Helping Our Toddlers, Developing Our Childrens Skills

(HOT DOCS):
A Problem-Solving Approach for Parents of Young
Children with Autism Spectrum Disorders
Jillian L. Childres, Emily Shaffer-Hudkins, &
Kathleen Armstrong
University of South Florida
Autism spectrum disorder (ASD) is a developmental disorder marked by
signifcant delays in socialization, communication, and behavior. ASD
is one of the most prevalent and debilitating developmental disorders
in children, and as such, many professional groups have recommended
early screening and intervention. Consequently, the demands for effec-
tive treatment in very young children have increased, yet few interven-
tions have documented effcacy in improving behaviors related to ASD.
The purpose of this study was to examine the outcomes of participation
in the Helping Our Toddlers, Developing Our Childrens Skills (HOT
DOCS) parenting program for 155 caregivers and service providers of
young children (1.5-10 years) with ASD. While HOT DOCS was not
originally developed for young children with ASD, it was developed for
children presenting with developmental delays and challenging behav-
iors. It includes many of the key elements of evidence-based programs
recommended for use with the ASD population. Participants included
parents, caregivers, and child service professionals whose children/
clients displayed challenging behaviors and had a diagnosis of ASD.
Upon completion of the 6-week program, participants demonstrated sat-
isfactory knowledge related to child development and problem-solving
behaviors; indicated that the program was benefcial to their family; and
that participation resulted in changes in their parenting/professional
practices. Participants also reported signifcant positive changes in rat-
ings of the severity of their childs problem behaviors, most notably for
problems with inattention, aggression, and behaviors related to Perva-
sive Developmental Delay (PDD), a specifc form of ASD.
Keywords: autism spectrum disorder (ASD), young children, challeng-
ing behavior, early intervention, behavioral parent training, HOT DOCS
Correspondence regarding this article should be addressed to Jillian L. Childres, Univer-
sity of South Florida, Child Development Clinic, 13101 N. Bruce B Downs Blvd., Tampa,
Florida, 33612. E-mail: jwillia6@health.usf.edu
2 3 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
Overview of Young Children with ASD
Autism Spectrum Disorder (ASD) is a developmental disorder that impairs
social skills and interactions, delays communication, and is marked by restricted
and repetitive behaviors (American Psychiatric Association [DSM-IV-TR], 2000).
The current prevalence rate of children with ASD in the United States is 1 in 110
(Centers for Disease Control and Prevention [CDC], 2009), making ASD more
common in the pediatric population than some other widely known disorders such
as diabetes, cancer, or Down syndrome (Filipek et al., 1999).
As early as in the frst year of life, infants may show signs of the communi-
cation defcits which are characteristic of ASD (Osterling, Dawson, & Munson,
2002 ;Woods & Wetherby, 2003). Such defcits include attention to people, social
smiling, gaze and eye contact, orienting to name, pretend play, and imitation. The
absence of three key communication strategies by 18 months (i.e., protodeclara-
tive pointing, gaze monitoring, and pretend play) presents a reliable risk of ASD
(Baron-Cohen et al., 1996). Later diffculties include diffculties with emotional
regulation, attention, and organization of goal directed behavior. Social emotional
development is often affected by weak attachment relationships, which later dis-
rupts social exchanges. While research has shown that earlier detection of ASD
results in improved outcomes for children, the average age of diagnosis remains
at 48 months (Goin-Kochel, Mackintosh, & Myers, 2006). Given the increasing
concern to detect and treat ASD early in development, the American Academy of
Pediatrics (AAP, 2007) has developed guidelines which call for screening for ASD
at the 12-month and 24-month well child visits. While screening and detection
systems have improved, few treatment options have been well documented for this
very young population (National Autism Center, 2009).
Behavioral Intervention for Young Children with ASD
With the increased number of young children identifed with ASD, there is a
critical need for interventions that are effective for this population and their fami-
lies. The majority of intervention research for ASD has been focused on older,
school-aged children and often consists of intensive amounts (i.e., up to 40 hours
per week) of behavioral training for the child and caregivers (Peters-Scheffer,
Didden, Korzilius, & Sturmey, 2011; Rogers, 1998). Only recently have results of
a randomized study of a comprehensive intervention for toddlers with ASD been
published (Dawson et al., 2010). This study assessed the effcacy of the Early
Start Denver Model, consisting of 20 hours per week of intensive behavioral in-
tervention delivered in the home setting, in which parents delivered fve or more
hours of intervention per week to toddlers ages 2 years old. Dawson and her
colleagues reported signifcant improvements in IQ, language, adaptive behavior,
and a reduced severity of autism diagnosis.
