Original Articleped_3637 693..

700
AutismPro system in supporting treatment of children with autism
in Poland
Anna Waligrska,
1
Ewa Pisula,
2
Micha Waligrski
3
and Maciej Letachowicz
4
1
Department of Psychology, Warsaw School of Social Sciences and Humanities,
2
Department of Psychology, University of
Warsaw, Warsaw,
3
SOTIS Therapy Center and
4
Occupational Therapy Workshop in Grjec, Grjec, Poland
Abstract Background: The efcacy of early intervention programs for children with autism has been emphasized in many
studies. However, access for people with autism to professional services in Poland is very limited and the burden of
supporting a childs development often falls on parents, especially in families with low socioeconomic status and
families living far away from big cities. Using Internet resources in planning and delivering individualized intervention
may be useful. This study examined the effects of a home program of intervention based on the AutismPro system with
elements of consultative therapy.
Methods: Ten families of children with a diagnosis of autism participated in the project; nine of them completed the
6-month program of intervention. Parents were taught to use the AutismPro system and implement the intervention
techniques in a home setting. Modication of the intervention program to suit individual childrens needs and evaluations
of childrens progress were performed during consultation meetings with therapists. The pre- and post-treatment
measurement of child development was performed using the Psychoeducational Prole Revised (PEP-R).
Results: Children involved in the study progressed in total PEP-R scores and on the PEP-R subtest of ne motor, gross
motor, non-verbal and verbal cognitive skills and eyehand integration. Parents expressed positive opinions on the
program.
Conclusions: The results suggest that an intervention which combines the use of the Internet support tool and
professional consultations may provide benets to the children with autism. There are, however, methodological
limitations of the study to be taken into account when interpreting the results.
Key words autism, home-based treatment, Internet resources, parents satisfaction, therapy effectiveness.
Research on the effectiveness of autism treatment shows that
intensive, structured early intervention can positively affect the
functioning of young children with autism spectrum disorders
(ASD).
1,2
However, access to comprehensive services is very
limited.
3
Currently in Poland there is no governmental program
of intensive early intervention for children with autism. The
majority of only a handful of centers specializing in ASD treat-
ment are run either by non-governmental organizations, offering
professional treatment only for a small number of children, or
by private institutions, which provide comprehensive, but very
expensive intervention. Because of its high costs, this type of
treatment is available only to a minority of children with autism.
Families of lower socioeconomic status and families living in
small towns or villages have very little access to therapeutic
support.
4
As Wachtel and Carter
5
noted, the burden of coordinating,
advocating for, and making decisions about treatment often falls
on parents. They tend to use the Internet as the primary source of
information, along with information from other parents.
6,7
The
Internet cannot replace professional services, but it can help
parents in their efforts to support their childs development.
This, however, requires access to unbiased, scientically vali-
dated information.
One of the online resources which can help parents in plan-
ning and delivering individualized intervention for children with
autism is the AutismPro system.
8
This Internet tool employs three
features of an effective treatment program for children with
autism described by Ozonoff and Cathcart:
9
(i) using a structured
approach; (ii) training parents to implement the program at
home; and (iii) addressing the treatment program to young
children. AutismPro is a coherent, ample database of ASD and
various methods of treatment, combined with an assessment
questionnaire about a childs level of functioning (see: http://
www.autismpro.com). It enables caregivers to assess the childs
functioning and develop an intervention program adapted to the
individual requirements of their child. In addition, the system
helps parents learn strategies for interacting with the child and to
Correspondence: Ewa Pisula, PhD, Faculty of Psychology, University
of Warsaw, Stawki 5/7, 00-183 Warsaw, Poland. Email: ewa.pisula@
psych.uw.edu.pl
Received 28 April 2011; revised 16 November 2011; accepted 6
March 2012.
