Evaluation of Hanen Parent Program on Communication, Interaction and Language Skills in Children with Autism Spectrum Disorder: A Systematic Review

Abstract

Autism spectrum disorder (ASD) is a developmental disability that can cause significant communication challenges. Because communication skills are essential to developing other skills, it seems necessary to use early interventions to improve communication skills in children with ASD. Therefore, the aim of this systematic review was to summarize current research about the effect of the Hanen parent program on the communication, interaction, and language skills of children with ASD. Accordingly, it was searched for all articles and dissertations indexed in Persian and foreign databases, in ScienceDirect, Sagepub, Eric, Wiley, Springer, Pubmed, ProQuest, Noormags, Sid, Magiran, and Irandoc in the period 1990 to 2022; using a combination of expressions including “autism spectrum disorder”, “Hanen parent program”, “communication skills” and “early intervention”. Thus, according to the eligibility criteria (Inclusion and exclusion), thirteen articles were included in this systematic review. The results of these studies showed that the Hanen parent program can lead to the natural acquisition of communication skills in children with ASD by relying on strategies in the natural environment and parent-child interaction. Therefore, it is suggested that the Hanen parent program be used as a beneficial early intervention for children with ASD. However, due to the research limitations that reduce the generalization of the results, its effectiveness requires more detailed studies. Keywords: Hanen Parent Program, Communication Skills, Early Intervention, Autism Spectrum Disorder. Extended Abstract Introduction Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is characterized by deficits in social communication skills and restricted and repetitive behaviors in early childhood (American Psychiatric Association, 2022). One of the basic problems observed in children with ASD is a lack of social communication skills (Erbas, Özcebe and Esen, 2020). These children do not have enough communication skills to interact with others in verbal and non-verbal contexts. It should be noted that the problem of these people in communication skills may range from minimal limitation to serious damage (Mohan, Kunnath, Philip, Mohan and Thampi, 2017). The communication deficits of these children may reduce their opportunities to facilitate language development and social interactions. Parents, as the first and most important people related to a child, play an important role in promoting their language and social development (Edmunds, Kover and Stone, 2019). The communication challenges of children with ASD are related to the quantity, quality, and duration of parent-child interactions, and the greater the communication problems of a child with ASD, the less successful the parents are in the child's social upbringing. The more these communication problems are, the interactions between parent and child will be less and of lower quality, and the time will be more limited (Laurent and Gorman, 2017). Therefore, it is necessary to apply parent-mediated based early interventions for children with ASD. In recent years, more emphasis has been placed on the role of parents and their intervention training in improving the skills of children with ASD. Research results indicate the positive effect of parent-based interventions in improving the responsiveness, language, and social skills of children with ASD (Reichow, 2012; Alonso-Esteban and Alcantud-Marín, 2022; Vinen, Clark and Dissanayake, 2022). One intervention that is parent-mediated based is the Hanen more than word program (HMTW). Since HMTW is based on the child's natural environment and family system, it can increase the ability to generalize these skills in children with ASD (Akamoglu and Meadan,2018). Since it seems that the effectiveness of HMTW on the social interactions and language skills of children with ASD has not been systematically investigated, therefore the aim of the current research was the systematic review of researches that show the effectiveness of HMTW on these skills. Literature Review The research findings of Garnett, Davidson & Eadie (2022) showed that HMTW can be effective and reduce time and financial costs. The parents' insight towards the interaction, learning and behavior of themselves and their children was improved. Improvements in communication, interaction responsiveness and play in ASD children were also reported. But it didn't have much effect on parents' stress. Also, Lok, Qi & To (2021) emphasized that HTMW can affect the communication skills of children with ASD whose parents have a higher sense of competence. Erbas et al showed the effect of HTMW on parents' self-efficacy, anxiety, and stress. It also affects the parent-child interaction and language performance of children with ASD. Methodology The current research employed a systematic review