2 3 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
Behavioral training for children with ASD typically employs the principles of
applied behavior analysis (ABA) (Matson & Smith, 2008). ABA involves careful
measurement of behavior and its consequences, and utilizes behavioral technology
to improve or strengthen desired behaviors and to weaken undesirable behaviors
(Cooper, Heron, & Heward, 2007). These approaches are applied to address a
targeted behavioral skill set for children with ASD, such as increasing social in-
teraction (Strain & Schwartz, 2001), communication skills (Woods & Wetherby,
2003), or improving sleep hygiene (Durand, Gernet-Dott, & Mapstone, 1996), and
thus are referred to as discrete trial learning. Focused behavioral treatment strate-
gies are typically conducted as single-case or small group designs, as an intense
amount of work with the child and caregivers is typically required (Peters-Scheffer
et al., 2011; Rogers, 1998).
Evidence for behavioral interventions to improve the core defcits of ASD
specifcally targeted to young children is much more limited. Gains in language
and adaptive behavior have been found in children under 3 (mean age 30 and 35
months, respectively) when exposed to 25 or more hours of ABA discrete trial
training per week (Howard, Sparkman, Cohen, Green, & Stanislaw, 2005; Rem-
ington et al., 2007). Dawson et al. (2010) reported improvements in IQ, language,
adaptive skills, and autism diagnosis as a result of 20 hours per week of intensive
behavioral intervention. These studies support the gains that young children with
ASD may make with such approaches, yet even these highly intensive treatments
have not yielded consistent results (Sallows & Graupner, 2005). Moreover, inten-
sive treatments require a high level of professional support and are costly. Thus,
development of less time-intensive and more cost-effective treatments, which do
not compromise on effcacy or maintenance of treatment gains, is needed.
Group-delivered behavioral parent training is an effcient method for train-
ing caregivers on strategies to address problem behaviors and improve prosocial
skills for children across many ages (Shriver, 1998). Its application for parents of
young children with ASD has only recently been examined. A small pilot study
of a 12-month behavioral parent training program in England (Drew et al., 2002)
demonstrated only small improvements in childrens language skills and no sig-
nifcant differences in outcomes between participants and a control group. In this
intervention, parents of young children (mean age = 23 months) meeting Interna-
tional Classifcation of Diseases (ICD-10) criteria for autism were taught a variety
of behavioral principles to employ into daily routines and joint-attention play ac-
tivities. However, several methodological limitations such as a lack of systematic
checking of intervention delivery over this time period may have compromised
the fndings. Behavioral parent training showed signifcant gains in childrens
(age 25-68 months) adaptive behavior and cognitive skills following 12 weeks of
treatment (Anan, Warner, McGillivary, Chong, & Hines, 2008). Reinforcement
and teaching of selected skills was a focus of caregiver training. These inconsis-
tent fndings warrant the need for further research of behavioral parent training for
4 5 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
young children with ASD. Specifcally, an understanding of how specifc partici-
pant characteristics and intervention elements relate to successful outcomes would
better inform the delivery of such programs.
Across the literature base on both intensive ABA treatments and behavioral
parent training for young children with ASD, several key components have pro-
duced the most positive outcomes. These include parent involvement, behavioral
intervention, and a focus on development of communication and adaptive skills.
Implementation of intervention in the natural environment is also considered critical
for generalization (Dawson et al., 2010; Levy, Kim, & Olive, 2006). The Help-
ing Our Toddlers, Developing Our Childrens Skills, 2nd Edition program (HOT
DOCS; Armstrong, Curtiss, Williams, & Lilly, 2010) targets each of these areas
by teaching parents and caregivers a problem-solving approach towards designing
and implementing behavioral interventions, through improving communication
and developmental skills expressed by their children during routine interactions.
HOT DOCS as a Behavioral Parent Training Intervention for Young
Children with ASD
HOT DOCS is a behaviorally-based, group-delivered caregiver training
program, that is presented within a problem-solving framework in which caregivers
learn about the contingencies which shape their childrens behavior and how
they must change their own behavior to help children develop new skills that
will advance their development. Behavioral theory is taught in parent-friendly
terminology, and utilizes a problem solving chart to guide parents in focusing their
attempts to teach their children replacement behaviors including use of verbal and
non-verbal communication strategies, social skills, and self-regulation. Caregivers
learn to shift their focus from punitive disciplinary consequences for the challenging
behaviors, to prevention and reinforcement of prosocial and communication skills,
such as asking for help, signaling all done, or making choices.
While HOT DOCS was not originally developed for caregivers of young
children with ASD, the program was developed for toddlers and preschoolers
presenting with developmental delays and challenging behavior issues. As such,
it includes many of the aforementioned key elements of evidence-based programs
recommended for use with the ASD population. Unlike other parent training
programs that focus on teaching parents set parenting skills such as reinforcement
and disciplinary strategies, HOT DOCS employs a problem-solving process which
helps parents to understand the problem, develop and implement an intervention
specifc to their child, and document progress. HOT DOCS operates under the
premise that children exhibit challenging behaviors because they lack the knowledge
or skills to engage in more appropriate behaviors. Course content addresses the
implementation of predictable routines, visual aids to prepare children for new
4 5 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
or diffcult situations in the community, and giving effective directions. These
parenting strategies are particularly relevant for children with developmental delays
and those with ASD. Parents are encouraged to practice new skills during play
sessions with their child, and in doing so, focus on skills that promote joint attention,
turn-taking, and imitation. These skills are broken down into small steps, and
reinforced across day-to-day activities. The special weekly play sessions that are
described below are intended to help develop skills within a play routine.
