Effectiveness of a parent-implemented intervention for improving balance in a child with autism spectrum disorder

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Therefore, interventions targeting balance skills are crucial for children with ASD. This study examined whether a parent-implemented intervention could improve balance in a boy with ASD, using a multiple-probe design across behaviors. The targeted motor skills included sitting, half-kneeling, standing, and walking, whereas the object-control skills included throwing, catching, and rolling a ball. The target skill was observed for each behavior and the degree of improvement was indicated. Statistical analyses were conducted using the percentage of non-overlapping data (PND) and Tau-U. Additionally, the study used the Pediatric Berg Balance Score. Improvements were observed in gross motor and object control skills and were retained at three weeks post-intervention. These functional gains were reflected in the Pediatric Berg Balance Score. These findings suggest that parent-implemented interventions can improve gross motor and object control skills in children with ASD. autism spectrum disorder balance gross motor skills object control skills parent implemented intervention Figures Figure 1 Figure 2 Figure 3 Introduction Autism spectrum disorder (ASD) is primarily characterized by deficits in social communication and interaction along with restricted and repetitive behavioral patterns (American Psychiatric Association, 2013). Deficits in social communication and atypical behavioral characteristics are the core features of ASD. As a result of this emphasis on cognitive, communicative, and social traits, motor deficits in ASD are frequently overlooked. However, emerging evidence has demonstrated considerable deficits in locomotor and object control skills and motor coordination among children with ASD compared with neurotypical children (Fournier et al., 2010; Staples & Reid, 2010). Common gross motor deficits among children with ASD include decreased postural stability, reduced coordination between the upper and lower limbs, less-coordinated arm movements, and compromised gait patterns (Fournier et al., 2010; Mosconi & Sweeney, 2015). Delayed gross motor development often emerges early in children who are later diagnosed with ASD, specifically within the first few years of life, during infancy (Esposito et al., 2009; Teitelbaum et al., 1998) and toddlerhood (Lloyd et al., 2011; Provost et al., 2007). At younger ages, delayed motor skills development is more difficult to identify; however, these deficits become more prevalent with age. Martín-Diaz et al. (2024) reported that children and adolescents with ASD aged 6–18 experienced greater difficulty with motor skills and static and dynamic balance compared with their typically developing peers. Deficits in locomotor and object control skills (i.e., overhand throwing, underhand rolling, and catching) have also been observed across age groups, including those aged 6–8 years (Berkeley et al., 2001), 9–12 years (Staples & Reid, 2010) and 6–15 years (MacDonald et al., 2013). These gross motor deficits, particularly postural instability, may impede children’s ability to safely navigate their physical environments, thereby increasing their risk of falls. Such limitations can hinder their performance of daily tasks at home (e.g., getting dressed or putting on shoes) and reduced participation in physical activities at school (e.g., catching and throwing a ball or playing group sports). These limitations may contribute to an increased dependence on caregivers and heightened frustration in both children with ASD and their parents (Jarus et al., 2011). Studies examining exercise-based interventions among children with ASD have demonstrated their effectiveness in improving balance, motor skills, and physical fitness (Brand et al., 2015; Ketcheson et al., 2017; Sansi et al., 2021). For instance, Sansi et al. (2021) reported significant improvement in catching, overhand-throwing a ball, and movement skills among students with ASD aged 7–9 years, compared with their neurotypical peers, after two hours of exercise-based intervention per week as part of a 12-week physical activity program. Similarly, intensive motor skills training was significantly effective in improving locomotor activity, object control, and gross quotient among children with ASD aged 4–6 years (Ketcheson et al., 2017). In particular, interventions based on applied behavior analysis (ABA) principles, such as positive reinforcement, have demonstrated efficacy in teaching novel skills to children with ASD (Steinbrenner et al., 2020). Positive reinforcement procedures have been linked to increased proficiency, as newly acquired skills are strengthened through the presentation of social and tangible reinforcers (Cooper et al., 1987). For example, Brand et al. (2015) successfully utilized positive reinforcement to increase target behaviors over three weeks of training in catching, throwing a ball, and balance activities (e.g., one-leg standing, jumping, and standing on a balance beam) among children with ASD aged 7–13 years. Incorporating positive reinforcement may enhance the direct effects of training programs. Reinforcement-based procedures have been implemented frequently in studies of social communication and interaction (McConnell, 2002; Zanolli & Daggett, 1998) but are rarely used in interventions targeting motor skills. Parent-implemented interventions are an evidence-based practice that is widely recognized as effective in teaching children with ASD (Steinbrenner et al., 2020). Numerous studies have evaluated such approaches, including communication using incidental teaching (Hong et al., 2018), naturalistic development behavioral interventions (Gevarter et al., 2022), and imitation (Penney & Schwartz, 2019; Talyor, 2014). Parent-implemented interventions have shown positive outcomes among children with ASD as well as implementation fidelity (Gevarter et al., 2022; Hong et al., 2018; Penney & Schwartz, 2019). Implementation fidelity is closely associated with skill acquisition (Rogers et al., 2012; Waddington et al., 2020; Zitter et al., 2021), and strategies that enhance fidelity, such as behavioral skills training (BST) may therefore be beneficial. BST, which includes explicit instructions, modeling, rehearsal, and feedback, has been shown to be effective in parents (Dogan et al., 2017; Stewart et al., 2007; Ward-Horner & Sturmey, 2008), caregivers (Hsieh et al., 2011), and teachers (Gianoumis & Seiverling, 2012). A systematic review of 20 single-subject studies also found that BST was effective in teaching parents how to implement strategies targeting social and behavioral skills in their children (Schaefer et al., 2021). However, few studies have investigated whether the BST approach has similar positive effects on gross motor and object control skills among children with ASD receiving parent-implemented training. Incorporating parental support may enhance gross motor development within daily routines. This study examined the effects of a parent-implemented intervention to improve balance in a 4-year-old child with ASD. By evaluating the efficacy of parent-implemented interventions, this study aims to provide valuable evidence for addressing gross motor and object control skills in this population. Methodology Participant The study participant was a 4-year-old boy with ASD. He was diagnosed with argininosuccinic aciduria through newborn screening and was later identified as having developmental delay, with a tentative diagnosis of ASD at two years. At four years, he was diagnosed with ASD and moderate intellectual disability at a university-affiliated hospital using the Autism Diagnostic Observation Schedule-Generic and Social Maturity Scale (SMS). The participant’s Childhood Autism Rating Scale 2 score was 34 at 52 months, confirming the diagnosis of ASD. The social quotient and social age SMS scores were 67.21 and 2.91 years, respectively, indicating that the participant experienced difficulty with social interaction across various social contexts. The participant had a history of frequent falls, occurring approximately three or four times per day; however, these concerns had not been addressed because of other priority areas, such as speech and language delays, and his argininosuccinic aciduria. His motor skills were addressed separately through behavior analytic interventions by his Board-Certified Behavior Analyst (BCBA). The first author of this paper is both a BCBA and a licensed physical therapist who worked with the participant for two years at a private ABA center. Design A multiple-probe design was employed to detect differences between the baseline and intervention phases across behaviors (Carr, 2005). Performance level, variability, and overall trends were visually analyzed to compare the baseline and intervention phases (Cooper et al., 1987; Horner et al., 2005). The percentage of non-overlapping data (PND) and Tau-U statistics were utilized to evaluate the effectiveness of the intervention (Scruggs & Mastropieri, 1998). A Tau-U score of 0.66–0.92 indicates a moderate effect, while a score of 