Research in Developmental Disabilities, Vol. 15. No. 4, pp.

299-332, 1994
Copyright 0 1994 Elsevier Science Ltd
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Parenting Education for Parents With

Intel Iectual Disabilities: A Review of
Outcome Studies

Maurice A. Feldman

Surrey Place Centre and The University of Toronto

Parents with intellectual disabilities (i.e., IQ < 80; mental retardation) are
overrepresented in child maltreatment cases and have a variety of parenting
skill deficits. Their children are at risk for neglect, developmental delay, and
behavioral disorders. This review of parenting education interventions for such
parents identijied 20 published studies with adequate outcome data. A total of
190 such parents (188 mothers, 2 fathers), with IQs ranging from 50 to 79 were
involved. Parenting skills trained included basic child-care, safety, nutrition,
problem solving, positive parent-child interactions, and child behavior man-
agement. The most common instructional approach was behavioral (e.g.S task
analysis, modeling, feedback, reinforcement). Overall, initial training, follow-
up, and social validity results are encouraging. Generalization and child out-
come data are weak. Further research is needed to (a) identify variables associ-
ated with responsiveness to intervention, and (b) develop and compare innova-
tive programs that teach parents with cognitive disabilities the necessary gener-
alized skills to demonstrate long-term beneficial effects on their children.

There is increasing recognition of the rights and the risks of parenting by

persons with intellectual disabilities (i.e., IQ < 80), many of whom are

The execution of this article was funded in part by grants from the Ontario Mental Health
Foundation and the Ontario Ministry of Community and Social Services Research Grants
Program (administered by the Research and Program Evaluation Unit).
The author thanks J. Berg and R. Ward for their helpful comments, B. Sparks for his assistance
in the visual inspection of the figures, and A. Cheung for her help in preparation of the tables.
Requests for reprints should be sent to Maurice A. Feldman, Surrey Place Centre, 2 Surrey
Place, Toronto, Ontario, Canada M5S 2C2.

299
300 M. A. Feldman

labeled mentally retarded. On the one hand, court decisions are ban-
ning involuntary sterilization of persons with developmental disabilities
and upholding parenting as a basic right of all adult citizens (Hayman,
1990; Hertz, 1979; Wald, 1975). Cumulating evidence exists that chil-
dren of parents with low IQ are at risk for maltreatment (particularly
neglect), developmental delay, psychosocial mental retardation, and
behavior disorders (Feldman, Case, Towns, & Betel, 1985; Feldman &
Walton-Allen, 1993; Gillberg & Geijer-Karlsson, 1983; Reed & Reed,
1965; Schilling, Schinke, Blythe, & Barth, 1982; Seagull & Scheurer,
1986; Taylor et al., 1991). Despite the long-standing recognition of par-
enting problems of persons with mental retardation (Mickleson, 1947)
and the acknowledgment that these families are most in need of inter-
vention services (Ramey & Ramey, 1992, p. 338), until the 1980s there
was no published research on the effectiveness of child-care training
programs for these parents.
Although an operational definition of adequate parenting is lacking, the
courts typically look for the provision of a safe, healthy, nurturing, and
stimulating environment (Hayman, 1990; Hertz, 1979; Wald, 1975).
Parents with intellectual disabilities often have problems in: (a) making
appropriate decisions (Budd & Greenspan, 1984; Tymchuk, Andron, &
Rahbar, 1988; Tymchuk, Yokota, & Rahbar, 1990d); (b) ensuring that the
childs physical, nutritional, health, and safety needs are met (Feldman,
Case, & Sparks, 1992b; Feldman et al., 1992a; Tymchuk, Hamada,
Andron, & Anderson, 1990b,c); and (c) providing stimulating home envi-
ronments and interacting in a developmentally appropriate, sensitive,
affectionate, and responsive manner toward their children (Crittenden &
Bonvillian, 1984; Feldman, Case, Rincover, Towns, & Betel, 1989;
Feldman, Sparks, & Case, 1993; Feldman et al., 1985, 1986; Peterson,
Robinson, & Littman, 1983; Tymchuk & Andron, 1992). For their young
children, a lack of cognitive stimulation may be partly responsible for the
observed increased risk of developmental delay and learning problems
(Feldman & Walton-Allen, 1993; Feldman et al., 1985; Garber, 1988;
Reed & Reed, 1965). Furthermore, the parents lack of knowledge con-
cerning appropriate developmental expectations, effective positive-based
child management, and noncorporal disciplinary strategies may increase
the risk of physical abuse, as well as behavioral, emotional, and social
maladjustment in their older children (Feldman & Walton-Allen, 1993;
Gillberg & Geijer-Karlsson, 1983; ONeill, 1985). In addition to parenting
skill deficits, these families often have multiple problems related to pover-
ty, parental psychopathology, history of (and current) abuse, and the lack
of social supports (to name but a few), which may also adversely affect
the parents capacity to adequately raise children (Accardo & Whitman,
1990; Tymchuk, 1992).
 Parenting Education 301

With the overwhelming majority of persons with developmental disabili-

ties now growing up and socializing in the community, there are likely to
be more of them who, as adults, will exercise their rights to procreate and
parent. Family court statistics show that many of these parents lose their
children (Seagull & Scheurer, 1986; Taylor et al., 1991), often without
prima facie evidence of child maltreatment (Hayman, 1990). Despite a his-
torical societial bias against parents with intellectual disabilities (Tymchuk,
1990) and ongoing concerns about their children @chilling et al., 1982),
judges and child protection authorities are beginning to acknowledge that
removal of the child from the natural parents is, itself, fraught with prob-
lems (Finkelstein, 1980; Wald, 1975). However, with support and training,
many adults with cognitive challenges could be adequate parents (Budd &
Greenspan, 1984; Feldman, 1986; Haavik & Menninger, 1981; Hayman,
1990; Kaminer, Jedrysek, & Soles, 1981; Murphy, Coleman, & Abel, 1984;
Tymchuk & Feldman, 1991).
These families are considered to be the most difficult and time-consum-
ing cases for social service workers; yet specialized services remain under-
developed (Walton-Allen & Feldman, 1991). To make the fairest and most
enlightened decisions regarding parental competency and child custody,
child welfare agencies and the courts require empirical data pertaining to
the effectiveness of interventions with these families.
The purpose of this article is to critically review the parent training lit-
erature to determine if, in fact, parents with cognitive limitations and
their children do benefit from parent education efforts. To begin to
answer this question in an objective manner, this review covers those par-
ent training studies with measurable outcomes specifically on parents
with intellectual disabilities.