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Pediatrics International (2012) 54, 693700 doi: 10.1111/j.1442-200X.2012.03637.x
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
prepare the learning environment, deal with challenging behav-
iors, create a schedule of activities and measure progress. This
Internet-based system includes nine stages of assessment and
instruction leading to a coherent intervention program, individu-
ally adapted for the child. The stages of formulating a plan of
therapy are as follows:
1 Introductory survey on the basic information about the child
(name; sex; age; diagnosis)
2 Basic functional assessment (including communication, ste-
reotypical behavior, social competence)
3 Curriculum assessment (regarding areas of (i) social compe-
tence; (ii) expression and recognition of emotions; (iii) non-
verbal communication skills; (iv) receptive language; (v)
expressive language; (vi) cognitive functioning; (vii) self-help
skills; and (viii) motor skills)
4 Setting therapeutic priorities and current training objectives
(from the list of therapeutic objectives in the above-mentioned
eight areas of functioning, adapted to the assessed potential of
the child)
5 Choosing a set of therapeutic activities best tted for the child
from the list of exercises designed for each therapeutic objec-
tive, and then conducting selected activities according to the
detailed description of its procedure
6 Learning and applying strategies to prepare the learning envi-
ronment, and to interact with and respond to the child
7 Learning and applying strategies to deal with challenging
behaviors
8 Formulating a schedule of activities
9 Measuring progress.
When caregivers report that the child acquired selected skills,
the AutismPro system recommends new therapeutic objectives
and activities to continue the training program. The process
resembles the progress of consultative therapy combined with
home sessions performed by parents.
As was stated in previous studies,
10
the e-learning form of
training can be effective in teaching parents to use various treat-
ment methods. In the AutismPro system, parents are provided
with information about veried methods and techniques, educa-
tional directions and exercises from behavioral (ABA), develop-
mental and relationship-based curriculum. Depending on the
childs needs, exercises from different curricula can be com-
bined. A number of authors have recommended the use of an
integrative approach in the treatment of autism.
1113
The integra-
tive approach is also more likely to meet the parents expecta-
tions. In the study of Webster et al.,
13
25 out of 26 families
participating in the intensive early intervention program pre-
ferred a combination of techniques tted to their childs needs
over one selected method and therapeutic approach. Moreover,
previous surveys on AutismPro revealed a high level of parental
satisfaction about the tools adaptability.
8
There is extensive positive evidence on the effectiveness
of home-based treatment carried out by previously trained
parents.
9,1418
In the study conducted by Baker-Ericzn et al.,
15
parents were trained to use naturalistic techniques of behavioral
therapy (pivotal response training) for 3 months, and even this
relatively short period brought signicant progress in the devel-
opment of the childrens abilities. In a similar study by Ozonoff
and Cathcart,
9
parents were taught how to work with their chil-
dren with autism, using the TEACCH model. Results, measured
with Psychoeducational Prole Revised (PEP-R)
19
before and
after 4 months of treatment, demonstrated that children under
treatment improved signicantly more than children from the
control group in overall PEP-R scores and in several PEP-R
subtests.
These ndings suggest that home-based intervention can
bring positive changes in the development of children with
autism. As a far more affordable (although more demanding
of parents) form of treatment than extensive outside services,
it has become a basic form of intervention for many children
with autism. It should be mentioned though that to be successful,
this kind of intervention requires professional support for
parents.
The idea of the present study was to examine the effective-
ness of the intervention in which the Internet support tool for
parents the AutismPro system was combined and integrated
with a consultative therapy model. The purpose of the study was
to measure the effects of participation in the intervention program
for child development and convey parents opinions about the
AutismPro system and the combined (Internet tool use plus con-
sultative therapy) model of intervention. Another aim was to nd
out whether the AutismPro system a therapeutic tool created in
English by specialists from North America and Western Europe
would prove to be effective for parents in Poland.
Methods
The present study used a quasi-experimental prepost design to
measure child development indicators before and after involve-
ment in a 6-month intervention program. The group of nine
children with autism who participated in the program was exam-
ined using PEP-R
19
twice: before and after program participation.