0.93–1.00 indicates a strong effect. In addition, a pre-post comparison was conducted to determine whether the Pediatric Berg Balance Scale (PBS) score increased after the intervention. This 14-item assessment tool evaluates fall risk in children aged 5–15 years (Berg et al., 1992). The assessment items include sitting, standing, sit-to-stand, stand-to-sit, stepping, reaching forward, reaching to the floor, turning, and stepping on and off an elevated surface. Each item is rated on a five-point ordinal scale ranging from 0 (lowest level of functioning) to 4 (highest level of functioning). The PBS demonstrated satisfactory inter-rater (ICC > 0.9) and test-retest reliability (intra-class correlation coefficient [ICC] > 0.9). Scores less than 20 indicate a high fall risk, 21–40 indicate a medium risk, and scores greater than 41 indicate a low risk (Franjoine et al., 2003). The study protocol was reviewed and approved by the university’s Institutional Review Board (protocol #24HR34, approved 06/30/2024). Participation in this study was voluntary. Written informed consent was obtained from the child’s parents. Settings and Materials Parent training and assessment sessions were conducted at a private ABA center. The assessment room was 3 × 4 m and equipped with a 4 cm foam mattress on the floor to minimize the risk of injury from falls. For safety, the researcher and the child’s mother acted as spotters and were positioned directly beside or across from the child during all assessment sessions. Throughout the intervention, parents were provided with written instructions outlining the study’s operational definitions as well as a modeling video to ensure a high degree of procedural fidelity. All assessments were videotaped for interobserver agreement (IOA) analysis. A stopwatch was used to time any loss of balance during the assessments. Any stumbling or falling, lifting of the heel or forefoot off the floor, or being out of the testing position following antecedents during the target behaviors were recorded as incorrect responses. The child’s preferred edible items (e.g., chewable vitamins and madeleines) and activities (e.g., swinging, and jumping) were available as reinforcers during the training sessions but not the maintenance sessions. The reinforcer schedule ranged from a fixed ratio (FR) of 1 to a variable ratio (VR) of 5, depending on the task difficulty. Intervention The parent-implemented intervention was based on BST, which incorporates written and verbal instructions, modeling, rehearsal, and feedback (Miltenberger et al., 2009). The first author acted as the parent trainer throughout the study. At the onset of training, the parents received a written instruction sheet outlining the study procedures. The researcher then provided detailed verbal explanations of each target behavior’s operational definition accompanied by examples of both correct and incorrect responses. After confirming that the parents understood what was required of them, the researcher modeled each target behavior. The parents then rehearsed these behaviors multiple times under supervision. Immediate feedback was provided throughout this process to ensure accurate and consistent implementation. The training sessions typically took place at the child’s home and were conducted two to three times per week, with the exact frequency and duration adjusted according to the parents’ schedules and availability. During the assessments, parent–child intervention sessions were videotaped for subsequent data analysis. A maintenance phase was initiated three weeks after completing the primary intervention. In this phase, three to five data points were collected to assess the retention of the acquired skills. Additionally, generalization probes were conducted at home and videotaped by the child’s father at home throughout the intervention period to monitor ongoing progress and promote skill generalization. The intervention targeted two primary fundamental movement skill areas. Gross motor skills, the first skill area, includes sitting, half-kneeling, standing, and walking. Each gross motor skill set was further divided into one to three specific sub–target behaviors. The second area was object control skills such as throwing, catching, and rolling a ball. The operational definitions of the independent variables are listed in Table 1 . Table 1 Operational definitions of target behaviors Motor Skills Condition Target Behavior Operational Definition Gross motor skills Sitting Sitting on a gym ball (size: 45 cm in diameter) for 10 s Within 3 s of the antecedent stimulus ‘sit still’ or ‘hold,’ the child maintains balance while sitting on a gym ball for 10 s. Throwing a foam ball into a bucket while sitting on a gym ball The child catches the ball when parents pass it to them from various angles at a distance of approximately 30 cm. Within 3 s of the antecedent stimulus ‘throw,’ the child throws the ball into a bucket while maintaining balance on a gym ball. Half-kneeling Half kneeling for 10 s Within 3 s of the antecedent stimulus ‘hold’ or ‘hold steady,’ the child kneels on one knee for 10 s. Throwing a foam ball into a bucket while half kneeling The child catches the ball when parents pass it to them from various angles at a distance of approximately 30 cm. Within 3 s of the antecedent stimulus ‘throw,’ the child throws the ball into a bucket while maintaining balance. Standing One-leg standing Within 3 s of the antecedent stimulus ‘stand still,’ the child stands on one leg for longer than 3 s while maintaining balance. Tandem standing Within 3 s of the antecedent stimulus ‘stand still’ or ‘hold,’ the child stands with feet hip-width apart, places one foot directly in front of the other, and maintains balance for longer than 3 s. Walking Walking between two parallel lines (10 cm width, 2 m length) Within 3 s of the antecedent stimulus ‘walk between the lines,’ the child maintains balance while walking and places both feet inside the designated lines. Object control skills Ball Ball throwing Within 3 s of the antecedent stimulus ‘throw,’ the child raises both hands upward, extends them behind their body, and then moves both arms forward to release a foam ball. The ball should be thrown more than 1 m forward while maintaining balance. Ball catching Parents stand 1 m away from the child. The child places both hands at waist height. Within 3 s of the antecedent stimulus ‘catch,’ the parents toss the ball, and the child catches it while maintaining balance. Ball rolling The child holds a tennis ball in their throwing hand and places the opposite foot forward. Then, the child moves the throwing arm behind the body, moves it forward, and rolls the ball more than 1 m along the ground. The ball should not bounce and the child should maintain balance. Data Collection All assessments were videotaped and lasted for an average of 1 h with breaks as needed. The assessments were conducted in vivo using pencil and paper. Each dependent variable was investigated through 10 trials, except for half kneeling and one-leg standing, which were separately assessed for each leg (10 trials per leg). Each trial was scored as ‘+’ and ‘–’ for correct and incorrect responses, respectively, based on child’s performance. The percentage of correct responses was calculated by dividing the total number of correct responses by the total number of responses. Sub–target behavior scores were combined and averaged for each condition. Interobserver Agreement (IOA) The IOA was calculated for approximately 30% of the baseline, intervention, and maintenance sessions. A second trained observer reviewed the video sessions and scored them independently. The first author conducted reliability training, which included reviewing the operational definitions of target behaviors, data coding procedures, and discussing examples of correct and incorrect responses using video clips. For each target behavior, agreement was established if both observers marked a response as correct (+) or incorrect (–). Otherwise, there was considered to be disagreement. The IOA was calculated by dividing the number of agreements by the total number of responses evaluated, and then multiplying the result by 100. The overall IOA across all behaviors was 95.43% (range: 78–100%). Implementation Fidelity To assess intervention fidelity, two observers selected 30% of the intervention sessions at random for each treatment variable. The Teacher Performance Rate and Accuracy Scale (TPRA) was modified and used to evaluate the accuracy of delivery of instructional antecedents, behaviors, and consequences between the parents and the child (Ross et al., 2005). The procedures were as follows: 1) present the instructional antecedents correctly as written; 2) record the child’s response correctly based on each target behavior’s operational definition; and 3) provide social and/or tangible reinforcement correctly. With reference to the operational definitions, correct and incorrect responses were recorded as ‘+’ and ‘–,’ respectively. Intervention fidelity was calculated by dividing the number of correct responses by the total number of responses and multiplying it by 100. The average intervention fidelity was 97.38% (range: 