METHOD
Computerized and index searches of relevant English language journals
and books published revealed that prior to 1983 there were no studies focus-
ing on the training of parents with cognitive disabilities that provided suffi-
cient outcome data to judge the effectiveness of the intervention. Since that
time, however, 20 such articles have been published in peer-reviewed jour-
nals. Not included in this review are: (a) parent training program descrip-
tions with no or inadequate outcome data (e.g., Madsen, 1979; Whitman &
Accardo, 1990); (b) interventions for at-risk families (e.g., low income) that
did not separate out the results of parents with IQ less than 80 (e.g., Wasik,
Ramey, Bryant, & Sparling, 1990); and (c) child-focused out-of-home inter-
ventions that did not provide formal training and evaluation of parenting
skills per se (e.g., Garber, 1988; Martin, Ramey, & Ramey, 1990). Table 1
summarizes the method and results of each identified parent training study.
 TABLE 1
Summary of Studies Reviewed

Parent Child Training Experi- Follow- Other

Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

Sarberetal. 1 57 34 48 menu verbal and multiple no 20 no child relevance Final percent

(1983) (WAIS) planning; picture baseline custody of skills correct scores
grocery prompts; across trained were 100%
shopping matching; food in menu
modeling; groups planning and
rehearsal; grocery
praise shopping;
(home) transfer of
skills to new
store; child
returned to
home full
time.

Peterson 6 59-73 28-41 48. -68 increase: modeling; nonex- no 4 no no improve- In follow-up,
et al. (Stanford- desctip- roleplaying; perimen- ments parents with
(1983) Binet; tive and bug-in-ear tal: pre, noted by low IQ had
Calif. reflective coaching; post, others; lower fre-
Test of statements, self- follow- nonhandi- quencies of
Mental praise to recording up capped descriptive
Maturity child; at home; comparison statements
- when decrease: tangible groups and comm-
in school) commands rewards (II = 40) ands, but more
for descriptive
attendance praise than in
and self- 2 nonhandi-
recording capped parents
(clinic) groups.
 Parent Child Training Experi- Follow- Other
Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

Fantuzzo 3 54-60 M= 25 n/a describing game; multiple yes 10 no maltreat- relevance Mean percent
et al. (WAIS- use of: modeling; baseline ment of skills correct
(1986) R) parenting self-record; across reports trained; responses
skills feedback; skills improve- to parenting
(positive tangible ments questions in-
reinforce- reward for noted by creased from
ment, progress others 50% in base-
parent- (clinic) line to 92% in
child training, 93%
interactions, in generali-
noncorporal zation, and
punishment); 100% in
social skills follow-up;
(compliments, social skills
confrontation, correct
responses in-
creased from
30% in base-
line to 82% in
training, 73%
in generali-
zation, and
89% in follow-
P.

Slater 60 High- HLD HLD LLD grp: verbal and between yes 4 child Caldwell no Both HLD and
(1986) Level grp: grp: asking pictorial groups: cognitive HOME LLD groups
Distant- M = M = 49.5 questions prompts; High- vs. behaviors Inventory significantly
ing grp 27.4 LLD grp: of child, video Low-Level and devel- increased
(HLD): LLD M = 48.8 talking feedback; Distanc- opment HOME total
M = 75.1 grp: Control more to praise ing vs. scores, number
(Table continued on next page)
 TABLE 1. Continued

Parent Child Training Experi- Follow- Other

Parental Age Age SkillS Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

Low- M= m: child, (mobile Attention of words,

Level 29.4 M = 47.2 expansion lab) Control complexities,
Distant- Control and appro- and
ing grp: val. reinforcing
M = 30.4 HLD grp: comments;
:;D): same as HLD
M = 76.2 LLD, but mothers had
Control provide significantly
grp: more higher
M = 74.5 complex HOME
(WAIS-R) information scores, more
to child interrogatives,
orienting, and
highlighting
remarks than
LLD and
Control
mothers; both
HLD and LLD
children show-
ed significant
increases in
McCarthy
Scales of
Childrens
Abilities, and
had more
correct
answers to
questions than
 Parent Child Training Experi- Follow- Other
Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (rest) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

Control
children;
HLD
children
had more
correct and
complex
answers than
LLD children;
generalization
of improved
parent-child
interactions
seen on an
untrained
field-trip.

Feldman 7 64-77 21-31 4-22 praising verbal multiple yes 40 child no nonhandi- Parent and
et al. (1986) (WAIS) child; instructions baseline vocali- capped child behav-
imitating and discuss- across zations comparison iors increased
child ions; mod- skills group to levels of
vocali- eling; praise; (n = 8) nonhandi-
zations; feedback; capped
talking to self-record comparison
child; chart (group group; 2
looking home and language-
at child own delayed
children
showed
substantial
increases in
(Table continued on next page)
 TABLE 1. Continued

Parent Child Training Experi- Follow- Other

Parental Ape Aee Skills Procedures mental General UD Child Outcome Social
Study n IQ (test) (years) (moiths) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

vocalizations.

Watson- 1 n/a 28 12 home discrimina- multiple no yes no no relevance Inconsistent

Perczel et al. cleanliness ting clean baseline (length of skills improvement
(1988) and unclean across not trained; in 2 rooms;
items; written rooms; specified) improve- poor main-
and verbal changing ments tenance;
prompts; criterion noted by better results
corrective others with 2 other
and posted neglectful
feedback; nonbandi-
praise capped parents
(home)

Tymchuk 9 58-74 21-38 12-48 problem- didactic multiple yes 4 no no relevance Percentage of
et al. (WAIS-R) solving; instruction; baseline of skills mothers who
(1988) decision- modeling; across trained improved in-
making corrective component creased in 5 of
feedback skills 6 decision-
and praise; making steps;
tangible appropriate-
reward for ness of final
completion decisions
(clinic) increased for
high-risk
vignettes, but
not for low-
risk and
generalization
vignettes.
 Parent Child Training Experi- Follow- Other
Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

Tymchuk 1 74 32 18,63, praising group multiple yes 4 attend- no no Training not

& Andron (not 94 child; counseling; baseline ing; very effective
(1988) stated) labeling marital across complying; for most of the
the childs therapy; skills positive and parenting
behavior; written and negative skills; most
asking verbal speech improvement
questions; instruction; in modeling
modeling discussion; and
appro- modeling; labeling.
priate role playing;
behavior identifying
for child positive child
behaviors;
written,
verbal and
video-feed
back
(clinic and
home)

