A Review of the Components, Outcomes, and Cultural Responsiveness of the Pyramidal Parent Training Literature

Figures & data

Figure 1. Search and selection procedure.

Figure 2. Parent training within a family.

Figure 3. Parent training among families.

Table 1. Training participants, type, focus and duration.

Author(s)	Type of training	Training focus	Training dosage and duration	Settings	Master trainer	Tier 1 participants	Tier 2 and 3 participants	Children participants
Adubato et al. (1981)	Within a family	Appropriate instructions, full and partial physical guidance, avoidance of pre-empts.	Level 1: 3x per week, 18 sessions for 30 min (9 h total) Level 2: 9 sessions.	Clinic and home	Experimenter	1 mother	1 father	6-years-old boy with severe developmental delay (n = 1).
Bruder and Bricker (1985)	Among families	Choosing and defining target behavior, conducting task analysis, using antecedents, using consequences, data collection procedures.	4 one-hour sessions.	Classroom	Professional interventionist	3 mothers	3 Tier 2 mothers + 3 Tier 3 mothers	Children at-risk of developmental disability (n = 9). Age 10–26 months.
Neef (1995)	Among families	Review of teaching protocols, target behavior description, presenting stimuli, use of reinforcement.	15–30-min sessions until parent mastered procedure.	Classroom and clinic	Professional interventionist	5 parents	5 Tier 2 parents + 4 Tier 3 parents	Children with ASD (n = 14). Elementary school age.
Kuhn et al. (2003)	Within a family	Antecedent and consequence strategies for specific problem behaviors of each child.	3 × 1 hr sessions or 1 × 2 hr session in homes, until mastered.	Home	Experimenter	3 mothers	3 Tier 2 caregivers + 3 Tier 3 caregivers (all trained by Tier 1 mothers)	Children with developmental disability or signs of ASD (n = 3). Age 4–11 years.
Symon (2005)	Within a family	Training in basic Pivotal Response Training techniques.	Level 1: 5 h for 5 consecutive days. Total 25 h. Level 2: duration not specified.	Research and Training Center, community and home	Professional parent educators and clinicians—doctoral candidates	3 mothers	1 father and 2 professional caregivers	Children with behaviors common for ASD (n = 3). Age 2 years 10-months to 5 years and 4-months.
Loughrey et al. (2014)	Within a family	Eight skills associated with mand training: (e.g. preference assessment, differential reinforcement, shaping, data collection).	4 modules, duration and dosage not specified.	Treatment center and home	Experimenter and graduate students	2 mothers (1 mother participated as parent trainer).	1 father	Child with ASD (n = 1).
Hansen et al. (2017)	Among families	Basic principles of behavior, differential reinforcement, teaching eye contact, response interruption and redirection.	1 day training.	Hotel conference room	Students of behavioral science	6 parents	6 Tier 2 parents and 6 Tier 3 parents	Children with ASD (n = 15).
Knecht (2018)	Within a family	Differential reinforcement, teaching eye contact, response interruption and redirection.	Duration and dosage not specified.	Hotel conference room and treatment center	Students of behavioral science	3 fathers	3 mothers	Children with ASD (n = 3).
Conklin and Wallace (2019)	Among families	Reduction of child specific problem behaviors. Differential reinforcement, prompting.	1-h training.	University conference room	Experimenter	2 mothers and 1 father	3 mothers	Children with ASD, ADHD, speech disorders or no diagnosis (n = 6).

Table 2. Training components.

Study	Reading materials	Modelling	Skill rehearsal	Role-play	Feedback/ coaching	Data taking	Child participation	Training the trainer	Fidelity of training delivery
Adubato et al. (1981)	X	X	0	0	X	0	X	Mother asked to train husband and use any way of training.	0
Bruder and Bricker (1985)	X	X	0	0	X	X	X	Parent trainer provided with hand out and review of training with the professional.	Fidelity of parent delivered training assessed.
Neef (1995)	X	X	0	0	X	Only trainers of other parents were trained.	X	Parents provided with training to become trainers.	0
Kuhn et al. (2003)	X	0	0	X	X	Only the primary caregiver was trained.	X	Provided parents with training to become trainers and mock trainings before allowed to train others.	Fidelity of parent delivered training assessed during mock trainings. Fidelity of expert trainers not assessed.
Symon (2005)	X	X	0	0	X	0	X	Only discussion how primary caregiver could train other caregivers.	0
Loughrey et al. (2014)	X	X	X	0	X	X	0	Parents instructed to use the same BST approach as when they were trained.	Fidelity of expert trainers assessed; fidelity of parent delivered trainings not assessed.
Hansen et al. (2017)	0	X	X	X	X	0	0	Parents used BST without specific training to become trainers.	Six step checklists for all who trained.
Knecht (2018)	0	0	X	X	X	0	0	Parents used BST without specific training to become trainers.	Six step checklists for all who trained.
Conklin and Wallace (2019)	X	X	X	X	X	0	0	Parents used BST without specific training to become trainers.	Fidelity of BST delivery of all who trained.

