2 kaufman

brief intelligence test, second edition, ADOS Autism diagnostic

observation schedule, general

Table 5 Scale means and standard deviations

EXP-pre EXP-post WL-pre WL-post

CHAOS-total score* 40.4 (11.7) 38.7 (9.1) 36.9 (10.7) 39.6 (14.5)

SIPA-total stress T-score 211.7 (32.4) 200.4 (35.3) 215.4 (50.4) 218.8 (49.9)

PSOC-parenting self-efficacy (mean) 4.05 (.78) 4.29 (.72) 4.46 (.83) 4.43 (.66)

* Significant interaction effect (group 9 time) at p \ .05 EXP experimental group, WL waitlist control group, CHAOS confusion, hubbub, and order scale, SIPA stress index for parents of adolescents,

PSOC parenting sense of competence scale

Table 6 Mixed between-within subjects ANOVAS

Scale df F g p

CHAOS (Confusion, hubbub, and order scale)

Main effect: time (within subjects) 1, 62 0.18 .00 .67

Main effect: group (between subjects) 1, 62 .22 .00 .64

Interaction: time 9 group 1, 62 4.26 .06 .04

SIPA: total stress

Main effect: time (within subjects) 1, 62 0.60 .01 .44

Main effect: group (between subjects) 1, 62 1.44 .02 .20

Interaction: time 9 group 1, 62 1.63 .03 .23

PSOC: parenting self-efficacy

Main effect: time (within subjects) 1, 62 0.91 .01 .34

Main effect: group (between subjects) 1, 62 3.12 .05 .08

Interaction: time 9 group 1, 62 1.44 .02 .23

SIPA stress index for parents of adolescents, PSOC parenting sense of

competence scale

J Autism Dev Disord (2015) 45:752–765 759

123

between groups over time in total parenting stress (see

Fig. 3).

Parenting Self-Efficacy

There was not a significant main effect for time or group

when evaluating parenting self-efficacy from the PSOC.

Additionally, there was not a significant interaction

between time and group (p = .23, partial eta

squared = .02), suggesting no significant difference

between groups over time in the domain of parenting self-

efficacy (see Fig. 4). However, a planned analysis, via

paired samples t test, revealed a significant increase in

parenting self-efficacy in the experimental group,

t (32) = 2.18, p = .04, from pre- to post-intervention.

Discussion

There is a substantial body of research suggesting that

raising a child with ASD is associated with elevated levels

of family chaos and distress, increased parenting stress, and

decreased parenting self-efficacy. Comprehensive inter-

ventions for ASD should address these larger issues, as

systemic environmental changes appear necessary to

ensure maintenance of treatment gains and improve long-

term outcomes of therapy. However, family outcomes of

ASD intervention are rarely assessed. This study assessed

64 families of adolescents with high-functioning ASD to

determine whether involvement in the PEERS program

would facilitate decreased family chaos, decreased par-

enting stress, and increased parenting efficacy.

Conclusions

Findings with regard to the primary hypotheses were

mixed. There was a significant time 9 group interaction

effect found for family chaos (as measured on the

CHAOS), with the experimental group showing a non-

statistically significant decrease in family chaos while the

Fig. 3 Total parenting stress scores on the stress index for parents of adolescents (SIPA). Error bars represent standard error (±1 SE)

Fig. 4 Mean parenting self-efficacy scores from the parenting sense of competence scale (PSOC). Error bars represent standard error (±1

SE) Fig. 2 Total family chaos scores on the confusion, hubbub, and order scale (CHAOS). Error bars represent standard error (±1 SE)

760 J Autism Dev Disord (2015) 45:752–765

123

waitlist control group demonstrated an increase in chaos,

though this main effect was also not significant. The dif-

ference in change within the domain of family chaos

demonstrated a medium effect size (Cohen 1988; eta

squared = .064). Though the individual group changes

were not statistically significant, taken together it appears

that family involvement in PEERS may have a positive

impact on structure and order in the home.

The significant interaction found on the CHAOS mea-

sure reflects an important, and in some ways counterintu-

itive, potential benefit of PEERS intervention. Throughout

the program, families are asked to take on numerous

‘‘homework’’ tasks, including making both in-group and

out-of-group phone calls and hosting get-togethers with

same-aged peers. The additional time burden necessitated

by completing these tasks each week (in addition to

attending PEERS for 90 min each week) is a necessary

component of the intervention process that could poten-

tially increase family disruption. The fact that these

requirements did not increase chaos, and thus did not

mitigate the systemic benefits of improved adolescent

socialization, is extremely encouraging and suggests that

these families may have found these tasks meaningful and

beneficial despite the extra time and effort required.