Feldman 3 61,15, 22,27, 6, 13, 21 praising same as multiple yes 12,56, child no improve- Little improve-
et al. (1989) 19 28 child; Feldman baseline 72 development ments noted ment with
(not imitating et al. (1986) across weeks (vocalizations, by others; verbal instruc-
stated) child plus subjects (also, developmental nonhandi- tion; all par-
vocaliza- tangible and skills main- quotient, capped ents improved
tions; reinforce- tenance percent comparison with full train-
physical ment for with correct group ing package;
affection 1 mother new language (n = 17) transfer of
during child items on skills to new
maintenance born standardized baby born in
(home) during developmental follow-up for
(Table continued on next page)
 TABLE 1. Continued

Parent Child Training Experi- Follow- Other

Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

follow- tests) one mother;

UP) post training
scores at same
or higher
levels than
nonhandi-
capped
mothers;
develop-
mental
quotients of
the2
language-
delayed
children in-
creased from
52 to 59 and
62 to 90; per-
cent correct
language
items on
developmental
tests increased
from 67% to
87% and 37%
to 70%.

Leifer & 1 mild to 30 4 parent- psycho- nonex- no no attach- HOME; consumer Increase in
Smith (1990) moderate child therapy; peri- follow- ment, stress satisfaction positive
interactionsvisiting mental: P develop- measures; parent-child
 Parent Child Training Experi- Follow- Other
Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

(specific nurse; longitud- as ment, social interactions in

behaviors parent inal case treat- explor- support; clinic; de-
not des- training as study ment ation psycho- crease in over-
cribed) part of con- pathology all parental
O-3 tinued scale psychopath-
develop- for 4 ology, but
mental years depression
program score still
for high; no
child (details change in
not given) scores on
(clinic) Caldwell
HOME or
Bayley Scales
of Infant
Development
(remaining
low average);
strange situ-
ation test
given when
child was 12
and 18 months
indicated that
child was
securely
attached to
mother;
mother
reported
being
(Table continued on next page)
 TABLE 1. Continued

Parent Child Training Experi- Follow- Other

Parental Age Age SkillS Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

moderately
positive about
intervention.

Tymchuk 8 58-74 n/a n/a verbal verbal nonexper- no 4 no no relevance Mean percent
et al (1990a) (not answers to and written imental: of trained correct scores
stated) questions instructions; pre, post, skills; non- increased sign-
about discussion follow- handicapped ificantly in 2
reinforcing (clinic) up comparison of 3 question-
and dis- group naires about
ciplining (n = 23) appropriate
child parental res-
ponses to child
behavior

Tymchuk 4 69-7 1 25-11 n/a knowledge group multiple no 4 none no relevance Knowledge
et al. (1990b) and skill training baseline of skills and skills in-
in dealing written across trained creased in
with home information; skills training and
emergen- role-playing; maintained in
ties; praise, follow-up; no
grease fire; modeling data on res-
clothes fire;(clinic- ponses to
house fire; home) actual emer-
poisoning; gencies
bum; choking

Tymchuk 4 69-7 1 25-41 nla home written multiple no 4 no. child no relevance Training only
et al. (1990~) (WAIS-R) safety prompts; baseline accidents of skills partially suc-
praise; across trained cessful; 3 child
 Parent Child Training Experi- Follow- Other
Parental Age Age SkillS Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

corrective safety accidents in

feedback topics baseline, 6 in
(clinic and training, and 0
home) in follow-up

Tymchuk 4 nta nla n/a knowledge verbal nonexper- no 4-5 no no nonhandi- Increase in
(1991) of high and written imental: capped correct
risk instructions; pre, post, comparison answers to
household discussion follow-up group questions
products (classroom) (n = 3) about high
risk house-
hold products;
staff anecdot-
ally reported
improvement
in mothers
safe use of
high risk
products

Feldman 11 68-79 21-39 3-36 bathing verbal multiple no 4-74 elimin- no relevance All parents
et al. (1992a) (WARS-R) child; instruction; baseline ation of of skills improved and
treating pictorial across diaper trained; maintained on
diaper prompts; mothers rash and improve- all skills train-
rash modeling; and skills cradle ments ed; anecdotal
and cradle feedback; cap; noted by reports of con-
cap; clean- praise; weight others; non- comitant im-
ing baby tangible gain; handicapped provements in
bottles; rewards for toilet comparison child health
preparing performance trained group (e.g., rate of
formula; (home) (anecdotal) (n = 20); weight gain,
(Table continued on next page)
 TABLE 1. Continued
-_____
Parent Child Training Experi- Follow- Other
Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results
.___
toilet consumer elimination of
training satisfaction diaper rash,
toilet trained);
training and
follow-up
mean percent
correct similar
to nonhandi-
capped com-
parison group
(90% vs.
87%); con-
sumer satis-
faction
positive

Feldman 22 Training Training Training diapering; same as between- no 2-76 elimin- no. relevance Posttest:
et al. (1992b) grp: grp: grp: washing Feldman groups: ation of children of skills training
M = 71.6 M = 25.2 M = 9.2 babys et al. in training diaper taken trained; groups per-
control Control Control hair; crib press-a vs control rash; into improve- cent correct
grp: grp: grp: and sleep (home) weight custody ments child-care
M = 72.1 M = 26.6 M = 8.5 safety; gain; pre-post noted by skills signifi-
(WAIS-R) cleanliness: fewer others; cantly higher
nutrition; illnesses; nonhandi- than control
preparing toilet capped group; control
formula; trained comparison group signifi-
treating (anecdotal) group cantly increas-
diaper rash; (n = 12) ed percent
cleaning correct scores
baby;
 Parent Child Training Experi- Follow- Other
Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

bottles; when it subse-

toilet quently receiv-
training; ed training;
bathing anecdotal re-
ports of con-
comitant im-
provements in
child health;
whereas 82%
of the parents
had previously
lost their
children, only
19% had child
taken in cust-
ody in the year
following
training;
parents
with low IQ
had signifi-
cantly lower
skill scores
than non-
handicap-
ped com-
parison
parents on
pretest, but
not on post-
test.
(Table continued on next page)
 TABLE 1. Continued