Additionally, parents of the children completed two question-
naires in which they rated the AutismPro system and the actually
used form of intervention. The written consent of each parent was
collected. The research has been conducted in accordance with
local legal and ethical regulations concerning scientic research
in Poland.
Subjects and procedure
The sample was recruited from the group of 24 families who
positively responded to the information about the program pub-
lished in the discussion forum on autism and presented to the
patients of the Masovian Center of Psychiatry and Rehabilitation
for Children and Adolescents. Ten families were qualied to
participate in the study. They met the following criteria: childs
diagnosis of ASD, childs age (37 years), parents Internet
access, parents uency in English and good computer skills. The
childs diagnosis was made independently by expert psychiatrists
using World Health Organization ICD-10 criteria.
20
All mothers
and fathers were biological parents of their children with autism.
All of them were married and, in all cases but one, living with
694 A Waligrska et al.
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
their spouse. Finally, the only one father not living with his child
refused to complete the questionnaire, giving as his reason lack
of time to do that.
The families were enrolled in a 6-month intervention
program. Nine families who completed both pre- and post-
treatment assessment were included in the study sample (one
family after 2 months of participation in the program resigned
due to lack of time and resources for working with their child).
Childrens developmental age measured with PEP-R before
the intervention ranged from 16 months to 38 months (mean
25.77, SD 11.12). Before involvement in the program, ve chil-
dren had participated in low-intensity home-based treatment, and
four children had participated in consultative therapy of various
levels of intensity. During the pilot study, all these general treat-
ments were suspended with the exception of specialist sessions
(such as speech therapy or sensory integration), which were
continued on the previous, low-intensity schedule (once a week
or more rarely).
The group of participating families was stratied according
to the demographic and other criteria (i.e. place of residence,
uency in English, Internet access, computer skills). Most of the
participating parents had higher education, which reected the
typical education level of parents applying for the program. Four
of the children had siblings; the siblings were not involved when
the parent was working with the child with autism. Further demo-
graphic data on the parents, their children and families is pre-
sented in Table 1.
The program included parent training, pre-treatment and
outcome measures, and six consultations (one 2.5-h consultation
each month). Consultation meetings took place in two treatment
centers participating in the program. During consultation ses-
sions, Internet access was provided. The design of the program is
presented in Table 2.
Three consultants working with families were trained in using
AutismPro by the creators of the AutismPro system (through
workshops, presentations and webinars) and eight consultants
were trained through the train-the-trainer model (workshops, pre-
sentations, trial practice, training meetings). Two clinical psy-
chologists experienced in the treatment of individuals with ASD
and their families supervised the implementation of AutismPro
during consultations on a monthly basis. Each consultation with
a family was conducted by two professionals (psychologists
or special educators), of which at least one was an experienced
consultant specializing in autism. At least one of these two con-
sultants had a good command of English.
In the present intervention, the treatment approach (behav-
ioral, developmental or relationship-based) was chosen by con-
sultants on the basis of the functional assessment of the child and
teaching preferences expressed by parents. After consultants pre-
pared an individual treatment program (on the basis of the childs
assessment and with the use of the AutismPro system), parents
were trained in the techniques of working with their child, moti-
vating the child, structuring sessions, dealing with challenging
behaviors and using the AutismPro system (10 h of training in
total). To ensure delity of implementation of the AutismPro
program by the parents and assess the childs developmental
gains each month, the program was adjusted to the childs devel-
opmental progress, as measured by an extended form of behav-
ioral assessment, observations of activities completed during
consultation sessions and lm recordings of activities completed
by the child at home. Sessions with direct observations of childs
behavior and analysis of video material were conducted consecu-
tively (see Table 2). To make the setting as familiar as possible,
each child exercised with the person usually conducting sessions
(e.g. mother), using the same toys and equipment. Parents ques-
tions and specialists observations concerning proper implemen-
tation of the program and exercises were discussed during the
sessions (plus by phone or email between the consultations).