Structure of HOT DOCS Sessions
The HOT DOCS parent training program is delivered in six 2 hour sessions,
the objectives of which intend to teach specifc behavioral strategies within the
problem-solving process. Incorporated within each session are lecture, practice
exercises, group problem solving activities, role play, and video vignettes. HOT
DOCS is manualized, and includes both a provider manual for the trainer with
specifed directions to teach each session, and participant manual for the caregiver,
which includes practice and homework assignments to promote learning. Refer
to Table 1 for a summary of instructional topics included within each HOT DOCS
session.
Table 1
Topic, Parenting Tip, and Special Play Activity for Each HOT DOCS Session
Session Topic Parenting tip Special play activity
1 Early childhood development Give clear directions Bubbles
2
Routines and rituals Catch them being good Reading

3 Behavior and development Use a calm voice Coloring

4 Preventing problem behavior Use preventions Fun dough

5 Teaching new skills Follow-through Balls
6 Managing parent stress Take time for yourself Free choice
6 7 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
Purpose of the Current Study
The purpose of this study was to learn more about the effectiveness of the HOT
DOCS parent training program with caregivers and their young children with ASD.
This study provides a frst look at demographics of these caregivers, whether they
increased their knowledge and use of behavioral principles and parenting strategies
with their children, and how they reported behavioral outcomes for their children.
Method
Participants
Participants were recruited through community advertisement or referred
by health care providers. Participants included parents, caregivers (biological
relatives, adoptive parents, and legal guardians) and child service professionals
(e.g., speech therapists, early interventionists, daycare workers) whose children or
clients displayed challenging behaviors. Consent was obtained from the universitys
IRB to collect, analyze, and publish data. Target children were mostly male (81%)
and ranged in age from 18 months to 10 years (M = 46.55 months, SD = 18.79).
A total of 1,153 participants attended at least one session of HOT DOCS in the
classes conducted between August 2006 and August 2010, which were delivered
in English and in Spanish. Of these participants, 155 reported that their child or
client had a diagnosis of ASD, including PDD. Only the 155 participants reporting
a diagnosis of ASD were included in this study.
Participants were mostly females (66.5%) who ranged in age from 18 to 79
years (M = 36.14, SD = 9.76) and reported their race or ethnicity as White (52.9%),
Hispanic/Latino (29.0%), African American/Black (7.7%), Asian (2.6%), Native
American (1.9%), Mixed (1.9%), or did not report their race or ethnicity (3.9%).
Participants indicated their highest level of education to be less than a high school
diploma (2.6%), a high school diploma (30.3%), technical training or some col-
lege (22.6%), a 4-year college degree (25.8%), or a graduate level college degree
(14.2%). A majority of the participants (88.4%, n = 137) reported being the childs
biological or adoptive parent; 10 (6.5%) were the childs grandparent; 6 (3.9%)
were the childs aunt, uncle, or other relative; and 2 (1.3%) were the childs service
provider. Of the 155 participants, 81.3% (n = 126) attended classes delivered in
English and 18.7% (n = 29) attended classes delivered in Spanish.
Measures
HOT DOCS Demographics Form. The Demographics Form was developed
by the HOT DOCS authors in order to collect standardized information about the
participants and children. This form includes 16 questions referring to partici-
6 7 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
pants country of origin, relationship to target child, marital status, age, gender,
racial identity, ethnic group, and level of education. The form also asks questions
referring to the target childs age, gender, preexisting medical/genetic/behavioral
diagnoses, siblings, type of health insurance, primary guardian, current therapies/
services, and current school/daycare.
HOT DOCS Knowledge Test. The Knowledge Test was also developed by
the HOT DOCS authors in order to assess participants knowledge of child devel-
opment, behavioral principles, and parenting strategies prior to and subsequent to
participation in HOT DOCS classes. The test consists of 20 True/False state-
ments and takes approximately ten minutes to complete.
HOT DOCS Program Evaluation Survey. The Program Evaluation Survey
was developed by the HOT DOCS authors to assess participants perceptions of
the effectiveness of the parent training program. The survey consists of eight state-
ments about the benefts of HOT DOCS to participants, the teaching skills of HOT
DOCS trainers, and the impact of the program on child and family behaviors and
relationships. Participants were asked to respond on a 4-point Likert-type scale
as Strongly Agree, Agree, Disagree, or Strongly Disagree.