Parent Child Training Experi- Follow- Other

Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

Tymchuk 9 63-74 n/a n/a asking modeling; multiple no 1-8 attending no nonhandi- Nonhandi-
and Andron (pre- questions; verbal and baseline to task; capped low capped
(1992) school- praising video tape across compli- SES com- mothers had
age) child; feedback skills ance; parison higher (pre-
labeling; (clinic, positive group training)
modeling; home) and (n = 15) scores on 7/8
physical negative positive inter-
affection vocalizations actional skills.
Training in-
creased mater-
nal positive
interactions on
only about
30% of skills
(high baselines
obscured
training
results)

Tymchuk 3 50, 68, 24, 32, 60, 60, knowledge educational multiple yes 4 know- no relevance High baselines
et al. (1992) 69 33 84 of home materials; baseline reponse ledge of of skills obscures
(not dangers, group across gen. home trained; possible
stated) emergen- instruction; skills dangers, consumer training eff-
ties and roleplaying; emer- ects; little
precau- praise, gencies, improvement
tions; corrections and pre- in childrens
dangers (clinic) cautions knowledge of
and pre- home dangers;
cautions
 Parent Child Training Experi- Follow- Other
Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

taken in no generali-
home zation from
parents
knowledge of
dangers and
precautions to
behavior in
actual home
setting

Bakken 5 51-70 26-33 12-60 describing game; multiple yes 24 maladap- no no Game increas-
et al. (1993) (not and using: prompts; baseline response tive ed knowledge,
stated) praise, modeling; across gen. and behaviors; but not actual
imitation feedback; subjects setting vocalizations performance
and ex- tangible gen. with child;
pansion rewards clinic training
of child for atten- increased
vocali- dance and skills, but no
zation performance generalization
(clinic and to home; home
home) training
increased
skills and
maintained in
follow-up

Feldman 28 training training training praise; see between- no h4= 55 vocali- no. child- nonhandi- Posttest:
et al. grp: grp: imitation Feldman groups: (13-82) zations, ren taken capped training
(1993) M=73.5M=25.9%13.3 ofchild et al. training vs. verbali- into compari- groups mater-
control control control vocali- (1986) attention- zations; custody - son grp nal interac-
grp: grp: grp: zations; control Bayley pre-post (n = 25) tions, child
(Table continued on next page)
 TABLE 1. Continued

Parent Child Training Experi- Follow- Other

Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

M=69.4 M= M = 13.7 physical Scales; vocalizations

(WAIS-R) 27.9 affection item and verbali-
analysis of zations signif-
Bayley icantly higher
Scales; than control
quality group; control
of speech group signifi-
cantly increas-
ed target skills
when subse-
quently train-
ed; training
group chil-
dren start-
ed speaking
significantly
sooner than
controls; no
increase in
overall devel-
opmental quo-
tients of
Bayley Scales
of Infant Dev-
elopment, but
there was a
significant in-
crease in per-
cent correct
 Parent Child Training Experi- Follow- Other
Parental Age Age Skills Procedures mental General up Child Outcome Social
Study n IQ (test) (years) (months) Trained (Location) Design Probes (weeks) Measures Measures Validity Results

Bayley langu-
age and social
items; whereas
78% of the
parents had
previously lost
their children,
only 20% had
child taken
into custody
in the 3 years
following
318 h4. A. Feldman

Because 16 of the 20 studies presented individual subject data, an overall

impression of the effectiveness of parent training for these families was
obtained by summarizing outcomes in terms of percentage of demonstrated
improvements in trained skills. Improvement scores were based on visual
inspection by both the author and an experienced research associate of each
single-subject figure provided in the original articles (the tables presenting
individual time series data in Feldman et al., 1992b, 1993, and Tymchuk,
1991, were converted to graphs). The second rater scored independently,
and he was naive to the fact that his scores were to be used for reliability
purposes in a review article.
Visual inspection is considered to be a very conservative, yet most
appropriate way of interpreting single-subject data (Parsonson & Baer,
1986). Visual inspection has been criticized, however, for the lack of objec-
tive evaluation criteria, which may lead to poor interrater agreement on the
presence or absence of treatment effects (Ottenbacher, 1990). Therefore, in
this study, decisions regarding the effectiveness of interventions were based
on comparisons of baseline to available treatment, generalization, and fol-
low-up conditions, taking into account the following factors shown
(Ottenbacher, 1990) to influence the interpretation of graphic data: (a)
change in mean levels, (b) percentage of nonoverlapping points, (c) vari-
ability within and across conditions, and (d) changes in slope. The decision
rule used by the two raters was that when all four criteria depicted a change
of behavior in the desired direction, then this was considered an obvious
improvement from baseline (+); ambiguity in one or more of the visual
inspection criteria led to a judgement of no improvement from baseline
(O). If the goal of training was to decrease a parental or child behavior,
then a noticeable reduction in the behavior would be considered an
improvement. A percent improvement score for an entire study was calcu-
lated as the number of observed improvements divided by the total number
of improvement opportunities, for training, follow-up, generalization, and
child behaviors, respectively. For example, if a study involved 3 parents
learning 4 skills each, then there were 12 occasions to observe improve-
ments in training. If there was improvement in 9 of the 12 opportunities,
then the percent improvement score for the training condition of that study
would be 75% (9/l 2). Interrater agreement was checked for each improve-
ment opportunity in all reviewed studies; overall agreement on percent
improvement was then calculated as percentage agreements divided by
agreements + disagreements and equaled 87.6% (range, 60% to 100%).
This acceptable level of interrater agreement indicates that visual analysis
by two experienced observers using decision rules based on factors known
to influence judgements of graphed single-subject data may reduce inter-
rater inconsistencies found in studies using untrained raters inspecting
hypothetical data (e.g., Ottenbacher, 1990).
 Parenting Education 319

REVIEW OF RESULTS

Esfects of Training on Parenting Skills

The results of each study are summarized in Table 1. The three studies
(Feldman et al., 1992b, 1993; Slater, 1986) that used between-group
designs found significant differences between training and no training con-
trol groups on parent target behaviors after training. The percent improve-
ment scores of the 16 articles that presented individual parent data are sum-
marized in Table 2. These studies involved 84 parents (82 mothers, 2
fathers) and 57 different skills. Overall, across the 16 studies providing
individual data, 96% of the parents showed improvements in one or more
skills, and improvements were noted in 63% of skills in training (range,
19% to 100%). Eight studies (Bakken, Miltenberger, & Schauss, 1993;
Peterson et al., 1983; Sarber, Halasz, Messmer, Bickett, & Lutzker, 1983;
Tymchuk, 1991; Tymchuk & Andron, 1988, 1992; Tymchuk, Andron, &
Hagelstein, 1992; Tymchuk et al., 1990~) were encumbered by asymptotic
baseline parenting skill performance (i.e., 100% correct or scores 2 the
highest score in training), which may have obscured the impact of training.
For example, the percent improvement score of Tymchuk et al. (1992)
increases from 19.0 to 66.7 when figures depicting high parenting skill
baselines are excluded from the visual inspection to determine the percent
improvement score. Table 2 includes the overall mean percent improve-
ment scores when graphs across the eight studies with high baselines are
removed from the calculation; the mean percent improvement training
score increased 11.6 percentage points.