Instead, it is possible that the homework assignments had

an ‘‘organizational effect’’ on families, making it necessary

to integrate more structure and routine into the home and

therefore reducing chaos. In addition, it is notable that the

CHAOS measure specifically attempts to quantify envi-

ronmental confusion, and it is possible that the provision of

‘‘rules’’ within the PEERS treatment curriculum provides

families with more structure and order for managing social

interactions. Finally, it is possible that direct benefits of

PEERS on the adolescent participants (e.g., increased get-

togethers) allowed for a more developmentally normative

amount of ‘‘social time’’ for teens, opening up availability

for parents to regain order and establish a more regular

routine in the home.

When assessing parenting stress via the SIPA, we could

not reject the null hypothesis that parents participating in

PEERS experienced a decrease in parenting stress that was

significant over and above that of a waitlist control group.

Large variance in the overall sample and a small effect size

appeared to contribute to a lack of statistical significance

when assessing the time (pre to post intervention) 9 group

(experimental vs. waitlist control) interaction. Nonetheless,

the direction of the effect seen was in the hypothesized

direction and suggests that the effect of participation in

PEERS on parenting stress warrants further evaluation with

an increased sample size and/or use of a more sensitive

measure (perhaps an ASD-focused instrument).

With respect to parenting self-efficacy, there was an

increase in mean parenting self-efficacy (as measured on

the PSOC) in the experimental group, while the waitlist

group’s mean self-efficacy score remained essentially

unchanged. Paired sample t test analysis suggested that the

increase in parenting self-efficacy from pre to post-treat-

ment in the experimental group was statistically significant

at p \ .05. However, mixed between-within ANOVA analysis suggested that the time 9 group interaction effect

was not statistically significant. Thus, while there did

appear to be a statistically significant increase in parenting

self-efficacy for the experimental group following PEERS

intervention, this change was not significant over and

above a no-intervention waitlist control group. It is

believed that the increased variance in the waitlist group

contributed at least somewhat to the lack of a statistically

significant finding in this domain. This finding warrants

further investigation with an increased sample size, and it

is encouraging that participation in PEERS did appear to

increase parenting self-efficacy. Further research in this

domain appears important given the mediating effect

established for parenting self-efficacy between child

behavior problems and maternal mental health (Hastings

and Brown 2002).

Analysis of linear relationships among the entire sam-

ple (n = 64) prior to intervention also revealed very

interesting and meaningful associations among variables

of interest that should be considered when understanding

and evaluating parent outcomes of treatment. Replicating a

finding by Giallo et al. (2011), parenting self-efficacy was

negatively associated with parenting stress, suggesting that

parents who feel less confidence in their abilities feel more

overwhelmed by the many demands of raising a child with

an ASD. In addition, there was an inverse correlation

between parenting self-efficacy and family chaos, a rela-

tionship that warrants further analysis. It is possible that

parents with less confidence in their own abilities provide

less structure and order for the family, or conversely that a

chaotic household leaves parents feeling less in control

and thus less efficacious. In addition, it is notable that

neither adolescent intellectual functioning (as measured by

scores on the KBIT-2) nor ASD symptomology (as mea-

sured by total score on the ADOS-G) were associated with

parenting stress, parenting self-efficacy, or family chaos.

This finding replicates earlier research which demon-

strated no difference in parenting stress for parents of

children with or without cognitive deficits (Davis and

Carter 2008; Rao and Beidel 2009) or for parents of

children with varying severity of social and communica-

tive impairment (Tomanik et al. 2004). The fact that

parenting stress and self-efficacy do not appear related to

these domains of child functioning highlights the need for

parent involvement in treatment even when teens are

classified as ‘‘higher-functioning,’’ as was the case in the

present study.