X = component was used; 0 = component was not used.

Table 3. Study design and outcomes.

Study	Design	Skills taught to parents	Dependent variable(s)	Intervention to a child	IOA	Social validity	Reported outcomes: parents	Reported outcomes: child	Maintenance	Generalization	Results
Adubato et al. (1981)	Multiple baseline across behaviors designs. One for the mother and one for the father.	Module 1: Delivering appropriate task instructions, using any type of physical guidance. Module 2: partial guidance, reducing pre-empts, allowing child independent attempts	(1) Correct use of appropriate instruction, physical guidance, partial guidance, pre-empts avoidance (2) Child’s attention, independent completion of task steps, compliance	Parents implemented appropriate task instructions, using, physical guidance, partial guidance, and pre-empts reduction with child during dressing, eating and play	IOA scored across all conditions separately for each skill of each parent and each behavior of the child with mother and child with father. IOA ranged from 67% to 98%	NOT ASSESSED	Percentage of occurrence of the correct use of the target skill.	Percentage of occurrence of child’s appropriate behavior.	Parents Two years after training completion. Questionnaire on maintenance of training effects on parent skills. Child: Not reported	Generalization across two untrained child’s behaviors assessed. Both parents showed generalization to untrained activities.	Substantial positive changes in both parents’ child management skills. Clear-cut improvements of child’s attending and performance in dressing and toy use.
Bruder and Bricker (1985)	Multiple probe across participants (a variation of multiple baseline).	Choosing and defining target behavior, conducting task analysis, using antecedents, using consequences, data collection procedures	(1) Parent correct teaching behavior (2) Child’s correct responding (3) Acquisition of written content (4) Fidelity of training implementation by parents, (5) Child’s correct responses	Parent identified TB to be taught to a child, conducted task analysis and used antecedent and consequence strategies to teach new behaviors.	25% of sessions observed by two coders. IOA calculated separately for categorization of antecedents and consequences and children correct and incorrect responses 94% (range 90-99%). Product moment correlations computed scores .96 (range .8-1.0)	NOT ASSESSED	Percentage of appropriate teaching trials at each teaching session. Percentage of correct multiple choice answers.	Percentage of correct responses during each teaching session.	Parents: Single follow up probe after four weeks Child: Single follow up probe after four weeks	Not assessed Data outside of clinic not gathered.	A functional effect on all 9 parents use of intervention techniques. Tier 3 parents with less dramatic acceleration. Maintenance probe shows sustained responding. Children: 5 out of 9 clearly improved, 4 children ambiguous due to elevated baseline.
Neef (1995)	Multiple probe across three cohorts of participants (variation of multiple baseline)	Reviewing teaching protocols, describing target behaviors, presenting stimuli, use of prompts and reinforcement.	(1) Parent correct teaching behaviors (2) Child’s correct responding as defined individually for each child.	Parent identified 2–3 skills to be taught to a child based on IEP. Used antecedent and consequence strategies to teach new skill.	Point-by-point mean IOA conducted on 85% of probe sessions, scores ranged from 82.3% to 95.8%. IOA for child behavior assessed for 78% of probes averaged at 96%	NOT ASSESSED	Mean percentage of correct parent teaching behaviors	Mean percentage of correct child responses.	Parents: Follow up probe same as baseline after four to six weeks Child: Follow up probe same as baseline after four to six weeks	Generalization to novel child skill area	Performance of all parents on the training task increased substantially regardless the Level of training from baseline 35% to 92% on average and maintained at follow-up. 11 out of 14 children made significant improvements (increase from 20-95%). Three children made minimal progress.
Kuhn et al. (2003)	Non-concurrent multiple baseline across caregivers.	Using specific antecedent and consequence strategies for problem behavior reduction specific for each child (ex. noncontingent attention and time-out)	(1) Parent correct use of individual treatment protocols (2) Children’s stereotypic behavior, spitting and compliance	Parents identified problem behaviors; individual treatments were designed based on functional analysis. Used antecedent and consequence strategies for TB reduction or increase of compliance.	IOA scored for each child and caregiver separately during 37% to 58% of sessions. Mean IOA for treatment implementation ranged from 92% to 100% and mean IOA for child behavior ranged from 86% to 99%.	NOT ASSESSED	Percentage of correct responses during training sessions.	Response per minute of stereotypic behavior and spitting. Percentage of compliance during training session.	Parents: Follow up probe only with two out of three families on last day of training and one week after training Child: Follow up probe only with two out of three children on last day of training and one week after training	NOT ASSESSED	Correct responses of all caregivers increased substantially following training. Maintenance not evaluated. Child behavior: (1) Stereotypy reduced to near 0 levels. (2) Moderate reduction of spitting with some caregivers. (3) no effect on compliance. One out of three children made clear improvements.