Treatment Comparisons
Only four studies conducted comparisons of different training strate-
gies. Slater (1986), using a between-group design with random assign-
ment, found that teaching mothers more sophisticated and complex
forms of interaction (High-Level Distancing group) had more signifi-
cant positive results in posttest and follow-up on various measures of
mother-child interactions and child cognitive development than teaching
a less complicated form of maternal stimulation (Low-Level
Distancing group). Unfortunately, whether these group differences con-
tinued in the long-term could not be established because follow-up was
limited to only 4 weeks.
Watson-Perczel, Lutzker, Greene, and McGimpsey (1988) found that an
education procedure (discriminating clean from unclean items with cor-
rective feedback, but no praise) was not as effective as a package consist-
ing of posted record charts, homework, corrective practice, and trainer
praise for one mother. Feldman et al. (1989) found that verbal instruction
320 A4.A. Feldman

TABLE 2
Percentage Improvement Scores for Reviewed Studies That Provide Individual Subject
Outcome Data

Percent Improvement Score+

Parent Child

Study Training Follow-up General Training Follow-up

______ ___
Sarber et al. (1983) 80.0 80.0
Peterson et al. (1983) 72.2 52.8
Feldman et al. (1986) 90.0 100 88.9 42.9 57.1
Watson-Perczel et al. (1988)
Education 50.0
Full package 50.0 0.0
Tymchuk & Andron (1988) 36.7 36.7 50.0 60.0 60.0
Feldman et al. (1989)
Verbal inst. 25.0
Full package 100 85.7 83.3 100 100
Leifer & Smith (1990) 100 100
Tymchuk et al. (1990b) 94.4 83.3
Tymchuk et. al (1990~) 56.7 60.0
Tymchuk (1991) 70.0 75.0
Feldman et al. (1992a) 100 100
Feldman et al. (1992b) 95.2 100
Tymchuk & Andron (1992) 29.1 16.7 13.6 13.6
Tymchuk et al. (1992) 19.0 14.3 15.4 40.5 33.3
Bakken et al. (1993)
Game 100 100 0.0
Full package - clinic n/a 0.0
Full package-home 87.5 50.0
Feldman et al. (1993) 85.7 87.5 85.7 91.7
Mean percent improvement
(high baselines included) 62.8 55.2 21.4 43.7 38.6
Mean percent improvement
(high baselines excluded) 74.4 67.3 23.0 68.2 63.5

aNo. of observed increases over baseline data divided by the total number of improvement
opportunities for parent training, follow-up, generalization, and training and follow-up child
behavior results.

alone was not as effective as a full training package of instruction, model-

ing, corrective feedback, and trainer praise in teaching affectionate and
stimulating interactions to three mothers. The ABC multiple baseline
designs of both studies were subject to sequence confounds.
Finally, Bakken et al. (1993) compared a game format (cf., Fantuzzo,
Wray, Hall, Goins, & Azar, 1986) to behavioral instruction (i.e., prompting,
modeling, rehearsal, feedback, and positive reinforcement) in the clinic and
home (cf., Feldman et al., 1986, 1989). They found that although the par-
ents correct verbal responses during the game increased, actual
parent-child positive interactions only improved when performance-based
training was provided.
 Parenting Education 321

Maintenance

As seen in Tables 1 and 2, 19 studies conducted follow-up observations

(ranging from 2 to 82 weeks). Fifteen studies presented individual follow-
up data; across these studies, improvements were maintained in 92% of the
parents and 55% of skills (range, 0% to 100%). Once again, high baseline
parenting skill scores in 10 studies make it difficult to interpret mainte-
nance results. As seen in Table 2, the percent improvement maintenance
score increases when skills with high baselines are excluded. Three studies
(Feldman et al., 1989, 1992a, 1993) used (and faded) a lottery system dur-
ing follow-up to reinforce maintenance of skills at criterion levels. Feldman
et al. (1989) also showed maintenance of positive parenting interactions in
one mother with a new child born during the follow-up period.

Generalization

There are concerns about the ability of parents with developmental dis-
abilities to generalize their newly learned parenting skills to all situations in
which they are needed (Schilling et al., 1982). Nine studies conducted gen-
eralization probes, five of which reported individual generalization data
(see Table 2). In these five studies, improvements were noted in 14 of the
19 parents, but only in 21% of skills (range, 0% to 89%). This low general-
ization percent improvement score is due primarily to the failure to find
response generalization in two studies that examined correspondence from
saying to doing (Bakken et al., 1993 - positive interactions; Tymchuk et
al. - home safety). Removing these two studies yields a substantially
increased overall mean percent improvement generalization score of 76%.
Three studies (Fantuzzo et al., 1986; Tymchuk et al., 1988; Tymchuk,
Andron, & Tymchuk, 1990a) anecdotally described correspondence from
saying to doing. Because they presented no data and given the lack of
response generalization reported by Bakken et al. (1993) and Tymchuk et
al. (1992), these narrative accounts should be viewed cautiously.
When Bakken et al. (1993) provided performance-based training in the
clinic, they did use generalization strategies (i.e., common stimuli, multiple
exemplars, and mediating instructions) recommended by Stokes and Baer
(1977). These techniques had been shown to promote generalization of
interactional skills of parents with intellectual disabilities from the clinic to
the home (Feldman et al., 1986) and across different child-care activities
(Feldman et al., 1989). Bakken et al. (1993), however, failed to obtain set-
ting generalization. One crucial methodological difference between
Feldman et al. (1986) and Bakken et al. (1993) that may have accounted for
the discrepency in the generalization results was that the former study pro-
vided their clinic training in a home environment, whereas the latter did
322 M. A. Feldman

not. Thus, to maximize generalization, it may be necessary to provide par-

ent training in a home-like setting.