Between consultation meetings, parents were obliged to work
with their child at least 10 h/week using their AutismPro account
for necessary information on the updated program (including
descriptions of procedures schedule, e-learning center etc.).
Mean time spent on working with the child declared by parents
in the post-experiment self-assessment was 10.7 h/week (min. 9,
max. 12). All of the parents concerns and questions were
answered by their consultants by phone or email. Participants
Table 1 Demographic characteristics of the sample
Age of children (n = 9) Mean 4.84 (age range
37 years); SD 1.47
Sex of children
Boys n = 8
Girls n = 1
Childs diagnosis
Autism n = 7
Pervasive developmental
disorder not otherwise specied
n = 2
Age of parents (n = 17)
Mothers (n = 9) Mean 36.75 years (age
range 3243); SD 3.20
Fathers (n = 8) Mean 39.25 years (age
range 3255); SD 7.68
Level of parents education: n
Mothers
Secondary 1
Higher 8
Fathers
Secondary 0
Higher 8
Employment status n
Mothers
Full-time job 4
Part-time job 3
Unemployed 2
Fathers
Full-time job 8
Part-time job 0
Unemployed 0
Economic status n
Slightly below average 2
Average 13
Above average 2
Place of residence n
Town 100010 000 residents 2
Town 10 001100 000 residents 8
Town 100 0011 000 000 residents 1
City above 1 000 000 6
AutismPro in treatment of Polish children 695
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
were also offered technical support and had access to an Internet
discussion forum to exchange opinions with other parents
involved in the program. As parents became more experienced in
working with their child and monitoring the childs progress,
they were given increasing responsibility for managing the home
program although their questions could always be discussed
with the consultants during consultations or by phone.
Measurements
Child development
Childrens development was measured with use of the Polish
version of PEP-R.
19,21
The PEP-R is often used to measure the
effectiveness of interventions for children with ASD.
9,13
The PEP-R is a developmental scale designed for assessing
both the characteristic decits and potential of children with
autism. The tool is divided into seven sections referring to various
developmental domains (such as imitation, perception, ne and
gross motor skills, eyehand coordination, non-verbal conceptual
ability and verbal cognition). A child can score either pass,
emerging (meaning promising, though not completely acquired
skill) or fail on each test item. The number of passes is summed
up so that it reects a developmental age (that is an actual func-
tional level) in months. Similarly, the number of emerging skills
is converted to an emerging level of functioning. Scores from all
the seven domains were used in the current study.
The PEP-R measurement was conducted by a clinical
psychologist with 3 years experience of using the scale in the
functional diagnosis of children with ASD, working with another
specialist (psychologist or special educator). The examiners were
not blinded to the specics of the study, although they were not
involved in the other parts of the study.
Parents satisfaction
The opinion survey consisted of two scales. The rst of them
was used to measure the level of parents satisfaction with the
AutismPro system (questions were derived from the study by
Howroyd and Peeters
8
and the model of intervention imple-
mented in the study [Internet tool plus consultations]). Answers
were given on a 5-point Likert scale, in which 1 = strongly
disagree, and 5 = strongly agree. In the second scale, participants
answered four open-ended questions related to their opinions
about the strengths and weaknesses of AutismPro and the inter-
vention implemented in the study.
Results
A repeated measures anova was used to measure differences
between pre- and post-treatment results, with time as the within-
subjects repeated factor. The descriptive statistics are presented
in Table 3.
Children demonstrated signicant improvement on the total
post-test PEP-R score (F
(1,8)
= 22.56, P < 0.01, eta
2
= 0.74), as
well as on the Fine Motor subtest (F
(1,8)
= 21.44, P < 0.01, eta
2
=
0.73), the Gross Motor subtest (F
(1,8)
= 11.90, P < 0.01), eta
2
=
0.60, the Cognitive Performance subtest (F
(1,8)
= 6.19, P < 0.05, T
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696 A Waligrska et al.