Behavior Rating Scales. The Child Behavior Checklist (CBCL; Achenbach,
2001) was selected to assess participants perceptions of the severity of childrens
problem behaviors. The CBCL is a psychometrically sound instrument, as evi-
denced by validity and reliability estimates (Achenbach, 2001). There are multiple
versions of the CBCL that are used depending on the childs age (1 - 5 years;
6-18 years) and the source of information (parent/caregiver; teacher). The CBCL
problem behavior scores are grouped into two broadband scales (Internalizing and
Externalizing problems) which are composed of various subdomain scores. Ad-
ditionally, items are analyzed on a Diagnostic and Statistical Manual of Mental
Disorders (DSM)-Oriented scale composed of several specifc subdomains. All
versions of the CBCL are available in English and Spanish. This measure has been
used to identify behavioral symptoms among children with ASD and has shown
good sensitivity in detecting co-occurring behavioral disorders among preschool-
age youth with ASD (Pandolf, Magyar, & Dill, 2009). CBCL rating scales were
completed at the frst session and again six to eight weeks after the fnal class.
Procedures
Attendance data, demographics information, knowledge-based posttests, social
validity and acceptability measures and structured behavior rating scales were col-
lected. Participant attendance was recorded by the class instructor at the beginning
of each HOT DOCS session. The demographics form and behavior rating scales
were completed during the frst session. Participants completed the Knowledge
Posttest and the Program Evaluation Survey during the fnal session of training.
Two months after the fnal session a posttest behavior rating scale was administered.
8 9 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
During the four years in which data were collected no signifcant modifcations
were made to the HOT DOCS curriculum or data collection procedures. Please
refer to previously published articles for a full description of the development and
revisions of the HOT DOCS program (Armstrong, Hornbeck, Beam, Mack, & Pop-
kave, 2006; Williams, 2009; Williams, Armstrong, Curtiss, & Bradley-Klug, 2011).
Results
Patterns of Attendance and Rates of Attrition
Patterns of attendance and rates of attrition were similar to those found in
previous studies of this treatment program averaging 25.5% attrition (Agazzi et
al., 2010; Williams, 2007; Williams, 2009; Williams et al., 2011) and other group-
delivered behavioral parent training programs averaging 16-30% attrition (Eyberg
et al., 2001; Feinfeld & Baker, 2004; Kazdin, 1997; Sanders, Markie-Dadds, Tully,
& Bor, 2000). The average number of sessions attended was 4.50 of 6 (SD = 1.50)
and 86.5% of participants (n = 134) attended 3 or more sessions, which was the
criteria set for program completion in previous studies of the HOT DOCS pro-
gram (Williams, 2009).
Approximately 33% of participants did not complete posttest assessments
administered in session 6, including the Knowledge Test (n = 54) and the Program
Evaluation Survey (n = 49). As with previous evaluations of this treatment program,
much higher rates of attrition were found with the follow-up behavior rating scales
administered 2 months after the program ended, with 73.4% of those participants
who completed a pretest behavior (n = 109) rating scale failing to return a follow-
up rating scale (n = 80).
Effects of Participation in HOT DOCS for Caregivers of Young Children
with ASD
Participant Knowledge. Descriptive statistics were used to analyze partici-
pants scores on the Knowledge Posttest administered upon completion of the pro-
gram. Scores were analyzed as total number correct out of 20 items. Participants
scores on the posttest ranged from 13 (65%) to 20 (100%). The average score was
17.3 items (M = 86.5%, SD = 1.70). This score indicates that participants under-
stood and retained the majority of information covered in the posttest.
Social Validity and Acceptability. Participants mean ratings of satisfaction
with the intervention program were computed using quantitative data obtained from
the HOT DOCS Program Evaluation Survey. A total of 106 participants completed
the survey upon completion of the program. The majority of participants Agreed
or Strongly Agreed that the program was benefcial to their family or their profes-
sional practice (54.8% Strongly Agree, 13.5% Agree) and that the trainers were
8 9 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
knowledgeable and effective instructors (92.5% Strongly Agree, 7.5% Agree). The
statements for which two participants marked Disagree, related to the participants
ability to implement parenting strategies presented in class including Parenting Tips
and Special Play Activities, changes in childrens behavior, changes to parenting
or professional practices, and the participants overall evaluation of the program.
These results are similar to previous studies of this intervention program, including
caregivers of children with a variety of preexisting diagnoses as well as those who
are typically developing children. These fndings indicate that the specifc subgroup
of participants (caregivers of children with ASD) is satisfed with the intervention
program, despite having children whose psychological and behavioral needs may
be more intense than typically developing children or those with other diagnoses.
Changes in Participant Perceptions of Child Behavior. A two-factor re-
peated measures analysis of variance (ANOVA) was conducted to analyze the
differences between participants pre- and post-test scores on the Internalizing
and Externalizing scales on the CBCL. The two within-subjects (repeated) factors
were type of scale (i.e., Internalizing and Externalizing) and time (i.e., pretest and
posttest). Twenty-nine participants completed and returned both pre- and post-test
CBCL rating scales. Means and standard deviations of pre- and post-test rating
scale scores on the two subscales of the CBCL are reported in Table 2.