method, utilizing the PRISMA model to analyze collected data. Relevant research articles from reputable databases, including ScienceDirect, PubMed, ERIC, PsycINFO, Scopus, Web of Science, Noormags, SID, Magiran, and IranDoc, were searched using keywords such as 'autism spectrum disorder,' 'communication skills,' 'early interventions,' and 'Hanen Parent Program' for the period spanning 1990 to 2022. All relevant sources cited in these articles were also examined. Following an initial search of the research background, articles were screened based on titles and abstracts to remove duplicates and irrelevant studies. Subsequently, the full text of the remaining articles was reviewed and evaluated by two referees according to predefined inclusion and exclusion criteria to identify eligible research. To mitigate the risk of bias in the studies included in this research, we utilized the quantitative studies quality assessment tool from the Effective Public Health Practice Project (EPHPP, 1998). Two evaluators assessed the studies using this tool, and the level of agreement between them was measured using the Kappa coefficient. Results After conducting investigations, we identified 390 studies, with 138 remaining after removing duplicates. Subsequently, we examined the titles and abstracts, eliminating 79 unrelated studies. This left 59 studies for full-text review. Following the application of inclusion and exclusion criteria, 46 studies were removed, resulting in the identification of 13 relevant studies for our analysis. Among the identified studies, 7 were experimental or quasi-experimental (53.85%), with 1 utilizing mixed methods. Additionally, there were 4 case studies (30.77%), 1 single-subject study (7.7%), and 1 longitudinal study (7.7%). The quality of the research was assessed using the Kappa coefficient, yielding a score of 0.92. Thus, 3 articles were deemed to have good quality, 5 had medium quality, and 5 had low quality. Studies receiving a low rating often had limitations in research methodology, sample size, and data collection methods, hindering generalizability to the community. These results are shown in Table 1. Overall, the effectiveness of HMTW in these studies can be categorized into quantitative (with statistical analysis) and qualitative or mixed-method research (descriptive and single-subject). It's important to note that the results of quantitative studies varied. Table 1 Results of quality assessment of studies using the EPHPP Authors, year of publication Selection bias Study design Confounders Blinding Data collection methods Withdrawals and drop-outs Global rating Garnett, Davidson & Eadie (2022) 1 1 1 2 2 2 2 Lok et al (2021) 3 2 3 2 2 2 3 Erbas et al (2020) 4 1 2 2 2 2 2 Sokmum, Singh & Vandort (2017) 4 2 2 2 2 2 2 DeCarlos & Baixauli (2015) 1 1 1 2 1 1 1 Lieberman-Betz et al (2014) 2 2 2 1 2 3 2 Carter et al (2011) 3 3 2 3 2 3 3 Patterson & Smith (2011) 1 1 1 1 1 2 1 Prelock, Calhoun, Morris & Platt (2011) 1 1 1 1 1 2 1 Venker, McDuffie, Weismer & Abbeduto (2011) 2 2 1 1 1 2 2 Girolametto Sussman & Weitzman (2007) 1 1 1 1 1 2 1 McConachie, Randle, Hammal & LeCouteur (2005) 3 3 2 2 3 2 3 Sorensen (1992) 1 1 1 1 1 1 1 Discussion The results of this research indicate that the program is more effective than HMTW for improving the communication skills of children with ASD. However, except for Venkar et al.'s (2011) study, which showed a medium effect size, the rest reported weak effect sizes, attributed to small sample sizes and data collection methods. Active parental involvement in treatment supports the language and communication development of children with ASD (Lok et al., 2021). Conversely, Carter et al (2011) found HMTW to be more effective for children with ASD showing limited interest in objects. Children less interested in specific objects responded better to HMTW, while those more interested required additional support and different strategies. Therefore, attention should be given not only to the communication level but also to the level of interest in subjects. Furthermore, Sokmum et al (2017) concluded that parental intervention can be as effective as a therapist-led intervention. They observed minimal progress in communication skills among the control group subjected to clinical intervention compared to the experimental group undergoing HMTW. Conclusion In general, it can be said that HMTW emphasizes the natural life and daily activities of children with ASD and considers parents' education as the main social and communication base of the child, and considering the positive results that these studies have obtained from its effectiveness, it confirms its usability and training as an early intervention - alone or in combination with other interventions. However, the effectiveness of this intervention in order to ensure its generalizability to the entire society, requires more detailed investigations and a higher sample size.

Keywords

• hanen parent program
• communication skills
• early intervention
• autism spectrum disorder