J Autism Dev Disord (2015) 45:752–765 761

123

Implications

Overall, results from this study suggest that the PEERS

intervention offers promising adjunctive benefits for fam-

ilies in addition to the improved teen social outcomes

resulting from PEERS demonstrated in the larger project

encompassing this study as well as those conducted by

others research groups (e.g., Laugeson et al. 2011; Man-

delberg et al. 2014; Schohl et al. 2014). The significant

time 9 group interaction found on the CHAOS highlights

the way in which the PEERS intervention, through the use

of concurrent parent and teen sessions, may help improve

the trajectory of family chaos or dysfunction for families

heavily burdened by their child’s diagnosis and associated

impairments. Changes made during the intervention could

very well improve the home environment post-treatment,

making this setting more conducive to social gatherings,

decreasing family disruption that often impedes social

opportunities, and helping eliminate conflict that exacer-

bates ASD symptomology (Kelly et al. 2008). In addition,

the fact that parenting self-efficacy showed a statistically

significant increase following PEERS intervention (though

this was not significant over and above the waitlist control

group) appears very important given the relationship

between parenting self-efficacy and child behavior prob-

lems (Sofronoff and Farbotko 2002).

Limitations and Future Directions

There are several notable limitations to the present study.

Perhaps the most significant limitation were small effect

sizes found for the primary outcome variables, particularly

with respect to parenting stress and parenting self-efficacy.

An additional limitation was the lack of a control group

which did not include direct parent and family involve-

ment. Further, this study did not compare PEERS outcomes

to those of another form of intervention as is no ‘‘gold

standard’’ for social skills intervention, as no current for-

mat has yet to meet Chambless et al. (1996) criteria to be

considered empirically validated.

An unavoidable limitation resulted from the fact that the

control group was not restricted from participating in other

available interventions. However, parent report suggested

that adjunctive therapy for the waitlist control group was

minimal (i.e., only a few participants with psychophar-

macological intervention). Another limitation related to the

control group is that at the time of intake, while parents did

not know which group they would be assigned to, they did

know that they would be enrolled in an intervention soon if

their child met inclusion criteria. While a brief waiting

period was not preferable compared to immediate enroll-

ment, the paucity of therapies available for adolescents

with ASD also means that even parents in the control

group may have experienced increased hopefulness. Thus,

the promise of an empirically supported (and no-cost)

intervention was essentially made to all participants

meeting inclusion criteria, which may have altered parent

report prior to intervention across groups. In addition, the

fact that our intervention was offered free of charge to

families (in exchange for their research participation)

eliminated a common stressor associated with therapy for

families.

The use of parent-report measures in this study is an

additional limitation, as social desirability could introduce

bias in the results obtained. More objective measures (e.g.,

observational data) could be used in future studies to help

reduce this bias. Further, to ensure independence of data,

only one parent report per teen was obtained for this study.

Future research should also gather information regarding

the functioning and well-being of other parents or family

members in order to obtain a more robust understanding of

the systemic environment. This study was also limited by

the lack of data collection during PEERS, such as at a mid-

point during the intervention, which would have allowed

for assessment of non-linear patterns related to the vari-

ables of interest. PEERS intervention requires weekly

homework assignments which include having adolescents

enroll in one or two extracurricular activities, call friends

from social groups at school or in the community, and

having parents and teens to facilitate regular ‘‘get-toge-

thers.’’ These activities are often stressful for parents and

anxiety provoking for teens, as they often necessitate

approaching difficult tasks that have long been avoided.

Anecdotally, many parents acknowledged an initial

increase in both their own stress early in the intervention,

followed by a decrease in distress as the teens begin

developing meaningful relationships. A more regular

assessment of teen and parent functioning would help

identify if this was actually the case for most participants.

If this pattern does occur, it is possible that parenting stress

continues to decrease after intervention. Future studies

should include long-term collection of both parent and teen

data, which would allow for analysis of maintenance of

treatment gains.

It also should be noted that our sample was relatively

homogenous, consisting primarily of Caucasian families.

Though PEERS intervention for this study was offered free

of charge, the majority of the parents were also well-edu-

cated and reported relatively high incomes. It is hoped that

future studies will include families from more diverse

racial, ethnic, cultural, and socioeconomic backgrounds.

Further, because inclusion criteria included meeting a

minimum IQ composite score on the KBIT-2, our sample

consisted only of ‘‘high-functioning’’ adolescents with

ASD. Thus, our sample may not generalize to the greater

ASD population.

762 J Autism Dev Disord (2015) 45:752–765

123

Summary

This study extends the research base regarding PEERS

intervention and suggests that the benefits of PEERS

extend beyond the adolescent to the entire family system.

Data also suggest that parents benefit from PEERS through

increased confidence in their own parenting abilities.

Acknowledgments This research was part of a doctoral dissertation and was supported by grants from the Organization for Autism

Research (OAR) as well as the Marquette University Forward

Thinking Program. Collaboration and guidance for implementation of

PEERS was provided by Dr. Elizabeth Laugeson at the University of

California, Los Angeles.

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