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
eta
2
= 44), the Eyehand Integration subtest (F
(1,8)
= 7.45, P <
0.05, eta
2
= 0.48), and the Cognitive Verbal subtest (F
(1,8)
= 6.97,
P < 0.05, eta
2
= 0.47).
Along with changes in the level of actual functioning, children
also showed improvement in their emerging skills (PEP-R
emerging level of functioning measurement) (Table 4).
Signicant progress was made on the total post-test PEP-R
emerging score (F
(1,8)
= 16.45, P < 0.01, eta
2
= 0.67), and on the
Fine Motor emerging subtest (F
(1,8)
= 9.48, P < 0.05, eta
2
= 0.54),
the Gross Motor emerging subtest (F
(1,8)
= 8.47, P < 0.05, eta
2
=
0.51), and the Cognitive Performance emerging subtest (F
(1,8)
=
11.66, P < 0.01, eta
2
= 0.59).
There were no signicant differences between pretreatment
emerging functional level (in months: mean 36.22, SD 15.11) and
post-treatment actual functional level (in months: mean 34.88,
SD 13.24); t(1,8) = -0.501, P > 0.05. This indicates that children
who participated in the 6-month intervention program achieved
their emerging, potential level of functioning.
In addition, to evaluate the effects of treatment, the childrens
developmental quotient (DQ: developmental age/chronological
age 100) pre- and post-treatment values were compared. The
results are presented in Table 5.
Children demonstrated signicant improvement on the total
post-test PEP-R score (F
(1,8)
= 7.18, P < 0.05, eta
2
= 0.47), as well
as on the Fine Motor subtest (F
(1,8)
= 6.66, P < 0.05, eta
2
= 0.45).
The difference in the Gross Motor subtest was signicant at
tendency level (F
(1,8)
= 4.17, P = 0.075, eta
2
= 0.34).
The results of the parents opinion survey measuring the level
of satisfaction with the AutismPro system and the intervention
model implemented in the study are presented in Table 6.
The parents opinions about the advantages and disadvantages
of AutismPro and the intervention model implemented in the
Table 3 Differences in pre- and post-treatment PEP-R scores (in months) (n = 9)
Scale PEP-R Pretest Post-test Difference
in months
Mean SD Mean SD
Total PEP-R score 25.77 11.12 34.88 13.24 9.11*
Imitation 21.89 12.55 28.67 14.92 6.78
Perception 25.89 17.27 32.44 17.90 6.55
Fine motor 28.66 10.00 37.88 12.64 9.22**
Gross motor 31.66 9.16 44.44 14.08 12.78**
Eyehand integration 30.44 12.71 41.44 14.90 11.00*
Cognitive performance 20.77 10.92 28.66 15.07 7.89*
Cognitive verbal 24.44 16.67 29.33 16.65 4.89*
**P < 0.01; *P < 0.05. PEP-R, Psychoeducational Prole-Revised.
Table 4 Differences in pre- and post-treatment emerging PEP-R Scores (in months) (n = 9)
Scale Pretest Post-test Difference
in months
Mean SD Mean SD
Total PEP-R emerging score 36.22 15.11 47.56 13.80 11.34**
Imitation (emerging) 38.22 20.03 40.44 14.93 2.22
Perception (emerging) 34.56 16.09 40.89 17.67 6.33
Fine motor (emerging) 38.33 14.18 49.89 16.97 11.56*
Gross motor (emerging) 43.11 10.09 49.11 11.83 6.00*
Eyehand integration (emerging) 40.56 14.66 50.22 16.36 9.66
Cognitive performance (emerging) 34.22 16.24 42.44 16.13 8.22**
Cognitive verbal (emerging) 33.56 19.01 37.33 18.24 3.77
**P < 0.01; *P < 0.05. PEP-R, Psychoeducational Prole-Revised.
Table 5 Differences in pre- and post-treatment PEP-R scores presented as Developmental Quotient (n = 9)
Scale PEP-R Pretest Post-test Difference
Mean SD Mean SD
Total PEP-R score 81.94 8.63 95.18 11.21 13.24*
Imitation 68.76 11.41 78.06 13.80 9.30
Perception 84.66 16.30 89.25 16.89 4.59
Fine motor 93.86 11.21 105.18 13.44 11.32*
Gross motor 103.91 9.11 125.92 17.79 22.01
Eyehand integration 99.39 14.35 115.40 15.63 16.02
Cognitive performance 65.08 9.04 78.96 15.62 13.88
Cognitive verbal 73.70 12.94 75.85 12.56 2.15
*P < 0.05.