91–100%). Social Validity A social validity questionnaire was modified and administered to the parents and two observers after the intervention (Cihon et al., 2022; Schertz & Odom, 2007). The first observer holds a Master’s degree in Education and is pursuing a behavior analyst certification concurrent to providing behavior intervention services to the child. The second observer holds an undergraduate degree in Special Education and is a graduate student in ABA. This observer had more than a year of prior experience delivering behavior intervention services to the child. The questionnaire included the following seven items: (1) How important was it for the child to practice motor and balance skills?; (2) How would you rate the intervention’s acceptability?; (3) How would you rate the intervention’s effectiveness?; (4) How helpful were the motor and balance skills suggested by the researcher?; (5) How would you rate the intervention’s impact on the child’s daily activities?; (6) How appropriate was the amount of time the researcher spent each week? (approximately one hour per week); and (7) How helpful were the weekly discussions with the researcher (e.g., outlining goals, providing explanations, adjusting pace, offering guidance, and addressing concerns)? Each item was scored on a 5-point Likert scale, with 1 representing ‘strongly disagree’, ‘not at all effective’, and ‘not at all important’, and 5 representing ‘strongly agree’, ‘extremely effective’, ‘extremely important’, and ‘extremely acceptable’. The mean social validity scores for each question were as follows: (1) 5.00; (2) 4.25; (3) 4.50; (4) 5.00; (5) 4.75; (6) 4.50; and (7) 4.25. Results Visual analysis indicated an increase in all target variables during the intervention phase. At baseline, the percentage of correct responses was low for all independent variables (Fig. 1 ). However, substantial improvement was observed during the intervention phase. Performance gains were maintained across all conditions throughout the maintenance phase. A clear change in the level during walking was observed only in the later part of the intervention phase. Overall, an increasing trend was observed in the half-kneeling, standing, and walking conditions during the intervention phases, with further improvement observed during the maintenance phase. However, the sitting condition showed greater variability. The PND for correct responses between the baseline and intervention phases were as follows: 100% (sitting), 90% (half-kneeling), 87% (standing), and 100% (walking), respectively. Tau-U scores were 1.00 (sitting), 0.88 (half-kneeling), 1.00 (standing), and 1.00 (walking), respectively. In the ball-throwing condition, the number of correct responses increased during the intervention phase compared with baseline (Fig. 2 ). This increase continued throughout the maintenance phase. In the ball-catching condition, the percentage of correct responses increased during the intervention phase, with some variability, compared with baseline and remained high during the maintenance phase. In the ball-rolling condition, the percentage of correct responses increased substantially during both the intervention and maintenance phases compared with the baseline phase. The PND for correct responses between the baseline and intervention phases were as follows: 82% (catching), 47% (throwing), and 57% (rolling), respectively. The Tau-U scores for the target behaviors were 0.76 (catching), 0.63 (throwing), and 0.57 (rolling). Figure 3 presents the child’s PBS scores before and after the intervention. The mean PBS score increased from 26 to 52, indicating a lower risk of falls after the intervention. The items that exhibited the greatest improvement were standing with eyes closed, standing with feet together, standing with one foot in front of the other, standing on one foot, rotating 360°, and turning to look back. Discussion This study investigated the effects of a parent-implemented intervention to target gross motor and object control skills, while maintaining balance, in a child with ASD. A key finding was that the intervention improved the child’s gross motor and object control skills. Additionally, the child’s functional gains in motor skills following the intervention were reflected in the PBS clinical balance assessment. Specifically, the intervention effect was maintained at a three-week follow-up. These findings add to the limited body of literature on parent-implemented interventions for gross motor and object control skills in children with ASD, as most previous studies have prioritized communication, and social and behavioral outcomes. As identified by Steinbrenner et al. (2020), there is a paucity of evidence-based studies specifically examining balance interventions in this population, highlighting the need for further research in this area. Substantial variability was observed in the sitting condition during the intervention phase. There are two possible explanations for this variation. This condition was the first independent variable. Adjusting the body’s center of mass on a constantly moving ball to achieve postural stability likely requires more practice. Furthermore, the child needed to learn how to stabilize the gym ball by slightly extending both arms backward without looking behind them, and maintaining a firm hold on the ball with both hands. Considering that the child received a score of ‘0’ for the ‘turning to look back’ PBS item during the pretest, maintaining balance during this task was likely challenging for him. This might have contributed to the considerable variability observed for this condition. Less variability was observed between the intervention and maintenance phases in the other conditions. Visual analysis indicated that the functional stability gained during sitting improved under subsequent conditions. Tasks involving a ball required the child to stabilize the trunk and lower postural muscles to minimize subsequent postural disturbances. Adjusting postural instability in a feed-forward manner is commonly observed when engaging in daily activities, particularly during voluntary movements such as reaching, bending, or shifting weights (Maki & McIlroy 1997). This program included motor tasks requiring anticipatory balance control, such as one-leg standing, ball catching, and throwing in various positions (i.e., sitting on a ball, half-kneeling, and standing). This provided abundant opportunities for the child to develop fundamental movement skills. The program ensured effective maintenance of postural stability while performing various activities through the coordination of movements between the upper and lower limbs. Parental involvement played a significant role in this study. The direct delivery of the intervention resulted in the parents attempting to practice its steps in various settings, including the home and community, thus further strengthening the findings of this study. Consistent with previous research, parents provided high scores for the training program’s feasibility and acceptability (Dogan et al., 2017; Gauert et al., 2023; Stewart et al. 2007). Providing parents with structured and systematic guidance using the BST procedure enabled them to intervene effectively. By providing step-by-step instructions, modelling, rehearsal, and feedback, the BST procedure provides a structured and systematic approach that ensures that parents implement intervention strategies. Incorporating ABA principles, such as positive reinforcement, enhanced the effectiveness of the intervention. We provided tangible and social reinforcers on an FR or VR schedule, contingent on the occurrence of the target behaviors. Positive reinforcement is widely utilized to teach new skills, particularly in behavior intervention services (Steinbrenner et al., 2020). As demonstrated by the increasing trend lines from the baseline to the intervention phase, verbal praise, high fives, or other tangible reinforcers following the target behavior increased the frequency of correct responses in this study. Similar outcomes were observed when reinforcers were presented to children with ASD during an aerobic exercise intervention (Brand et al., 2015) and motor imitation tasks (Miller et al., 2015). Although positive reinforcement is a common strategy in ASD interventions, this study is among the few to directly apply it to the teaching of motor skills. Future research may benefit from incorporating behavior change tactics, such as token economy, task analysis, or prompts and prompt fading, to enhance the acquisition and maintenance of new skills. Despite the promising outcomes, this study has some limitations. First, the positive changes observed may have been limited by its single-subject research design. Including a larger sample was not feasible due to limited resources and the heterogeneity of ASD symptoms and severity levels. Studies incorporating motor skills with larger samples may be feasible through conducting play-based programs in preschools or early intensive behavioral interventions in the community. Additionally, although implementation fidelity was measured at the parent level, researcher fidelity was not directly assessed. Evaluating both researcher and parent fidelity may clarify the sources of intervention effectiveness. Further studies should evaluate researcher fidelity and the maintenance of parent-acquired skills (Gauert et al., 2023). Finally, this study examined basic locomotor and object control skills, but did not include advanced motor skills. More advanced and complex movement skills such as jumping or hopping are frequently required when engaging in sports or physical activities with peers, particularly in group settings. Studies evaluating motor skills from the perspective of motor development trajectories may enhance our understanding of training effects in children with motor deficits, while also addressing existing limitations in this research area. In conclusion, the parent-implemented intervention effectively targeted gross motor and object control skills in a child with ASD. The findings demonstrated that the child exhibited meaningful improvements in motor performance, as evidenced by an improved clinical balance assessment. 