Results revealed a signifcant interaction effect, F(1, 28) = 4.33, p < .05, a
statistically signifcant main effect for time, F(1, 28) = 6.92, p < .05, and a non-
signifcant main effect for scale (p > .05). The signifcant interaction effect indi-
cated that there were differences in caregivers ratings of the target childs behavior
due to time of testing and subscale of the CBCL. As seen in Figure 1, scores for
Externalizing behaviors decreased more across time (-6.1 points) than did scores
for Internalizing behaviors (-3.24 points).
Table 2

Means and Standard Deviations of Pre- and Post-test CBCL Scores by Scale


Pretest Post-test
CBCL Scales M SD M SD
Internalizing 63.93 8.71 60.6 9.60
Externalizing 64.41 11.56 58.31 10.64
Marginal Means 64.17 59.50
Note. n = 29
10 11 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
Figure 1. Pre- and post-test mean scores for CBCL scales.
Note. n = 29
The main effect for time of testing was followed up with a comparison of
CBCL pretest and posttest overall mean scores (i.e., marginal means) and results
indicated that participants perceived severity of childrens problem behavior was
greater at pretest (M = 64.17) as compared to posttest (M = 59.50) across both the
Internalizing and Externalizing scales. On the CBCL, higher scores indicate more
severe levels of problem behavior; therefore, a decrease in scores from pretest
to posttest indicates participants perceived children to have less severe levels of
problem behavior following participation in the program.
Despite signifcant differences in participants ratings of the severity of chil-
drens behavior before and after the intervention, interpretation of mean scores
shows that the average score on both the Internalizing and Externalizing scales
was within the Borderline Clinical range (1.5 standard deviations above the mean)
prior to beginning the intervention program. This means that although participants
were concerned about their childs behavior enough to voluntarily seek out and
participate in a treatment program, a large proportion of participants ratings of
child behavior were in the sub-clinical range of behavior problems on the Internal-
izing (49.2%) as well as the Externalizing (55.4%) scales at the time of entry to the
program. This fnding is similar to previous studies of the HOT DOCS program
10 11 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
Figure 2. Pre- and post-test mean scores for CBCL subdomains by scale.
Note. n = 109 (pretest), 29 (post-test); Too few posttest rating scales for ages 6-18 years
were returned to calculate all additional subdomain scores.
including children with and without a variety of preexisting medical, genetic, and
behavioral diagnoses (Williams, 2007; Williams, 2009; Williams et al., 2011).
Subdomains of Challenging Behavior. Further analysis of the CBCL scales
was conducted at the subdomain level (Refer to Figures 2 and 3). Subdomain
scores are also reported as T-scores (M = 50, SD = 10) and are categorized as Non-
signifcant (< 65), Borderline (65-69), and Clinically Signifcant (70+). Subdomain
scores which contribute to the Internalizing scale include Emotionally Reactive
(CBCL 1 -5 only), Anxious/Depressed, Somatic Complaints, and Withdrawn.
Subdomain scores which contribute to the Externalizing scale include Attention
Problems, Aggressive Behavior, and Rule Breaking Behavior (CBCL 6-18 only).
There are three additional subdomains, which are reported separately from the In-
ternalizing and Externalizing scales, including Sleep Problems (CBCL 1 -5 only),
Social Problems (CBCL 6-18 only), and Thought Problems (CBCL 6-18 only).
The CBCL subdomain scores are also reported as a DSM-Oriented scale in-
cluding Affective Problems, Anxiety Problems, Pervasive Developmental Prob-
lems (CBCL 1 -5 only), Attention Defcit/Hyperactivity Problems, Oppositional
Defant Problems, Somatic Problems (CBCL 6-18 only), and Conduct Problems
(CBCL 6-18 only). Means and standard deviations for each of the subscale scores
are reported in Table 3 and Figures 2 and 3.
12 13 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
Figure 3. Pre- and post-test mean CBCL scores for DSM-Oriented subdomains.
Note. n = 109 (pretest), 29 (post-test) ; Too few posttest rating scales for ages 6-18 years
were returned to calculate all additional subdomain scores.
Several dependent means t-tests were calculated between participants pre- and
post-test scores on the various subdomains of the CBCL. Of the 109 participants
who completed the CBCL at pretest, only 29 completed a CBCL at posttest. T-tests
could not be conducted for several of the subdomains unique to the CBCL 6-18
form, since only 1 participant returned a posttest rating scale for this age range.
The results of the t-tests indicate several subdomains which changed signifcantly
(p < .05) from pretest to posttest time, including Attention Problems, Aggressive
Behavior, Pervasive Developmental Problems, Attention Defcit/Hyperactivity
Problems, and Oppositional Defant Problems. As seen in Figures 2 and 3, the
mean score at posttest for each of these fve subdomains was signifcantly lower
than the mean score at pretest, indicating that participants perceived childrens
behavior to decrease in severity over time.