AutismPro in treatment of Polish children 697
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
study are shown in Table 7. The parents answers to open-ended
questions were referred by raters to the common categories; the
result of this was demonstrated in percentages. Only the catego-
ries indicated by at least two parents were taken into account.
Discussion
The aim of the presented study was to conduct an initial assess-
ment of the efcacy of a consultative model of autism treatment
based on a new kind of Internet support the AutismPro system.
Due to the pilot character of the study program and implied small
sample, the main focus was to assess the advisability of imple-
menting this Internet tool in association with professional
support for parents. Apart from qualitative data and participants
suggestions, we found a statistically signicant progress in chil-
drens functioning, important enough to present along with the
qualitative results of the program. It must be stressed however,
that due to signicant design limitations, this study may be con-
sidered only as a preliminary report.
Results suggest that the AutismPro system in combination
with consultations and parent training may be considered as a
support tool in developing an effective home-based program for
young children with autism. The comparison of pre- and post-
treatment PEP-R scores indicated that the cognitive and devel-
opmental skills of children participating in the study have
improved, especially in such domains as motor skills, eyehand
integration and cognitive performance. Children demonstrated
signicant improvement both on the total post-treatment PEP-R
score (mean 9.1 months of developmental age), and the Cognitive
Performance subtest (mean 7.9 months), the Cognitive Verbal
subtest (mean 4.9 months), the Fine Motor subtest (mean 9.2
months), the Gross Motor subtest (mean 12.8 months), and
the Eyehand Integration subtest (mean 11 months). Some of the
outcomes were compatible with the ndings of the study of the
TEACCH home-based program,
9
which showed similar dynam-
ics of progress in the treatment group. In that study, the childrens
overall progress (measured with PEP-R) was 7 months of devel-
opmental age following a 4-month program. This result was
signicantly better than in the control, non-treatment group. The
developmental progress demonstrated after 4 months of a home-
based treatment in the study conducted by Ozonoff and Cathcart
9
is comparable with the outcomes of the present study in terms
of the developmental progress after 6 months of a home-based
program.
The comparison between pre- and post-treatment DQ values
revealed a signicant improvement in the total post-test PEP-R
score and the Fine Motor subtest. The difference in the Gross
Motor subtest was signicant at tendency level, and in the other
scales there were no differences between pre- and post-treatment
values. Still, it is worth noting that the mean results changed in
Table 6 Results of the parents opinion survey: the level of parents satisfaction with the AutismPro system and the model of intervention used in
the study
Items Mean SD
1. Structure of the AutismPro system is understandable for parents 4.4 0.55
2. Consultations support me in conducting activities with my child 4.5 0.41
3. I typically exercise with my child approximately . . . hrs/week 10.7 0.61
4. Apart from consultations I need approximately . . . hrs of contact with the consultant of my child 1.5 0.85
5. I wish to continue working with my child using AutismPro 4.0 0.55
6. AutismPro helps users decide on a treatment method 4.3 0.61
7. AutismPro helps users decide on treatment goals (Objectives) 4.4 0.52
8. AutismPro helps users implement positive behavioral supports 4.1 0.74
9. AutismPro helps users implement teaching strategies 4.0 0.63
10. AutismPro helps users update and evolve a plan in response to a childs changing needs 4.4 0.55
11. AutismPro helps users understand when they need to try something new 4.2 0.52
12. AutismPro is a valuable decision-support and guidance tool for parents 4.1 0.61
13. AutismPro enables parents to manage treatment effectively 4.4 0.41
14. Do you believe the relevance and quality of educational therapy plans will be enhanced by the use of this program? 4.5 0.52
15. Would you recommend AutismPro to other parents? 4.8 0.41
Table 7 Results of the parents opinion survey: parents opinions about