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J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., Mengye, G., & Dawson, G. (2012). Effects of a brief Early Start Denver Model (ESDM) -based parent intervention on toddlers at risk for autism spectrum disorders: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry , 51 (10), 1052–1065. Ross, D. E., Singer-Dudek, J., & Greer, R. D. (2005). The Teacher Performance Rate and Accuracy scale (TPRA): Training as evaluation. Education and Training in Developmental Disabilities , 411–423. Sansi, A., Nalbant, S., & Ozer, D. (2021). Effects of an inclusive physical activity program on the motor skills, social skills and attitudes of students with and without autism spectrum disorder. Journal of Autism and Developmental Disorders , 51 (7), 2254–2270. Schaefer, J. M., & Andzik, N. R. (2021). Evaluating behavioral skills training as an evidence-based practice when training parents to intervene with their children. Behavior Modification , 45 (6), 887–910. https://doi.org/10.1177/0145445520923996 Schertz, H. H., & Odom, S. L. (2007). Promoting joint attention in toddlers with autism: A parent-mediated developmental model. Journal of Autism and Developmental Disorders , 37 , 1562–1575. Scruggs, T. E., & Mastropieri, M. A. (1998). Summarizing single-subject research: Issues and applications. Behavior Modification , 22 (3), 221–242. Staples, K. L., & Reid, G. (2010). Fundamental movement skills and autism spectrum disorders. Journal of Autism and Developmental Disorders , 40 , 209–217. Steinbrenner, J. R., Hume, K., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yücesoy-Özkan, S., & Savage, M. N. (2020). Evidence-based practices for children, youth, and young adults with autism. University of North Carolina at Chapel Hill, Frank Porter Graham Child Development Institute, National Clearinghouse on Autism Evidence and Practice Review Team. Stewart, K. K., Carr, J. E., & LeBlanc, L. A. (2007). Evaluation of family-implemented behavioral skills training for teaching social skills to a child with Asperger’s disorder. Clinical Case Studies , 6 (3), 252–262. Taylor, J. (2014). Teaching Reciprocal Imitation Training to parents of children with autism spectrum disorder (ASD) through combined internet-based and in vivo instruction (Doctoral dissertation, University of Pittsburgh). Teitelbaum, P., Teitelbaum, O., Nye, J., Fryman, J., & Maurer, R. G. (1998). Movement analysis in infancy may be useful for early diagnosis of autism. Proceedings of the National Academy of Sciences , 95 (23), 13982–13987. Waddington, H., van der Meer, L., Sigafoos, J., & Whitehouse, A. (2020). Examining parent use of specific intervention techniques during a 12-week training program based on the Early Start Denver Model. Autism , 24 (2), 484–498. Ward-Horner, J., & Sturmey, P. (2008). The effects of general‐case training and behavioral skills training on the generalization of parents’ use of discrete‐trial teaching, child correct responses, and child maladaptive behavior. Behavioral Interventions: Theory & Practice in Residential & Community‐Based Clinical Programs , 23 (4), 271–284. Zanolli, K., & Daggett, J. (1998). The effects of reinforcement rate on the spontaneous social initiations of socially withdrawn preschoolers. Journal of Applied Behavior Analysis , 31 (1), 117–125. Zitter, A., Rinn, H., Szapuova, Z., Avila-Pons, V. M., Coulter, K. L., Stahmer, A. C., Robins, D. L., & Vivanti, G. (2021). Does treatment fidelity of the early start Denver model impact skill acquisition in young children with autism? Journal of Autism and Developmental Disorders , 1–11. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Apr, 2026 Read the published version in Journal of Behavioral Education → Version 1 posted Editorial decision: Revision requested 27 Dec, 2025 Reviews received at journal 07 Aug, 2025 Reviewers agreed at journal 17 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers invited by journal 15 Jul, 2025 Editor assigned by journal 20 Jun, 2025 Submission checks completed at journal 20 Jun, 2025 First submitted to journal 18 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6926263","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":487032069,"identity":"0e72d83d-d7ba-4854-8dce-4cfd99279b53","order_by":0,"name":"Sungeun Lee","email":"","orcid":"","institution":"Baekseok University","correspondingAuthor":false,"prefix":"","firstName":"Sungeun","middleName":"","lastName":"Lee","suffix":""},{"id":487032070,"identity":"770a2507-a1e3-4dc4-aa90-444e1e491a76","order_by":1,"name":"Youngzie Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYFAC5gYGxgYGBn4JCNeACC2MEC2SM0jWYnCDWC0G5w82Pvi4w07O+HaPAcOPGgZj8wZCWg4cbDaceSbZ2OzOGQPGnmMMZjIHCGk52NgmzdvGnLjtRo4BA28Dg40EQYcdZmz//betvn7zjBwDxr9EaTnG2MbM2HY4wUAix4AZaIsZQS2SZxibJXvPHDeccedYwWGZYxLGBLXwnT988MPPHdXy/LObNz58U2NjOIOQFoUDSBwgm6AdDAzyDYTVjIJRMApGwUgHAFNLQO8c5kEaAAAAAElFTkSuQmCC","orcid":"","institution":"Baekseok University","correspondingAuthor":true,"prefix":"","firstName":"Youngzie","middleName":"","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2025-06-18 23:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6926263/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6926263/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10864-026-09627-w","type":"published","date":"2026-04-02T15:57:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87358002,"identity":"c0bb7ac1-a395-4d4a-be94-1a796434a4b9","added_by":"auto","created_at":"2025-07-23 05:33:05","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":392531,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of correct responses for gross motor skills\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6926263/v1/d2f50c5bf883bc8614805214.jpeg"},{"id":87357992,"identity":"ad55e90b-b74f-485b-adfa-6a319b75bf96","added_by":"auto","created_at":"2025-07-23 05:33:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":19975,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of correct responses for object control skills using a ball\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6926263/v1/86d69153191e426eff148369.png"},{"id":87357993,"identity":"b290ad22-43f5-4b55-8ccf-eeb3605373cf","added_by":"auto","created_at":"2025-07-23 05:33:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":8720,"visible":true,"origin":"","legend":"\u003cp\u003ePediatric Berg Balance Scale Scores\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6926263/v1/3e4eafb7f5a649cbab13f714.png"},{"id":106344576,"identity":"5e18d77f-a813-42f4-8769-3379f8681c00","added_by":"auto","created_at":"2026-04-07 16:15:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":917992,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6926263/v1/29ebd6ae-d710-436e-893f-b2ab29b3ece0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of a parent-implemented intervention for improving balance in a child with autism spectrum disorder","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAutism spectrum disorder (ASD) is primarily characterized by deficits in social communication and interaction along with restricted and repetitive behavioral patterns (American Psychiatric Association, 2013). Deficits in social communication and atypical behavioral characteristics are the core features of ASD. As a result of this emphasis on cognitive, communicative, and social traits, motor deficits in ASD are frequently overlooked. However, emerging evidence has demonstrated considerable deficits in locomotor and object control skills and motor coordination among children with ASD compared with neurotypical children (Fournier et al., 2010; Staples \u0026amp; Reid, 2010). Common gross motor deficits among children with ASD include decreased postural stability, reduced coordination between the upper and lower limbs, less-coordinated arm movements, and compromised gait patterns (Fournier et al., 2010; Mosconi \u0026amp; Sweeney, 2015).