It is noteworthy that all of the subdomains that showed signifcant decreases
are components of the Externalizing scale, as the treatment program was designed
to address challenging behaviors, such as non-compliance and aggression, and does
not specifcally include information regarding Internalizing behaviors. It is also
important to notice that participants ratings on the PDD subdomain signifcantly de-
creased after completing the treatment program. This particular subdomain includes
12 13 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
Table 3
CBCL Ratings by Subdomain at Pretest and Post-test
Pretest (n = 109) Post-test (n = 29)
Subdomain M SD M SD
Internalizing
Emotionally Reactive
a
62.84 8.89 59.07 8.83
Anxious/Depressed 57.30 8.07 54.69 6.93
Somatic Complaints 59.58 8.46 57.83 7.63
Withdrawn 72.29 10.65 70.69 12.20
Externalizing

Attention Problems* 65.51 8.81 62.93 8.61
Aggressive Behavior* 64.17 12.71 58.52 9.26
Rule-Breaking Behavior
b
57.85 6.40.
Additional Subdomains

Sleep Problems
a
60.81 13.22 57.61 8.61
Social Problems
b
63.15 8.51.
.
Thought Problems
b
65.77 10.03 . .
DSM-Oriented Scales
Affective Problems 65.04 9.02 59.59 10.10
Anxiety Problems 60.50 9.58 58.79 9.68
Pervasive Developmental Problems
a
* 74.74 8.41 71.32 10.14
Attention Defcit/Hyperactivity Problems* 62.61 8.10 58.86 6.654
Oppositional Defant Problems* 61.97 9.80 57.03 7.70
Somatic Problems
b
54.25 9.27 .
.
Conduct Problems
b
60.69 8.63 .
.
Note.
a
= Subdomain only included on CBCL 1-5;
b
= Subdomain only included
on CBCL 6-18.
*
= t-test comparing pre/post scores was signifcant at p < .05. Cells without M and
SD scores indicate subdomains with too few posttest scales returned to calculate
totals.

14 15 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
items focusing on behaviors indicative of ASD, such as avoiding eye contact,
trouble with changes in routines, diffculties with verbal communication, limited
social interaction with peers, stereotypic body movements, and little or no affection
with caregivers. Although participants mean score at posttest for this subdomain
was still within the Clinically Signifcant range (M = 71.32, SD = 10.14), results
indicated that participants perceived a statistically signifcant reduction in the
severity of ASD symptoms in their children overall.
Discussion
ASD is recognized as one of the most prevalent and debilitating developmental
disorders in children, and as such, many professional groups including the Ameri-
can Academy of Pediatrics have recommended early screening and intervention
to offset these diffculties. Consequently, the demands for effective treatment for
ASD in very young children have increased, yet few interventions have documented
effcacy in improving behaviors related to ASD. The purpose of this study was
to examine the beneft of the HOT DOCS parenting program with 155 families
of young children with ASD. After the relatively short treatment duration of 15
hours, spread over 6 weeks, caregivers demonstrated suffcient knowledge related
to understanding and problem-solving behavior, which was used to prevent and
modify problem behavior through the use of antecedent strategies, skill develop-
ment, and effective consequences. Furthermore, the vast majority of these care-
givers indicated that they felt that the HOT DOCS program was benefcial to their
family and resulted in changes in their parenting practices and in their childrens
behavior. Caregiver completion rates of 85.6% exceeded many of those reported
in the literature by other group delivered behavioral parent training programs.
Families that completed this intervention also showed signifcant positive changes
in ratings of their childs problem behaviors on the CBCL and this difference was
most notable for problems related to inattention and aggression.
Conclusions
The outcomes from this study included signifcant decreases in caregiver
ratings for childrens problem behaviors related to inattention, aggression, and
symptoms of PDD. This suggests that HOT DOCS, a group parent training ap-
proach which teaches parents and caregivers to use behavioral strategies within
their home and other natural environments may be a promising intervention for use
with young children with ASD and their families. While previous interventions
for this population have also resulted in behavioral improvements as well as other
developmental gains, these approaches require a signifcant level of resources in
terms of therapy hours and training level of providers (Dawson et al., 2010; Howard
et al., 2005). HOT DOCS requires a nominal amount of direct contact hours with
14 15 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
families and can be implemented in community settings by trained providers, who
are not necessarily licensed clinicians. The focus on problem-solving and caregiv-
ers use of these strategies in their home likely contributes to the success of this
relatively short-term intervention.
As health care costs rise, it will become increasingly more important to develop
time- and cost-effective interventions such as the HOT DOCS curriculum, which
emphasize the importance of proactive, positive parenting with young children
with ASD. The advantage of HOT DOCS rests upon its problem-solving approach
which helps caregivers to individualize the intervention for their child and family
across many areas of functioning.