strengths and weaknesses of the AutismPro and model of intervention
Parents opinions Percentage
1. Biggest advantages of the AutismPro system are:
Support for parents 76.5%
Ability to choose therapeutic objectives 88.2%
Precise description of activities 70.6%
Teaching knowledge of autism therapy 41.2%
Creating coherent plan of therapy 58.8%
Possibility of systematic adjustment of therapeutic program 52.9%
Possibility to observe progress 41.2%
Activities interesting for the family 11.8%
2. Biggest drawbacks of the AutismPro system are:
Foreign language 58.8%
Technical issues 11.8%
3. Biggest advantages of the consultations program are:
Support for parents 82.4%
Help in the choice of therapeutic objectives 64.7%
Explaining the activities 47.1%
Acquiring knowledge of autism therapy 41.2%
Creating coherent plan of therapy 41.2%
Possibility of systematic adjustment of therapeutic program 58.8%
Possibility to assess progress 35.3%
Possibility to consult the doubts with a specialist 52.9%
Possibility to acquire additional information 11.8%
4. Biggest drawbacks of the consultations program are:
Necessity of traveling for the consultations 52.9%
Effort of working with the child 15.8%
698 A Waligrska et al.
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
the expected direction. It should also be noted that there were
signicant individual differences between children in terms of
increase in skills. This was to be expected given the differences in
baseline skills between individual participants, nevertheless, it
would be interesting to analyze the factors that have determined
the extent of progress made by each child. Data collected in this
study are too scarce to propose a denitive explanation. However,
this issue merits further investigation.
In general, 10 h/week spent by parents on working with
the child (which was the initial condition of participation) was
similar not only to the actual time of activities reported by parents
in the nal survey (10.7 h/week), but also to the mean time of
service requested by the families in an intensive institutional
early intervention program.
13
The 10-h limit seems to be a
minimal effective support for children, which would be possible
to perform at home by parents.
Home intervention programs require considerable time com-
mitment by parents, along with nancial demands. Implementing
a program at home may become an additional stress factor for the
family routine. Moreover, supervision of a home program is
necessary to ensure proper use of treatment methods and to adjust
exercises to support the development of the child. For this reason,
the purpose of this pilot program, combining the use of a thera-
peutic tool and sessions with a specialist, was to establish
whether this type of treatment can be effective for families in
Poland. The overall results of the opinion survey showed that
parents rated the usefulness of this form of intervention highly.
The most positive responses concerned establishing treatment
goals, adjusting intervention to the current level of childs devel-
opment, managing the intervention, intelligibility of the tool and
support achieved through consultations. The results of the survey
conrm the high level of parents satisfaction with AutismPro
reported by Howroyd and Peeters.
8
In general, as the ease of
implementation seems to contribute to the choice of treatment
method,
6
the usability and usefulness of the tool are likely the two
major factors contributing to parental satisfaction.
Parents rated precise descriptions of the exercises very highly.
It may be argued that positive opinions offered by all parents
after the intervention and their descriptions of their childrens
responses resulted from the fact that activities as a rule imitated
natural situations, yet were easy to replicate due to precise descrip-
tion of procedures. In general, naturalistic interventions enhance
positive affect of the child more effectively than highly structured
ones.
22
This was seen is such opinions as: Participation inAutism-
Pro program made me realize that there are many therapeutic
possibilities for my child to learn through play. This is a particu-
larly exible approach, adjusting activities to the needs, disposi-
tion and interests of the child and to parents suggestions (E. K.
and D. K., parents of a 4.5-year-old boy); Activities suited B.