\u003c/p\u003e\u003cp\u003eDelayed gross motor development often emerges early in children who are later diagnosed with ASD, specifically within the first few years of life, during infancy (Esposito et al., 2009; Teitelbaum et al., 1998) and toddlerhood (Lloyd et al., 2011; Provost et al., 2007). At younger ages, delayed motor skills development is more difficult to identify; however, these deficits become more prevalent with age. Mart\u0026iacute;n-Diaz et al. (2024) reported that children and adolescents with ASD aged 6\u0026ndash;18 experienced greater difficulty with motor skills and static and dynamic balance compared with their typically developing peers. Deficits in locomotor and object control skills (i.e., overhand throwing, underhand rolling, and catching) have also been observed across age groups, including those aged 6\u0026ndash;8 years (Berkeley et al., 2001), 9\u0026ndash;12 years (Staples \u0026amp; Reid, 2010) and 6\u0026ndash;15 years (MacDonald et al., 2013). These gross motor deficits, particularly postural instability, may impede children\u0026rsquo;s ability to safely navigate their physical environments, thereby increasing their risk of falls. Such limitations can hinder their performance of daily tasks at home (e.g., getting dressed or putting on shoes) and reduced participation in physical activities at school (e.g., catching and throwing a ball or playing group sports). These limitations may contribute to an increased dependence on caregivers and heightened frustration in both children with ASD and their parents (Jarus et al., 2011).\u003c/p\u003e\u003cp\u003eStudies examining exercise-based interventions among children with ASD have demonstrated their effectiveness in improving balance, motor skills, and physical fitness (Brand et al., 2015; Ketcheson et al., 2017; Sansi et al., 2021). For instance, Sansi et al. (2021) reported significant improvement in catching, overhand-throwing a ball, and movement skills among students with ASD aged 7\u0026ndash;9 years, compared with their neurotypical peers, after two hours of exercise-based intervention per week as part of a 12-week physical activity program. Similarly, intensive motor skills training was significantly effective in improving locomotor activity, object control, and gross quotient among children with ASD aged 4\u0026ndash;6 years (Ketcheson et al., 2017). In particular, interventions based on applied behavior analysis (ABA) principles, such as positive reinforcement, have demonstrated efficacy in teaching novel skills to children with ASD (Steinbrenner et al., 2020). Positive reinforcement procedures have been linked to increased proficiency, as newly acquired skills are strengthened through the presentation of social and tangible reinforcers (Cooper et al., 1987). For example, Brand et al. (2015) successfully utilized positive reinforcement to increase target behaviors over three weeks of training in catching, throwing a ball, and balance activities (e.g., one-leg standing, jumping, and standing on a balance beam) among children with ASD aged 7\u0026ndash;13 years. Incorporating positive reinforcement may enhance the direct effects of training programs. Reinforcement-based procedures have been implemented frequently in studies of social communication and interaction (McConnell, 2002; Zanolli \u0026amp; Daggett, 1998) but are rarely used in interventions targeting motor skills.\u003c/p\u003e\u003cp\u003eParent-implemented interventions are an evidence-based practice that is widely recognized as effective in teaching children with ASD (Steinbrenner et al., 2020). Numerous studies have evaluated such approaches, including communication using incidental teaching (Hong et al., 2018), naturalistic development behavioral interventions (Gevarter et al., 2022), and imitation (Penney \u0026amp; Schwartz, 2019; Talyor, 2014). Parent-implemented interventions have shown positive outcomes among children with ASD as well as implementation fidelity (Gevarter et al., 2022; Hong et al., 2018; Penney \u0026amp; Schwartz, 2019). Implementation fidelity is closely associated with skill acquisition (Rogers et al., 2012; Waddington et al., 2020; Zitter et al., 2021), and strategies that enhance fidelity, such as behavioral skills training (BST) may therefore be beneficial. BST, which includes explicit instructions, modeling, rehearsal, and feedback, has been shown to be effective in parents (Dogan et al., 2017; Stewart et al., 2007; Ward-Horner \u0026amp; Sturmey, 2008), caregivers (Hsieh et al., 2011), and teachers (Gianoumis \u0026amp; Seiverling, 2012). A systematic review of 20 single-subject studies also found that BST was effective in teaching parents how to implement strategies targeting social and behavioral skills in their children (Schaefer et al., 2021). However, few studies have investigated whether the BST approach has similar positive effects on gross motor and object control skills among children with ASD receiving parent-implemented training. Incorporating parental support may enhance gross motor development within daily routines. This study examined the effects of a parent-implemented intervention to improve balance in a 4-year-old child with ASD. By evaluating the efficacy of parent-implemented interventions, this study aims to provide valuable evidence for addressing gross motor and object control skills in this population.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipant\u003c/h2\u003e\u003cp\u003eThe study participant was a 4-year-old boy with ASD. He was diagnosed with argininosuccinic aciduria through newborn screening and was later identified as having developmental delay, with a tentative diagnosis of ASD at two years. At four years, he was diagnosed with ASD and moderate intellectual disability at a university-affiliated hospital using the Autism Diagnostic Observation Schedule-Generic and Social Maturity Scale (SMS). The participant\u0026rsquo;s Childhood Autism Rating Scale 2 score was 34 at 52 months, confirming the diagnosis of ASD. The social quotient and social age SMS scores were 67.21 and 2.91 years, respectively, indicating that the participant experienced difficulty with social interaction across various social contexts.\u003c/p\u003e\u003cp\u003eThe participant had a history of frequent falls, occurring approximately three or four times per day; however, these concerns had not been addressed because of other priority areas, such as speech and language delays, and his argininosuccinic aciduria. His motor skills were addressed separately through behavior analytic interventions by his Board-Certified Behavior Analyst (BCBA). The first author of this paper is both a BCBA and a licensed physical therapist who worked with the participant for two years at a private ABA center.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDesign\u003c/h3\u003e\n\u003cp\u003eA multiple-probe design was employed to detect differences between the baseline and intervention phases across behaviors (Carr, 2005). Performance level, variability, and overall trends were visually analyzed to compare the baseline and intervention phases (Cooper et al., 1987; Horner et al., 2005). The percentage of non-overlapping data (PND) and Tau-U statistics were utilized to evaluate the effectiveness of the intervention (Scruggs \u0026amp; Mastropieri, 1998). A Tau-U score of 0.66\u0026ndash;0.92 indicates a moderate effect, while a score of 0.93\u0026ndash;1.00 indicates a strong effect. In addition, a pre-post comparison was conducted to determine whether the Pediatric Berg Balance Scale (PBS) score increased after the intervention. This 14-item assessment tool evaluates fall risk in children aged 5\u0026ndash;15 years (Berg et al., 1992). The assessment items include sitting, standing, sit-to-stand, stand-to-sit, stepping, reaching forward, reaching to the floor, turning, and stepping on and off an elevated surface. Each item is rated on a five-point ordinal scale ranging from 0 (lowest level of functioning) to 4 (highest level of functioning). The PBS demonstrated satisfactory inter-rater (ICC\u0026thinsp;\u0026gt;\u0026thinsp;0.9) and test-retest reliability (intra-class correlation coefficient [ICC]\u0026thinsp;\u0026gt;\u0026thinsp;0.9). Scores less than 20 indicate a high fall risk, 21\u0026ndash;40 indicate a medium risk, and scores greater than 41 indicate a low risk (Franjoine et al., 2003). The study protocol was reviewed and approved by the university\u0026rsquo;s Institutional Review Board (protocol #24HR34, approved 06/30/2024). Participation in this study was voluntary. Written informed consent was obtained from the child\u0026rsquo;s parents.\u003c/p\u003e\n\u003ch3\u003eSettings and Materials\u003c/h3\u003e\n\u003cp\u003eParent training and assessment sessions were conducted at a private ABA center. The assessment room was 3 \u0026times; 4 m and equipped with a 4 cm foam mattress on the floor to minimize the risk of injury from falls. For safety, the researcher and the child\u0026rsquo;s mother acted as spotters and were positioned directly beside or across from the child during all assessment sessions. Throughout the intervention, parents were provided with written instructions outlining the study\u0026rsquo;s operational definitions as well as a modeling video to ensure a high degree of procedural fidelity.