Future Directions
A randomized, control trial is clearly needed in order to evaluate the effcacy
of the HOT DOCS curriculum for caregivers and their children with ASD, as well
as children with other issues. Furthermore, other behavioral parent training geared
for children with ASD have assessed gains in desirable skills (language, adaptive)
(Anan et al., 2008; Drew et al., 2002) versus reductions in problem behaviors.
Thus, assessing gains in strengths and functional skills would provide additional
evidence for the beneft of the HOT DOCS approach. Since the end of data col-
lection for this study, a new measure of participant knowledge has been developed
utilizing item analysis and feedback from a panel of experts. The new test includes
31 items in multiple choice format addressing specifc content areas of the treat-
ment program. As reported in a pilot study (Agazzi & Childres, in submission) the
psychometric properties of this instrument indicate that it will provide much more
detailed and accurate information about participants understanding and retention
of information covered in the program.
Lastly, given the risk that ASD has for negatively impacting development and
functioning over the lifespan (Levy, 2006), the addition of one-to-one coaching
sessions to ensure that parents are able to implement the HOT DOCS skills suc-
cessfully may produce more improvement and enduring outcomes. These sessions
would still offer a more cost-effective approach than intensive treatments requir-
ing twenty or more hours per week of professional guidance (e.g., Howard et al.,
2005; Remington et al., 2007).

16 17 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
References
Achenbach, T. (2001). Manual for the Achenbach system of empirically based
assessment (ASEBA). Burlington, VT: University of Vermont, Research Center
for Children, Youth, & Families.
Agazzi, H., Salinas, A., Williams, J., Chiriboga, D., Ortiz, C. & Armstrong, K.
(2010). Adaptation of a behavioral parent training curriculum for Hispanic
caregivers: HOT DOCS Espaol. Infant Mental Health Journal, 32, 182-200.
Agazzi, H. & Childres, J. (in submission). An instrument to assess caregiver
knowledge of behavioral principles as applied to young children.
American Academy of Pediatrics (2007). AAP clinical reports: Guidance for
the clinician in rendering pediatric care. American Academy of Pediatrics.
Retrieved May 2, 2011 from http://www2.aap.org.
American Psychiatric Association. (2000). Diagnostic and statistical manual of
mental disorders (Revised 4th ed.). Washington, DC: Author.
Anan, R. M., Warner, L. J., McGillivary, J. E., Chong, I. M., & Hines, S. J. (2008).
Group Intensive Family Training (GIFT) for preschoolers with autism
spectrum disorders. Behavioral Interventions, 23 (3), 165-180.
Armstrong, K., Hornbeck, M., Beam, B., Mack, K., & Popkave, K. (2006).
Evaluation of a curriculum designed for caregivers of young children with
challenging behavior. Journal of Early Childhood and Infant Psychology,
2, 51-61.
Armstrong, K., Curtiss, H., Williams, J., & Lilly, C. (2010). Helping our toddlers
developing our childrens skills, 2nd Edition. Tampa, FL: University of South
Florida, Department of Pediatrics, Division of Child Development.
Baron-Cohen, S., Cox., A., Baird, G. Swettenham, J., Nightingale, N., Morgan,
K, Charman, T. (1996). Psychological markers in the detection of autism
in infancy in a large population. British Journal of Psychiatry, 168, 158-163.
Centers for Disease Control (2009). Prevalence of autism spectrum disorders.
Surveillance Summaries, 58(SS10), 1-20. Retrieved April 28, 2011 from
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5810a1.htm.
Cooper, J., Heron, T. & Heward, W. (2007). Applied behavior analysis (2nd ed).
Columbus, OH: Merrill.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J.,Varley,
J. (2010). Randomized, controlled trial of an intervention for toddlers with
autism: The Early Start Denver Model. Pediatrics, 125 (1), 17-23.
Drew, A., Baird, G., Baron-Cohen, S., Cox, A., Slonims, V., Wheelwright, S.,
Charman, T. (2002). A pilot randomized control trial of a parent training
intervention for pre-school children with autism: Preliminary fndings and
methodological challenges. European Child & Adolescent Psychiatry, 11,
266-272.
16 17 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
Durand, V., Gernet-Dott, P., & Mapstone, E. (1996). Treatment of sleep disorders
in children with developmental disabilities. Journal of the Association for
Persons with Severe Handicaps, 21 (3), 114-122.
Eyberg, S., Funderburk, B., Hembree-Kigin, T., McNeil, C., Querido, J., & Hood,
K. (2001). Parent-child interaction therapy with behavior problem children:
One and two year maintenance of treatment effects in the family. Child &
Family Behavior Therapy, 23, 1-20.
Feinfeld, K. & Baker, B. (2004). Empirical support for a treatment program for
families of young children with externalizing problems. Journal of Clinical
Child and Adolescent Psychology, 33, 182-195.
Filipek, P., Accardo, P., Baranek, G., Cook, E., Dawson, G., Gordon, B.,Volkmar,
F. (1999). Screening and diagnosis of autistic spectrum disorders. Journal of
Autism and Developmental Disorders, 29, 439-484.