Symon (2005)	Non-concurrent multiple-baseline across participants.	Use of six Pivotal Response Training techniques.	(1) Primary caregiver use of PRT and (2) Child appropriate behavior with primary caregiver. (3) Secondary caregiver use of PRT and (4) Child appropriate behavior with secondary caregiver.	Parents and secondary caregivers used PRT techniques in context of child’s everyday activities (ex., provided clear and uninterrupted instructions, reinforcement related to child’s response)	IOA scored separately for each primary and each secondary caregiver skill ranging from 92% to 98% and for each child behavior separately with primary and secondary caregivers ragging from 83% to 94% of agreements.	NOT ASSESSED	Fidelity of PRT implementation score measured for primary caregivers as % of correct implementations Fidelity of PRT implementation score measured for secondary caregivers at follow-up as % of correct implementations	Percentage of intervals of children’s functional verbal language and appropriate behaviors with primary caregiver and secondary caregivers measured at follow-up.	Secondary caregiver: Follow up probe same as baseline after one to two months. Assessed in the home. Child: Follow up probe same as baseline after one to two months. Assessed in the home.	Generalization described as the spread of the effects of the program from parent-child interactions to interaction of caregiver with child. Generalization from treated communication skills to untreated areas of appropriate behavior.	All parents demonstrated mastery of PRT skills at or above 80% after training and at follow-up. All children demonstrated significant increase in functional verbal utterances and appropriate behaviors.
Loughrey et al. (2014)	Concurrent multiple baseline across modules (behaviors). One for the mother and one for the father.	Use of eight skills associated with mand training: (e.g. preference assessment, differential reinforcement, shaping, data collection). BST approach used.	(1) Parent correct use of eight target skills for teaching mands (e.g., conducting preference assessment, contriving motivation, data collection) (2) Child spontaneous and prompted mands as a secondary dependent measure.	Parents used eight skills while training manding with their child.	IOA measured for 67% of sessions of caregiver performance with IOA 97% (range 90–100%). IOA on child behavior for 59% of sessions. IOA 86% (range 70% to 97%)	Six item questionnaires with 5-point Licker scale after training to be completed at home. Results not provided.	Percentage of correct implementation of steps in mand training as measured on 32-item checklist.	Percentage of intervals with child’s spontaneous and prompted mands.	Follow-up probe for all participants at 5 weeks after training.	Generalization described as transfer of parent skill performance from working with graduate student to working with own child.	Substantial changes in both parents’ skills of mand training with over 80% fidelity. Decrease at follow-up. Less clear change in the child manding repertoire. Increase of unprompted mands. Clear gains of mand repertoire at follow-up.
Hansen et al. (2017)	Pretest-Posttest design	Basic principles of behavior and skills: differential reinforcement, teaching eye contact, response interruption and redirection.	(1) Parents correct use of praising compliance, teaching eye contact and using responses interruption and redirection	NOT PROVIDED	IOA for 23.5% parent skill steps acquisition and quality ratings. IOA was 87.5% (range 75% to 100%)	Social validity measured by post training nine-item questionnaire using 5-point Licker scale. Ratings varied from 3.9 to 5 on average.	Mean number of skill steps acquired and mean quality of acquisition as measured on 5-point Likert scale.	NOT ASSESSED	Described as 20% of parents making contact with investigators one month after training	NOT ASSESSED	Statistically significant gains in all three skill areas for the parents trained at all levels. No significant difference between levels of training.
Knecht (2018)	Pretest-Posttest design	Differential reinforcement, teaching eye contact, response interruption and redirection. BST approach used.	(1) Parents correct use of praising compliance, teaching eye contact and using response interruption and redirection	NOT PROVIDED	IOA assessed for 81% of the session. The IOA for steps completed and quality of performance was 82%.	Social validity assessed by verbal comments of the training participants.	Number of steps completed by each individual and quality of the skill provided to a confederate as measured on 5-point Likert scale.	NOT ASSESSED	NOT ASSESSED	NOT ASSESSED	All participants improved substantially in the number of steps performed and quality of skill implementation. Elevated pre-test scores at some skill areas for some participants.
Conklin and Wallace (2019)	Multiple baseline across participants	Differential reinforcement and prompting aimed at reduction of child specific problem behaviors. BST approach used.	Parents appropriate responding using DRA procedure.	NOT PROVIDED	IOA specifically for 79% of baseline, 100% of training and 100% maintenance sessions. Mean IOA was 95.8 (range 33-100%), 98.9% (range 90-100%) and N/A respectively.	Five questions utilizing Likert scale ranging from 1 to 5. Average mean score was 22.8 range from 3 to 5.	Percentage of correct implementation of DRA measured by percentage of opportunities implemented correctly with a confederate.	NOT ASSESSED	Maintenance probe 1–2 weeks after training	NOT ASSESSED	Clear improvement in DRA procedures for all parents. Tier 1 from mean 34.6% to 96% correct and Tier 2 participants from 33% at baseline to 96.6% correct. Skills sustained at follow-up.