\u003c/p\u003e\u003cp\u003eAll assessments were videotaped for interobserver agreement (IOA) analysis. A stopwatch was used to time any loss of balance during the assessments. Any stumbling or falling, lifting of the heel or forefoot off the floor, or being out of the testing position following antecedents during the target behaviors were recorded as incorrect responses.\u003c/p\u003e\u003cp\u003eThe child\u0026rsquo;s preferred edible items (e.g., chewable vitamins and madeleines) and activities (e.g., swinging, and jumping) were available as reinforcers during the training sessions but not the maintenance sessions. The reinforcer schedule ranged from a fixed ratio (FR) of 1 to a variable ratio (VR) of 5, depending on the task difficulty.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe parent-implemented intervention was based on BST, which incorporates written and verbal instructions, modeling, rehearsal, and feedback (Miltenberger et al., 2009). The first author acted as the parent trainer throughout the study. At the onset of training, the parents received a written instruction sheet outlining the study procedures. The researcher then provided detailed verbal explanations of each target behavior\u0026rsquo;s operational definition accompanied by examples of both correct and incorrect responses. After confirming that the parents understood what was required of them, the researcher modeled each target behavior. The parents then rehearsed these behaviors multiple times under supervision. Immediate feedback was provided throughout this process to ensure accurate and consistent implementation. The training sessions typically took place at the child\u0026rsquo;s home and were conducted two to three times per week, with the exact frequency and duration adjusted according to the parents\u0026rsquo; schedules and availability. During the assessments, parent\u0026ndash;child intervention sessions were videotaped for subsequent data analysis. A maintenance phase was initiated three weeks after completing the primary intervention. In this phase, three to five data points were collected to assess the retention of the acquired skills. Additionally, generalization probes were conducted at home and videotaped by the child\u0026rsquo;s father at home throughout the intervention period to monitor ongoing progress and promote skill generalization.\u003c/p\u003e\u003cp\u003eThe intervention targeted two primary fundamental movement skill areas. Gross motor skills, the first skill area, includes sitting, half-kneeling, standing, and walking. Each gross motor skill set was further divided into one to three specific sub\u0026ndash;target behaviors. The second area was object control skills such as throwing, catching, and rolling a ball. The operational definitions of the independent variables are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOperational definitions of target behaviors\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMotor Skills\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCondition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTarget Behavior\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOperational Definition\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003eGross motor skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSitting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSitting on a gym ball (size: 45 cm in diameter) for 10 s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWithin 3 s of the antecedent stimulus \u0026lsquo;sit still\u0026rsquo; or \u0026lsquo;hold,\u0026rsquo; the child maintains balance while sitting on a gym ball for 10 s.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThrowing a foam ball into a bucket while sitting on a gym ball\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eThe child catches the ball when parents pass it to them from various angles at a distance of approximately 30 cm. Within 3 s of the antecedent stimulus \u0026lsquo;throw,\u0026rsquo; the child throws the ball into a bucket while maintaining balance on a gym ball.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHalf-kneeling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHalf kneeling for 10 s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWithin 3 s of the antecedent stimulus \u0026lsquo;hold\u0026rsquo; or \u0026lsquo;hold steady,\u0026rsquo; the child kneels on one knee for 10 s.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThrowing a foam ball into a bucket while half kneeling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eThe child catches the ball when parents pass it to them from various angles at a distance of approximately 30 cm. Within 3 s of the antecedent stimulus \u0026lsquo;throw,\u0026rsquo; the child throws the ball into a bucket while maintaining balance.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eStanding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOne-leg standing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWithin 3 s of the antecedent stimulus \u0026lsquo;stand still,\u0026rsquo; the child stands on one leg for longer than 3 s while maintaining balance.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTandem standing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWithin 3 s of the antecedent stimulus \u0026lsquo;stand still\u0026rsquo; or \u0026lsquo;hold,\u0026rsquo; the child stands with feet hip-width apart, places one foot directly in front of the other, and maintains balance for longer than 3 s.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWalking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWalking between two parallel lines (10 cm width, 2 m length)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWithin 3 s of the antecedent stimulus \u0026lsquo;walk between the lines,\u0026rsquo; the child maintains balance while walking and places both feet inside the designated lines.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eObject control skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eBall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBall throwing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWithin 3 s of the antecedent stimulus \u0026lsquo;throw,\u0026rsquo; the child raises both hands upward, extends them behind their body, and then moves both arms forward to release a foam ball. The ball should be thrown more than 1 m forward while maintaining balance.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBall catching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents stand 1 m away from the child. The child places both hands at waist height. Within 3 s of the antecedent stimulus \u0026lsquo;catch,\u0026rsquo; the parents toss the ball, and the child catches it while maintaining balance.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBall rolling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eThe child holds a tennis ball in their throwing hand and places the opposite foot forward.\u003c/p\u003e\u003cp\u003eThen, the child moves the throwing arm behind the body, moves it forward, and rolls the ball more than 1 m along the ground. The ball should not bounce and the child should maintain balance.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eAll assessments were videotaped and lasted for an average of 1 h with breaks as needed. The assessments were conducted in vivo using pencil and paper. Each dependent variable was investigated through 10 trials, except for half kneeling and one-leg standing, which were separately assessed for each leg (10 trials per leg). Each trial was scored as \u0026lsquo;+\u0026rsquo; and \u0026lsquo;\u0026ndash;\u0026rsquo; for correct and incorrect responses, respectively, based on child\u0026rsquo;s performance. The percentage of correct responses was calculated by dividing the total number of correct responses by the total number of responses. Sub\u0026ndash;target behavior scores were combined and averaged for each condition.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eInterobserver Agreement (IOA)\u003c/h2\u003e\u003cp\u003eThe IOA was calculated for approximately 30% of the baseline, intervention, and maintenance sessions. A second trained observer reviewed the video sessions and scored them independently. The first author conducted reliability training, which included reviewing the operational definitions of target behaviors, data coding procedures, and discussing examples of correct and incorrect responses using video clips. For each target behavior, agreement was established if both observers marked a response as correct (+) or incorrect (\u0026ndash;). Otherwise, there was considered to be disagreement. The IOA was calculated by dividing the number of agreements by the total number of responses evaluated, and then multiplying the result by 100. The overall IOA across all behaviors was 95.43% (range: 78\u0026ndash;100%).