Child Measures

Tables 1 and 2 show that 10 studies presented data on the effects of par-
ent training on the children. With the exception of Slater (1986) and
Feldman et al. (1993), deficiencies in the experimental designs utilized pre-
cluded clear causeeffect demonstrations of parent training on child out-
comes (i.e., maturational effects were not controlled). Slater (1986) found
that increasing maternal positive interactions significantly increased cogni-
tive skills of preschoolers. Feldman et al. (1993) showed that after parental
interactional training, toddlers of mothers with intellectual disabilities
spoke their first words sooner, had more vocalizations and verbalizations
during mother-child interactions, and scored higher on language and social
items of the Bayley Scales of Infant Development (Bayley, 1969) than did
age-matched children whose mothers did not have such training.
As seen in Table 2, mean percent improvement scores for child behaviors
were low in most of the seven studies providing individual child data.
These low scores reflect, to some extent, that four studies (Feldman et al.,
1986; Tymchuk & Andron, 1988, 1992; Tymchuk et al., 1992) reporting
child data had high baseline child measures that impede a clear interpreta-
tion of the effects of parent training on the child. As seen in Table 2, when
these ambiguous child data are removed, the mean percent improvement
scores increase considerably in both training and follow-up.
Bakken et al. (1993) provided aggregate data on five children who, unlike
Feldman et al. (1989, 1993), showed no increase in child vocalizations after
training the parents in positive and stimulating interactions. With respect to
anecdotal reports, a home safety training study (Tymchuk et al., 199Oc) found
that although child accidents increased during training, none was reported in
the 4-week follow-up. Two other studies (Feldman et al., 1992a, 1992b) pro-
vided anecdotal accounts of benefits to the childrens health, which were cor-
roborated by the family physicians, visiting nurses, and other workers. The
remaining studies provided no information on the effects of parent training on
the child. This omission is most unfortunate because the raison detre for par-
ent training for parents with mental retardation is to ensure that the childs
welfare is protected and his or her development encouraged.

Other Outcome Measures

As seen in Table 1, only six studies measured other important collateral

outcomes of parent training with parents who are intellectually disabled,
 Parenting Education 323

such as maltreatment episodes (Fantuzzo et al., 1986), family continuance

(Feldman et al., 1992b, 1993; Sarber et al., 1983), family and/or individual
functioning (Leifer & Smith, 1990), and the overall quality of the home
environment (Leifer & Smith, 1990; Slater, 1986).

Social Validity Outcome Measures

No study systematically collected data on the subjective evaluation

(Kazdin, 1977) of either naive observers or professionals involved with
the family to determine whether they noticed posttraining improvements
in parenting skills, child behavior and development, the quality of the
home environment, as well as a reduced risk of child maltreatment. Six
studies, however, anecdotally reported positive comments made by
other professionals.
Ten studies conducted a social comparison (Kazdin, 1977), wherein
the performance of parents with intellectual disabilities was contrasted with
a group of nondisabled parents. In these studies, the pretraining scores of
the parents with low IQ were usually significantly below that of the non-
handicapped parents; training tended to eliminate these differences (e.g.,
Feldman et al., 1986, 1989, 1993). Watson-Perczel et al. (1988) found,
however, that their home cleanliness training package was more effective
for two neglectful nonhandicapped mothers than for a mother with mental
retardation. Although groups of nonhandicapped parents were useful in the
identification of skills in need of training and in the evaluation of training
results, the small sample sizes preclude calling these comparison groups
normative. Also, some of these groups tended to be middle-class only, or
of mixed low and middle socioeconomic status; thus, they may not have
represented an appropriately matched comparison group because virtually
all parents labeled mentally retarded are living in poverty (Tymchuk &
Andron, 1992). Tymchuk and Andron (1992), however, found similar (pre-
training) differences in positive interactional skills between mothers with
mental retardation and matched low-income controls, as had been previ-
ously detected between middle-class mothers with mental retardation
(Feldman et al., 1986) and mixed low- and middle-class (Feldman et al.,
1989, 1993) nonretarded mothers.
Only three studies (Feldman et al., 1992b; Leifer & Smith, 1990;
Tymchuk et al., 1992) formally solicited consumer satisfaction ratings,
which were generally favorable. Given that parents with cognitive limi-
tations may not see the necessity or value of child-care training
(Walton-Allen & Feldman, 1991), it is important to show that in fact the
parents liked the training and felt that they and their child benefitted
from it.
324 M. A. Feldman

REVIEW OF METHODOLOGIES

Confidence in the results of the studies is a function of the rigor of their

design and implementation. Methodological imperfections seen in many of
these studies may often reflect the inevitable logistical difficulties encoun-
tered in attempting to conduct a systematic evaluation of services for these
multiproblem families. For example, one cannot let diaper rash continue
simply for the sake of preserving a multiple baseline design, without pro-
viding the parent with immediate training in how to treat it. Likewise, a
researcher cannot demand the withdrawal of other services so that a pure
evaluation of the target program can be conducted. Despite these problems,
most of the studies reviewed here are sufficiently sound to allow for a rela-
tively unambiguous interpretation of their findings.

Samples

The reviewed studies represented a total of 190 parents (188 mothers, 2

fathers), with IQs ranging from 50 to 79. There are concerns (Tymchuk &
Feldman, 1991; Whitman & Accardo, 1990), however, about the sizes and
representativeness of the samples. As seen in Table 1, 16 studies involved
fewer than 10 subjects, with 4 being single case studies. Furthermore, 12
studies included parents labeled mentally retarded who would not meet the
criteria for diagnosis of mental retardation because their IQ scores were over
70 (Grossman, 1983). This may be a moot issue, however, because IQ may
not be a good predictor of parental incompetency or responsiveness to parent
training interventions until it falls below 60 (Tymchuk & Feldman, 1991).
What is obvious in these studies is that the parents, whether properly
diagnosed as mentally retarded or not, had IQs of less than 80 and had
already come to the attention of child welfare authorities or social service
workers who were concerned that the parents cognitive deficits contraindi-
cated adequate parenting. Thus, the parents involved in the training studies
probably were not representative of all parents with low IQ (Tymchuk &
Feldman, 1991). It is likely that these referred parents, who were given the
chance to rear their children, portray the midrange of parenting abilities of
parents with cognitive deficits. That is, more severely impaired persons
who need the assistance of others (e.g., group home staff) to perform activ-
ities of daily living would likely not be allowed to take their newborns
home from the hospital even with supervision, support, and training,
whereas more competent parents may not need such services.
All studies have focused on mothers; only two studies (Bakken et al.,
1993; Peterson et al., 1983) trained couples, and no studies involved single
fathers with mental retardation. Thus, it has not been established whether
fathers would respond in a similar fashion as mothers, and whether training
 Parenting Education 325

provided to both, rather than one, of the parents would result in greater
benefits to the child and family.