Table 4. Culturally responsive rubric literature evaluation.

	Adubato et al. (1981)	Bruder and Bricker (1985)	Neef (1995)	Kuhn et al. (2003)	Symon (2005)	Loughrey et al. (2014)	Hansen et al. (2017)	Conklin and Wallace (2019)
Rubric item
Problem Formation
1. Construct	1	1	0	1	1	1	2	1
2. Relevancy	1	2	2	0	2	2	2	1
3. Literature	0	1	0	1	2	0	0	0
4. Theoretical	0	0	0	0	0	1	1	1
Design & Logic
5. Participants	0	1	0	1	2	1	2	2
6. Researchers	0	0	0	0	1	0	0	0
7. Sampling	0	1	1	0	0	0	1	1
8. Setting	1	0	1	0	1	1	1	1
Sources of Evidence
9. Data collection	0	0	1	0	0	0	0	0
10. Intervention	1	1	1	1	2	1	1	1
11. Intervention design	0	0	0	0	0	0	0	1
Measurement Process
12. Assess intervention	2	2	2	2	2	2	2	2
Analysis & Interpretation
13. Finding present	1	1	0	1	1	1	0	1
14. Analysis and interpretation	0	0	0	0	0	0	0	1
Dissemination
15. Dissemination	0	0	0	0	0	0	0	0
Total	7	10	8	7	14	10	12	13

Adubato, S. A., Adams, M. K., & Budd, K. S. (1981). Teaching a parent to train a spouse in child management techniques. Journal of Applied Behavior Analysis, 14(2), 193–205. https://doi.org/10.1901/jaba.1981.14-193

 PubMed Web of Science ®Google Scholar

Bruder, M. B., & Bricker, D. (1985). Parents as teachers of their children and other parents. Journal of Early Intervention, 9(2), 136–150.

 Google Scholar

Neef, N. A. (1995). Pyramidal parent training by peers. Journal of Applied Behavior Analysis, 28(3), 333–337. https://doi.org/10.1901/jaba.1995.28-333

 PubMed Web of Science ®Google Scholar

Kuhn, S. A. C., Lerman, D. C., & Vorndran, C. M. (2003). Pyramidal training for families of children with problem behavior. Journal of Applied Behavior Analysis, 36(1), 77–88. https://doi.org/10.1901/jaba.2003.36-77

 PubMed Web of Science ®Google Scholar

Symon, J. B. (2005). Expanding interventions for children with autism: Parents as trainers. Journal of Positive Behavior Interventions, 7(3), 159–173.

 Web of Science ®Google Scholar

Loughrey, T. O., Contreras, B. P., Majdalany, L. M., Rudy, N., Sinn, S., Teague, P., Marshall, G., McGreevy, P., & Harvey, A. C. (2014). Caregivers as interventionists and trainers: Teaching mands to children with developmental disabilities. The Analysis of Verbal Behavior, 30(2), 128–140. https://doi.org/10.1007/s40616-014-0005-z

 PubMedGoogle Scholar

Hansen, B. D., Orton, E. L., Adams, C., Knecht, L., Rindlisbaker, S., Jurtoski, F., & Trajkovski, V. (2017). A pilot study of a behavioral parent training in the Republic of Macedonia. Journal of Autism and Developmental Disorders, 47(6), 1878–1889. https://doi.org/10.1007/s10803-017-3112-6

 PubMed Web of Science ®Google Scholar

Conklin, S. M., & Wallace, M. D. (2019). Training caregivers in the use of a differential reinforcement procedure. Behavioral Interventions, 34(3), 377–387.

 Web of Science ®Google Scholar

Knecht, L. L. (2018). Pyramidal parent training for children with autism spectrum disorder in Southeast Europe [Provo: Brigham Young University. All Theses and Dissertations]. 6987. https://scholarsarchive.byu.edu/etd/6987

 Google Scholar