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eImplementation Fidelity\u003c/h3\u003e\n\u003cp\u003eTo assess intervention fidelity, two observers selected 30% of the intervention sessions at random for each treatment variable. The Teacher Performance Rate and Accuracy Scale (TPRA) was modified and used to evaluate the accuracy of delivery of instructional antecedents, behaviors, and consequences between the parents and the child (Ross et al., 2005). The procedures were as follows: 1) present the instructional antecedents correctly as written; 2) record the child\u0026rsquo;s response correctly based on each target behavior\u0026rsquo;s operational definition; and 3) provide social and/or tangible reinforcement correctly. With reference to the operational definitions, correct and incorrect responses were recorded as \u0026lsquo;+\u0026rsquo; and \u0026lsquo;\u0026ndash;,\u0026rsquo; respectively. Intervention fidelity was calculated by dividing the number of correct responses by the total number of responses and multiplying it by 100. The average intervention fidelity was 97.38% (range: 91\u0026ndash;100%).\u003c/p\u003e\n\u003ch3\u003eSocial Validity\u003c/h3\u003e\n\u003cp\u003eA social validity questionnaire was modified and administered to the parents and two observers after the intervention (Cihon et al., 2022; Schertz \u0026amp; Odom, 2007). The first observer holds a Master\u0026rsquo;s degree in Education and is pursuing a behavior analyst certification concurrent to providing behavior intervention services to the child. The second observer holds an undergraduate degree in Special Education and is a graduate student in ABA. This observer had more than a year of prior experience delivering behavior intervention services to the child.\u003c/p\u003e\u003cp\u003eThe questionnaire included the following seven items: (1) How important was it for the child to practice motor and balance skills?; (2) How would you rate the intervention\u0026rsquo;s acceptability?; (3) How would you rate the intervention\u0026rsquo;s effectiveness?; (4) How helpful were the motor and balance skills suggested by the researcher?; (5) How would you rate the intervention\u0026rsquo;s impact on the child\u0026rsquo;s daily activities?; (6) How appropriate was the amount of time the researcher spent each week? (approximately one hour per week); and (7) How helpful were the weekly discussions with the researcher (e.g., outlining goals, providing explanations, adjusting pace, offering guidance, and addressing concerns)? Each item was scored on a 5-point Likert scale, with 1 representing \u0026lsquo;strongly disagree\u0026rsquo;, \u0026lsquo;not at all effective\u0026rsquo;, and \u0026lsquo;not at all important\u0026rsquo;, and 5 representing \u0026lsquo;strongly agree\u0026rsquo;, \u0026lsquo;extremely effective\u0026rsquo;, \u0026lsquo;extremely important\u0026rsquo;, and \u0026lsquo;extremely acceptable\u0026rsquo;. The mean social validity scores for each question were as follows: (1) 5.00; (2) 4.25; (3) 4.50; (4) 5.00; (5) 4.75; (6) 4.50; and (7) 4.25.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eVisual analysis indicated an increase in all target variables during the intervention phase.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAt baseline, the percentage of correct responses was low for all independent variables (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). However, substantial improvement was observed during the intervention phase. Performance gains were maintained across all conditions throughout the maintenance phase. A clear change in the level during walking was observed only in the later part of the intervention phase. Overall, an increasing trend was observed in the half-kneeling, standing, and walking conditions during the intervention phases, with further improvement observed during the maintenance phase. However, the sitting condition showed greater variability.\u003c/p\u003e\u003cp\u003eThe PND for correct responses between the baseline and intervention phases were as follows: 100% (sitting), 90% (half-kneeling), 87% (standing), and 100% (walking), respectively. Tau-U scores were 1.00 (sitting), 0.88 (half-kneeling), 1.00 (standing), and 1.00 (walking), respectively.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the ball-throwing condition, the number of correct responses increased during the intervention phase compared with baseline (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This increase continued throughout the maintenance phase. In the ball-catching condition, the percentage of correct responses increased during the intervention phase, with some variability, compared with baseline and remained high during the maintenance phase. In the ball-rolling condition, the percentage of correct responses increased substantially during both the intervention and maintenance phases compared with the baseline phase. The PND for correct responses between the baseline and intervention phases were as follows: 82% (catching), 47% (throwing), and 57% (rolling), respectively. The Tau-U scores for the target behaviors were 0.76 (catching), 0.63 (throwing), and 0.57 (rolling).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the child\u0026rsquo;s PBS scores before and after the intervention. The mean PBS score increased from 26 to 52, indicating a lower risk of falls after the intervention. The items that exhibited the greatest improvement were standing with eyes closed, standing with feet together, standing with one foot in front of the other, standing on one foot, rotating 360\u0026deg;, and turning to look back.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the effects of a parent-implemented intervention to target gross motor and object control skills, while maintaining balance, in a child with ASD. A key finding was that the intervention improved the child\u0026rsquo;s gross motor and object control skills. Additionally, the child\u0026rsquo;s functional gains in motor skills following the intervention were reflected in the PBS clinical balance assessment. Specifically, the intervention effect was maintained at a three-week follow-up. These findings add to the limited body of literature on parent-implemented interventions for gross motor and object control skills in children with ASD, as most previous studies have prioritized communication, and social and behavioral outcomes. As identified by Steinbrenner et al. (2020), there is a paucity of evidence-based studies specifically examining balance interventions in this population, highlighting the need for further research in this area.\u003c/p\u003e\u003cp\u003eSubstantial variability was observed in the sitting condition during the intervention phase. There are two possible explanations for this variation. This condition was the first independent variable. Adjusting the body\u0026rsquo;s center of mass on a constantly moving ball to achieve postural stability likely requires more practice. Furthermore, the child needed to learn how to stabilize the gym ball by slightly extending both arms backward without looking behind them, and maintaining a firm hold on the ball with both hands. Considering that the child received a score of \u0026lsquo;0\u0026rsquo; for the \u0026lsquo;turning to look back\u0026rsquo; PBS item during the pretest, maintaining balance during this task was likely challenging for him. This might have contributed to the considerable variability observed for this condition. Less variability was observed between the intervention and maintenance phases in the other conditions. Visual analysis indicated that the functional stability gained during sitting improved under subsequent conditions.\u003c/p\u003e\u003cp\u003eTasks involving a ball required the child to stabilize the trunk and lower postural muscles to minimize subsequent postural disturbances. Adjusting postural instability in a feed-forward manner is commonly observed when engaging in daily activities, particularly during voluntary movements such as reaching, bending, or shifting weights (Maki \u0026amp; McIlroy 1997). This program included motor tasks requiring anticipatory balance control, such as one-leg standing, ball catching, and throwing in various positions (i.e., sitting on a ball, half-kneeling, and standing). This provided abundant opportunities for the child to develop fundamental movement skills. The program ensured effective maintenance of postural stability while performing various activities through the coordination of movements between the upper and lower limbs.\u003c/p\u003e\u003cp\u003eParental involvement played a significant role in this study. The direct delivery of the intervention resulted in the parents attempting to practice its steps in various settings, including the home and community, thus further strengthening the findings of this study. Consistent with previous research, parents provided high scores for the training program\u0026rsquo;s feasibility and acceptability (Dogan et al., 2017; Gauert et al., 2023; Stewart et al. 2007). Providing parents with structured and systematic guidance using the BST procedure enabled them to intervene effectively. By providing step-by-step instructions, modelling, rehearsal, and feedback, the BST procedure provides a structured and systematic approach that ensures that parents implement intervention strategies.