Dependent Measures

Overall, the studies encompassed a wide range of parenting skills neces-

sary to demonstrate adequate parenting in the eyes of the court (Wald,
1975). Areas covered included: (a) basic child-care (e.g., Feldman et al.,
1992a, 1992b); (b) nutrition (e.g., Sarber et al., 1983); (c) home safety and
emergencies (e.g., Tymchuk, 1991; Tymchuk et al., 1990b, 1990~); (d)
stimulating interactions (e.g., Feldman et al., 1986, 1989, 1993; Slater,
1986); and (d) child behavior management (Fantuzzo et al., 1986;
Tymchuk & Andron, 1988). Ten studies had other parents and professionals
judge the social relevance (i.e., appropriateness, importance, and complete-
ness) of the parenting skills chosen for training. For example, Feldman et
al. (in 1992a, 1992b) had their child-care task analysis checklists reviewed
and revised by pediatric health-care professionals, whereas Tymchuk et al.
(1990b) solicited the advice of the Red Cross, a poison information center,
and a fire department in designing their emergency training curriculum.
There were several deficiencies regarding the measurement of skills. In
some studies interobserver reliability was low (Peterson et al., 1983) or not
fully reported (Slater, 1986; Tymchuk, 1991; Tymchuk & Andron, 1988,
1992; Tymchuk et al., 1988, 1990b, 1992). Also, in many of the studies, the
parent trainers were present when the observations of parental performance
were recorded, oftentimes by the trainers themselves. This situation may
reflect a common difficulty in arranging observations by naive reliability
checkers because these families are often reluctant to be video taped or vis-
ited by strangers. It is possible, therefore, that the trainers were cues for
correct performance during and following training. This concern is mitigat-
ed by the use of naive reliability checkers. Notable evidence of ongoing use
of the trained parenting skills is provided by improvements in the children
(e.g., Feldman et al., 1989, 1992a, 1992b, 1993). It would be unlikely, for
example, that diaper rash would disappear, the child would have substantial
weight gain, or increased language abilities if the mother was performing
correctly only during the trainers weekly home visit.
Thirteen studies actually observed the parent performing the trained
child-care skills at home. Three others (Leifer & Smith, 1990; Peterson et
al., 1983; Slater, 1986) reported changes in parent-child interactions only
in the clinic. In seven studies (Bakken et al., 1993; Fantuzzo et al., 1986;
Tymchuk, 1991; Tymchuk et al., 1988, 1990a, 1990b, 199Oc, 1992) train-
ing focused on increasing the parents knowledge instead of, or in addition
to, the actual performance of the child-care skill. When actual performance
326 M. A. Feldman

is monitored, the results suggest that there is little transfer from knowledge
to skill in parents with low IQ (Bakken et al., 1993; Tymchuk et al., 1992).

Designs and Confounds

Another methodological issue is the extent to which internal and external

validity of the studies had been established. As seen in Table 1, 4 studies
did not employ an experimental design, 13 studies used single-subject
experimental multiple baseline designs (Barlow & Hersen, 1984), which
have relatively good internal, but weak external validity, and only 3 studies
employed a more rigorous repeated measures between-group design with
random assignment to training and control groups.
Certain variables may confound demonstrations of the effectiveness of
particular interventions. Often these families have several workers, includ-
ing visiting nurses, advocates, and child welfare personnel, all of whom
may have been advising the parents on child-care (e.g., Leifer & Smith,
1990). In relation to this, parental and child participation in other therapies
(e.g., psychotherapy, marital therapy, play therapy) may have an undeter-
mined impact on the parent education component (e.g., Leifer & Smith,
1990; Tymchuk & Andron, 1988). Several characteristics of the parents
(e.g., genetic and biological status, physical and mental health, substance
abuse), the child (e.g., prematurity, disability, birth problems), and the fam-
ily ecology (e.g., marital status and satisfaction, income, social support,
insularity, the threat of child removal) may impact on responsiveness to
parent training to varying degrees. These potentially influential variables
should be reported and investigated (Feldman et al., 1993; Tymchuk &
Andron, 1992).

Training Procedures

Although three studies (Tymchuk, 1991; Tymchuk et al., 1990a, 1992)

relied primarily on didactic instruction, (with moderate results; see also the
verbal instruction phase of Feldman et al., 1989), the majority of parent
training studies utilized behavioral techniques (e.g., task analysis, model-
ing, feedback, reinforcement) that are similar to those used to teach other
community living skills to persons with developmental disabilities (e.g.,
Matson, 1981) and child behavior management skills to nonhandicapped
parents (e.g., Hudson, 1982). Eight studies (Bakken et al., 1993; Fantuzzo
et al., 1986; Feldman et al., 1989, 1992a, 1992b, 1993; Peterson et al.,
1983; Tymchuk & Andron, 1992) provided tangible incentives for atten-
dance, progress, and/or maintenance of skills. Eight studies provided train-
ing in a clinic or classroom only, six at home only, and six in both locations.
 Parenting Education 327

Some of the studies included in this review used variations of the stan-
dard behavioral training procedures. Three studies used video taped feed-
back (Slater, 1986; Tymchuk & Andron, 1988, 1992). Peterson et al. (1983)
used a bug-in-the-ear device as part of their training. Five studies (Feldman
et al., 1992a, 1992b; Sarber et al., 1983; Slater, 1986; Tymchuk et al.,
1990a) utilized pictorial prompts as part of the training package, but none
of these studies evaluated the self-instructional potential of these materials
alone. Fantuzzo et al. (1986) adapted a social skills game (Foxx,
McMorrow, & Schloss, 1983) to teach both child management and social
skills to three single known neglectful mothers with mental retardation.
This game, however, taught these parents only to identify correctly appro-
priate and effective parenting responses (p. 140, emphasis added); actual
parent-child interactions were not observed. Bakken et al. (1993) replicat-
ed Fantuzzo et al. (1986) favorable game results on the parents verbal
responses, but not with respect to in vivo parent-child interactions. Bakken
et al. (1993) only found parental behavior change when they used the
behavioral instructional package of Feldman et al. (1986). Certainly, given
the potential cost-effectiveness of the group game format, it should be eval-
uated further, with appropriate generalization strategies and tests, as a tool
for teaching generalized parenting and other related skills.
In an interesting case study report, Leifer and Smith (1990) combined
psychodynamic therapy with parent training to improve the nurturance of a
single depressed mother with mental retardation. The purpose of the thera-
py was to give the mother the opportunity to explore her traumatic child-
hood experiences and facilitate more accurate perceptions of her intent (p.
307). Observational ratings of mother-child interactions in the therapy ses-
sions did not significantly improve until after the mother began participat-
ing in a structured infant stimulation/parent training program. It was possi-
ble, however, that the previous 9 months of therapy made the mother more
receptive to the subsequent parent training.