Goin-Kochel, R., Mackintosh, V., & Myers, B. (2006). How many doctors does It
take to make an autism-spectrum diagnosis? Autism, 10, 439-451.
Howard, J., Sparkman, C., Cohen, H., Green, G., & Stanislaw, H. (2005). A
comparison of intensive behavior analytic and eclectic treatment for young
children with autism. Research in Developmental Disabilities, 26, 359383.
Kazdin, A. (1997). Parent management training: Evidence, outcomes, and issues.
Journal of the American Academy of Child and Adolescent Psychiatry, 36,
1349-1356.
Levy, S., Kim, A., & Olive, M. (2006). Interventions for young children with autism:
A synthesis of the literature. Focus on Autism and Other Developmental
Disabilities, 21, 55-62.
Matson, J., & Smith, K. (2008). Current status of intensive behavioral interventions
for young children with autism and PDD-NOS. Research in Autism Spectrum
Disorders, 2, 60-74.
National Autism Center (2009). National standards report. Randolph, MA: Author.
Osterling, J., Dawson, G., & Munson, J.A. (2002). Early recognition of 1-year-
old infants with autism spectrum disorder versus mental retardation.
Developmental and Psychopathology, 14, 239-251.
Pandolf, V., Magyar, C. I., & Dill, C. A. (2009). Confrmatory factor analysis of the
Child Behavior Checklist 1.55 in a sample of children with autism spectrum
disorders. Journal Of Autism And Developmental Disorders, 39(7), 986-995.
Peters-Scheffer, N. Didden, R., Korzilius, H. & Sturmey, P. (2011). A meta-analytic
study of on the effectiveness of comprehensive ABA-based early intervention
programs for children with Autism Spectrum Disorder. Research in Autism
Spectrum Disorders, 5 (1), 60-69.
Remington, B., Hastings, R., Kovshoff, H., degli Espinosa, F., Jahr, W., Brown,
T.,Warn, N. (2007). A feld effectiveness study of early intensive behavioral

\
18 19 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
intervention: Outcomes for children with autism and their parents after two
years. American Journal of Mental Retardation, 112, 418438.
Rogers, S. (1998). Neuropsychology of autism and its implications for early
intervention. Mental Retardation and Developmental Disabilities Research
Reviews, 4, 104-112.
Sallows, G., & Graupner, T. (2005). Intensive behavioral treatment for children
with Autism: Four-year outcome and predictors. American Journal on Mental
Retardation, 110, 417438.
Sanders, M., Markie-Dadds, C., Tully, L., & Bor, W. (2000). The Triple P-Positive
Parenting Program: A comparison of enhanced, standard, and self-directed
behavioral family intervention for parents of children with early onset conduct
problems. Journal of Consulting and Clinical Psychology, 68, 624-640.
Shriver, M. D. (1998). Teaching parenting skills. In Watson, T.S. & Gresham,
F.M. (Eds). Handbook of child behavior therapy (pp. 165-182). New York:
Plenum Press.
Strain, P. S. & Schwartz, I. (2001). ABA and the development of meaningful social
relations for young children with autism. Focus on autism and other related
developmental disabilities, 16 (2), 120-128.
Williams, J. (2007). Caregivers Perceptions of the Effectiveness of the Helping
Our Toddlers, Developing Our Childrens Skills Parent Training Program:
A Pilot Study. Psychological and Social Foundations. Tampa, University of
South Florida. Educational Specialist (EdS): 163.
Williams, J. (2009). Helping our toddlers, developing our childrens skills (HOT
DOCS): An Investigation of a parenting program to address challenging
behavior in young children. Psychological and Social Foundations. Tampa,
University of South Florida. Doctor of Philosophy (PhD): 217.
Williams, J., Armstrong, K., Curtiss, H., & Bradley-Klug, K. (2011). Helping
Our Toddlers, Developing Our Childrens Skills (HOT DOCS): A parenting
intervention to prevent and address challenging behavior in young children.
Journal of Early Childhood & Infant Psychology, 6, 1-20.
Woods, J. & Wetherby, A. (2003). Early identifcation of and intervention for infants
and toddlers who are at risk for autism spectrum disorder. Language, Speech
and Hearing Services in the Schools, 36, 62-72.
18 19 Volume 8, 2012 JECIP PAReNTS oF CHIlDReN WITH ASD
Author Note
Jillian L. Childres, Department of Pediatrics, University of South Florida; Emily
Shaffer-Hudkins, Department of Psychology and Social Foundations, University
of South Florida; Kathleen Armstrong, Department of Pediatrics, University of
South Florida.
This research was supported in part by funding through the University of South
Florida, College of Medicine and the Childrens Board of Hillsborough County.
The opinions expressed in this publication are those of the authors and do not
necessarily refect those of the University of South Florida College of Medicine
or the Childrens Board of Hillsborough County.