\u003c/p\u003e\u003cp\u003eIncorporating ABA principles, such as positive reinforcement, enhanced the effectiveness of the intervention. We provided tangible and social reinforcers on an FR or VR schedule, contingent on the occurrence of the target behaviors. Positive reinforcement is widely utilized to teach new skills, particularly in behavior intervention services (Steinbrenner et al., 2020). As demonstrated by the increasing trend lines from the baseline to the intervention phase, verbal praise, high fives, or other tangible reinforcers following the target behavior increased the frequency of correct responses in this study. Similar outcomes were observed when reinforcers were presented to children with ASD during an aerobic exercise intervention (Brand et al., 2015) and motor imitation tasks (Miller et al., 2015). Although positive reinforcement is a common strategy in ASD interventions, this study is among the few to directly apply it to the teaching of motor skills. Future research may benefit from incorporating behavior change tactics, such as token economy, task analysis, or prompts and prompt fading, to enhance the acquisition and maintenance of new skills.\u003c/p\u003e\u003cp\u003eDespite the promising outcomes, this study has some limitations. First, the positive changes observed may have been limited by its single-subject research design. Including a larger sample was not feasible due to limited resources and the heterogeneity of ASD symptoms and severity levels. Studies incorporating motor skills with larger samples may be feasible through conducting play-based programs in preschools or early intensive behavioral interventions in the community. Additionally, although implementation fidelity was measured at the parent level, researcher fidelity was not directly assessed. Evaluating both researcher and parent fidelity may clarify the sources of intervention effectiveness. Further studies should evaluate researcher fidelity and the maintenance of parent-acquired skills (Gauert et al., 2023). Finally, this study examined basic locomotor and object control skills, but did not include advanced motor skills. More advanced and complex movement skills such as jumping or hopping are frequently required when engaging in sports or physical activities with peers, particularly in group settings. Studies evaluating motor skills from the perspective of motor development trajectories may enhance our understanding of training effects in children with motor deficits, while also addressing existing limitations in this research area.\u003c/p\u003e\u003cp\u003eIn conclusion, the parent-implemented intervention effectively targeted gross motor and object control skills in a child with ASD. The findings demonstrated that the child exhibited meaningful improvements in motor performance, as evidenced by an improved clinical balance assessment. These functional gains were retained at a three-week follow-up.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSL conceived of the presented idea. SL and YL planned and carried out the experiments. SL took the lead in writing the manuscript. Both authors contributed to the final version of the manuscript. YL supervised the project.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe express our sincere gratitude to the parents who participated in this study for their valuable contributions.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association, DSM-5 Task Force. (2013). \u003cem\u003eDiagnostic and statistical manual of mental disorders\u003c/em\u003e (5th ed.). American Psychiatric Publishing Inc. https://doi.org/10.1176/appi.books.9780890425596\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerg, K.O., Wood-Dauphinee, S.L., Williams, J.I., \u0026amp; Maki, B. (1992) Measuring balance in the elderly: Validation of an instrument. \u003cem\u003eCanadian Journal of Public Health\u003c/em\u003e, \u003cem\u003e82\u003c/em\u003e, 7\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerkeley, S. L., Zittel, L. L., Pitney, L. V., \u0026amp; Nichols, S. E. (2001). Locomotor and object control skills of children diagnosed with autism. \u003cem\u003eAdapted Physical Activity Quarterly\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(4), 405\u0026ndash;416.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrand, S., Jossen, S., Holsboer-Trachsler, E., P\u0026uuml;hse, U., \u0026amp; Gerber, M. (2015). Impact of aerobic exercise on sleep and motor skills in children with autism spectrum disorders: A pilot study. \u003cem\u003eNeuropsychiatric Disease and Treatment\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e, 1911\u0026ndash;1920. https://doi.org/10.2147/NDT.S85650\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarr, J. E. (2005). Recommendations for reporting multiple-baseline designs across participants. \u003cem\u003eBehavioral Interventions, 20\u003c/em\u003e, 219\u0026ndash;224. https://doi.org/10.1002/bin.191\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCihon, J. H., Ferguson, J. L., Lee, M., Leaf, J. B., Leaf, R., \u0026amp; McEachin, J. (2022). Evaluating the cool versus not cool procedure via telehealth. \u003cem\u003eBehavioral Analysis Practice\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e, 260\u0026ndash;268. https://doi.org/10.1007/s40617-021-00553-z\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCooper, J. O., Heron, T. 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Does treatment fidelity of the early start Denver model impact skill acquisition in young children with autism? \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e, 1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-behavioral-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jobe","sideBox":"Learn more about [Journal of Behavioral Education](http://link.springer.com/journal/10864)","snPcode":"10864","submissionUrl":"https://submission.springernature.com/new-submission/10864/3","title":"Journal of Behavioral Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"autism spectrum disorder, balance, gross motor skills, object control skills, parent implemented intervention","lastPublishedDoi":"10.21203/rs.3.rs-6926263/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6926263/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Gross motor skills are important for children's daily activities; however, children with autism spectrum disorder (ASD) often have difficulties in these areas, limiting their participation in everyday life. Therefore, interventions targeting balance skills are crucial for children with ASD. This study examined whether a parent-implemented intervention could improve balance in a boy with ASD, using a multiple-probe design across behaviors. The targeted motor skills included sitting, half-kneeling, standing, and walking, whereas the object-control skills included throwing, catching, and rolling a ball. The target skill was observed for each behavior and the degree of improvement was indicated. Statistical analyses were conducted using the percentage of non-overlapping data (PND) and Tau-U. Additionally, the study used the Pediatric Berg Balance Score. Improvements were observed in gross motor and object control skills and were retained at three weeks post-intervention. These functional gains were reflected in the Pediatric Berg Balance Score. These findings suggest that parent-implemented interventions can improve gross motor and object control skills in children with ASD.","manuscriptTitle":"Effectiveness of a parent-implemented intervention for improving balance in a child with autism spectrum disorder","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 05:33:00","doi":"10.21203/rs.3.rs-6926263/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-27T15:51:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-07T16:53:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258609920330749144041816063722372800999","date":"2025-07-17T17:07:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1088348048947691554977915418864121432","date":"2025-07-15T16:56:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-15T16:28:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-20T13:11:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-20T13:10:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Behavioral Education","date":"2025-06-18T23:49:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-behavioral-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jobe","sideBox":"Learn more about [Journal of Behavioral Education](http://link.springer.com/journal/10864)","snPcode":"10864","submissionUrl":"https://submission.springernature.com/new-submission/10864/3","title":"Journal of Behavioral Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bce2ad90-f1be-4130-97bc-517a9a4c8e9d","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:12:30+00:00","versionOfRecord":{"articleIdentity":"rs-6926263","link":"https://doi.org/10.1007/s10864-026-09627-w","journal":{"identity":"journal-of-behavioral-education","isVorOnly":false,"title":"Journal of Behavioral Education"},"publishedOn":"2026-04-02 15:57:53","publishedOnDateReadable":"April 2nd, 2026"},"versionCreatedAt":"2025-07-23 05:33:00","video":"","vorDoi":"10.1007/s10864-026-09627-w","vorDoiUrl":"https://doi.org/10.1007/s10864-026-09627-w","workflowStages":[]},"version":"v1","identity":"rs-6926263","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6926263","identity":"rs-6926263","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}