TRAINING ISSUES AND FUTURE RESEARCH

Program Recommendations

Based on this review, it appears that current best practice parenting

education for parents with intellectual disabilities would involve specific
skill assessment utilizing direct observational techniques. Training should
be performance- rather than knowledge-based and utilize modeling, prac-
tice, feedback, and praise. Providing tangible reinforcers may promote
attendance, rapid acquisition, and maintenance. If training is provided out-
of-home, it should be in as home-like an environment as possible; to ensure
the parenting skills are actually utilized in the home and elsewhere, it is
328 M. A. Feldman

crucial to program for generalization and conduct in vivo probes; programs

should be adaptable to provide training in the actual environments in which
the skills are needed.

Research Recommendations

This review reveals that although great strides have been made in the last
10 years to develop and evaluate parent education programs for parents
with mental retardation, there are still numerous gaps in our knowledge and
provision of effective services. First, more data are required to increase
confidence in the effectiveness of parent education, particularly with
respect to: (a) the generalization and long-term maintenance of newly
learned skills across settings, child-care activities, and new children; (b) the
immediate and extended benefits to the child (e.g., physical health; cogni-
tive, emotional, and social development; academic achievement; social
adjustment); (c) incidents of maltreatment and child removal; (d) collateral
effects (e.g., parental stress, marital satisfaction, self-esteem, attitude
toward child and child-rearing, overall quality of the home environment);
and (e) social validation measures (e.g., normative data, subjective evalua-
tions by other workers, consumer satisfaction).
Second, more research is needed on how various individual, family, child,
and environmental variables affect initial parenting problems and respon-
siveness to intervention. Some variables that have been implicated in the
child maltreatment literature in general (Belsky, 1980), which require closer
examination with families with low IQ parents, include: (a) social isolation
and support, marital status and satisfaction; (b) parental IQ and education,
physical/mental health, substance abuse status, parental history of abuse,
and role-models; and (c) number and characteristics of the children in the
home, supervision by child welfare (Tymchuk & Feldman, 1991).
Third, more innovative programs need to be developed and evaluated.
For example, the parents could temporarily live in group homes where they
would receive child-care training while the children would be monitored by
live-in staff. Also, perhaps specially trained foster parents could take in
both the parent and the child and teach the natural parent to eventually
independently care full-time for the child. The social isolation often experi-
enced by these parents has been shown to be significantly correlated with
child behavior disorders (Feldman & Walton-Allen, 1993); perhaps
increasing natural social support networks (e.g., friends, neighbors, family)
may enhance the effectiveness of parent training (Dunst & Trivette, 1990).
Research should be also be undertaken comparing the cost-effectiveness
and long-term impact to the child of: (a) foster-care versus parent training,
and (b) parent training alone or with specialized daycare (e.g., Garber,
 Parenting Education 329

1988; Martin et al,, 1990; Peterson et al., 1983; Ramey & Ramey, 1992).
Because it is unlikely that parent education by itself will resolve the numer-
ous problems faced by these families (Tymchuk & Feldman, 1991), more
evaluations are needed of concurrent or sequential multiple interventions.
Many of these families may need ongoing parent education in child-care
skill training, parent-child positive interaction training, child behavior
management, problem-solving, and stress management. Moreover, the fam-
ily situation may benefit from interventions not directly related to parent-
ing, such as job coaching, substance abuse counseling, marital therapy, and
psychotherapy. Other studies should examine ways of making existing pro-
grams less intense and costly through group training (e.g., Feldman et al.,
1986; Tymchuk et al., 1990a) or self-instruction (cf., Barone, Greene, &
Lutzker, 1986).
Fifth, because several studies have revealed that older children raised by
parents with intellectual disabilities are at risk for behavioral, emotional,
and learning problems (Feldman & Walton-Allen, 1993; Gillberg 8z Geijer-
Karlsson, 1983; ONeill, 1985), there is a need to develop and evaluate pre-
ventative and remedial interventions that focus on teaching parents supervi-
sion, positive-based child behavior management, stress/anger management,
noncorporal discipline, and cognitive stimulation. School-age children and
adolescents of parents with cognitive disabilities may benefit from special-
ized counseling, social skills training, and academic tutoring.

CONCLUSION
This review of the first generation of parent training studies of parents
with intellectual disabilities shows that an effective parent education tech-
nology designed specifically for these families is being developed. Despite
methodological deficiencies that often reflect the less than conducive envi-
ronments for conducting research, the studies reviewed here have sufficient
strengths to allow one to be encouraged by their generally positive find-
ings. These interventions offer case workers and the courts viable ahema-
tives to removing the child from the home. Given the likely increase in par-
ents with intellectual disabilities and the demonstrated risks to their chil-
dren, there is an ongoing need to improve and extend these initial efforts.
As crucial decisions regarding child custody and the continuance of parent-
ing rights are often made based, in part, on the availability of programs and
supports (Taylor et al., 1991), these families and society need more parent
education efforts with sound empirical demonstrations of effectiveness.
Such evaluations should report the information and utilize the methods that
constitute the headings of Table 1 (i.e., details on the target families, clear
definitions of target behavior and reliability, use of an experimental design,
generalization, maintenance, child, social validity, and collateral measures).
330 M. A. Feldman

Continuing research will no doubt provide more information about the

abilities of parents with low IQ and their children to profit from parent edu-
cation interventions. The overall findings of this literature review, however,
suggest that given current instructional technology, which emphasizes per-
formance-based behavioral strategies such as task-analysis, modeling, feed-
back, and reinforcement, many parents with intellectual disabilities may be
able to improve and maintain important parenting skills with corresponding
benefits to their children. More research is needed to develop cost-effective
and feasible interventions that not only reduce the risk to the child, but also
break the intergenerational recurrence of problems, and have extensive and
long-term benefits for all the family members.

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