[son] very much. All family members were involved in the exer-
cises, and another advantage of the program was that everyone
working with our son applied the same procedure described in the
program (J. P. and A. P., parents of a 6-year-old boy).
1
It may be argued that the parents participating in the pilot
project were particularly active and engaged in activities with
their child. Their involvement was not measured, but as they
fullled the requirements associated with participation (working
with the child for at least 10 h/week, lming successful and
difcult interactions, coming to the consultations, sometimes
from remote locations in Poland etc.), we may assume that it was
deep. The one family that was less involved in the intervention
due to other obligations (birth of another child), did not complete
the requirements of the pilot program. We can assume that the
approach demanding substantial effort from families will only be
successful in the case of active and cooperative parents.
Parental involvement is a very important factor in successful
treatment of young children with autism,
23
helping to develop
skills maintenance and generalization
24
and enhancing family
well-being.
25
It may be relevant, particularly in the treatment
using Internet tools, such as AutismPro, which requires a lot of
independence from parents. In the present research, it was
ensured that parents actually worked with their children, and kept
a detailed record of results (day and week forms listing the
number of activities performed and their results), which is a
strength of this study. Still, further studies are needed to establish
the role of parental commitment.
Although language difference was described by parents as
one of the major difculties with using the program, it was not
a severe obstacle to childrens progress. This result is similar to
previous observations by Baker-Ericzn et al.
15
who found that a
pivotal response training program for parents was equally ef-
cient in families of different cultural/linguistic background and
limited uency in English, despite the fact that training sessions
were conducted in this language exclusively. Also, data on adap-
tation of another method included in the AutismPro system
(TEACCH) to the culturally different population of China
shows that the application was successful.
26
It seems that an
efcient and structured therapeutic program is adaptable and can
form a useful base for treatment even transferred to different
culture. Naturally, this observation does not put into question
the need for linguistic and cultural adaptation of therapeutic
tools. It may be argued, however, that sometimes children can
benet from intervention programs even before such adaptation
is completed, as long as their families are provided with the
means of translation.
The present study has very important limitations. All partici-
pating children (nine of whom completed the program) were
involved in the therapeutic program and subjected to pre- and
post-intervention measurements. There was no control group
involved. The changes in childrens development were measured
only twice. Moreover, the main outcome measure was limited to
a single indirect rating scale. The study was also limited by the
number of participants. These limitations are related to the pre-
liminary pilot character of the study, similarly to the data reported
by other authors.
2729
As noted by researchers participating in the
workshop run by Charman and Howlin,
30
small group designs
should be used when interventions are rst introduced in order to
examine if the treatment is appropriate for larger-scale random-
ized trials. In accordance with these recommendations,
31,32
the
next stage of the evaluation will be randomized clinical trials
under controlled conditions, and evaluation of outcomes in com-
munity settings. It should be noted, however, that the control over
AutismPro in treatment of Polish children 699
2012 The Authors
Pediatrics International 2012 Japan Pediatric Society
the factors affecting changes in childrens development was
limited in the presented study. The results should be interpreted
with caution.
Our results seem to indicate that the AutismPro system, as a
basis of a home program, may be considered as a promisingly
supportive tool in the treatment of autism. Further research (ran-
domized clinical trials under controlled conditions, larger sample
size and measures in community settings as well as a greater
number of outcomes measured) is needed to conclude the evalu-
ation of its effectiveness.
Conclusions
1 Children participating in the study progressed in their devel-
opment. The progress was most profound in ne motor skills.
2 Parents of children involved in the study declared satisfaction
with using the AutismPro system in combination with profes-
sional consultations.
3 It should be stressed that using the AutismPro system to
support the development of a child with autism should be
neither the sole nor even primary element of the intervention.
Every child should have access to professional diagnostic and
therapeutic care.
4 The results of this study, given the signicant methodological
limitations, should be treated only as a very preliminary report.
For complete text of participants opinions (in Polish) see: http://
www.autismpro.pl
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