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ORIGINAL PAPER

Comparison of a Self-Directed and Therapist-Assisted Telehealth Parent-Mediated Intervention for Children with ASD: A Pilot RCT

Brooke Ingersoll1 • Allison L. Wainer1,2 • Natalie I. Berger1 • Katherine E. Pickard1 •

Nicole Bonter1

Published online: 27 February 2016

� Springer Science+Business Media New York 2016

Abstract This pilot RCT compared the effect of a self-

directed and therapist-assisted telehealth-based parent-

mediated intervention for young children with ASD.

Families were randomly assigned to a self-directed or

therapist-assisted program. Parents in both groups

improved their intervention fidelity, self-efficacy, stress,

and positive perceptions of their child; however, the ther-

apist-assisted group had greater gains in parent fidelity and

positive perceptions of child. Children in both groups

improved on language measures, with a trend towards

greater gains during a parent–child interaction for the

therapist-assisted group. Only the children in the therapist-

assisted group improved in social skills. Both models show

promise for delivering parent-mediated intervention; how-

ever, therapist assistance provided an added benefit for

some outcomes. A full-scale comparative efficacy trial is

warranted.

Keywords Autism � Parent training � Telehealth

Introduction

Autism spectrum disorder (ASD) is characterized by per-

vasive deficits in social communication and the presence of

restricted and repetitive behaviors (American Psychiatric

Association 2013). Individuals with ASD often require

intensive and comprehensive intervention across the life

span (National Research Council 2001). There has been a

dramatic increase in the number of individuals with this

diagnosis over the last two decades (Fombonne 2009)

without a corresponding growth in the availability of evi-

dence-based intervention services, which has contributed to

high levels of unmet service needs for individuals with

ASD and their families (Bitterman et al. 2008; Kogan et al.

2008). Thus, systematic research examining strategies for

increasing access to evidence-based ASD services is a high

priority.

Parent-mediated intervention (PMI) programs are one

potentially cost-effective strategy to increase access to

evidence-based ASD intervention. Teaching parents to

provide intervention themselves can increase the number of

intervention hours a child receives and has been shown to

result in improvements in child social-communication

skills (e.g., Kasari et al. 2015; Wetherby et al. 2014) and

parent well-being (Keen et al. 2010). Yet, formal PMI

programs are rare in community-based settings for young

children with ASD (Thomas et al. 2007a, b). Barriers

include a shortage of trained professionals, lengthy wait-

lists, limited financial resources and transportation, lack of

child care, geographic isolation, and time limitations (Sy-

mon 2005). Thus, it is essential to consider the adaptation

of evidence-based PMI to non-traditional service delivery

models.

Telehealth, or the provision of health services and

information over the Internet and related technologies, has

the potential to replace or augment traditional service

models to increase access to evidence-based intervention

(Baggett et al. 2010; United States Department of Educa-

tion, Office of Planning, Evaluation, and Policy Develop-

ment 2010). Telehealth programs can reduce costs and

increase provider system coverage relative to traditional in-

& Brooke Ingersoll [email protected]

1 Department of Psychology, Michigan State University, 316

Physics Rd., East Lansing, MI 48824, USA

2 Present Address: Rush University Medical Center, Chicago,

IL, USA

123

J Autism Dev Disord (2016) 46:2275–2284

DOI 10.1007/s10803-016-2755-z

person service delivery models (Gros et al. 2013). Such

programs have improved care for patients with chronic

diseases (Wootton 2012), and increased access to evidence-

based health promotion, psychological, and parenting

interventions (e.g., Andersson and Cuijpers 2009; Krebs

et al. 2010; Nieuwboer et al. 2013). Patients report high

levels of satisfaction with care received via telehealth

(Gustke et al. 2000) and efficacy studies have found

moderate to large effects of telehealth interventions on

participant knowledge and behavior change (Andersson

and Cuijpers; Krebs et al.; Nieuwboer et al. 2013). Further,

several meta-analyses have found that cognitive behavioral

therapy (CBT) delivered via telehealth is as effective as

traditional therapy (Andrews et al. 2010).

Telehealth interventions can be either self-directed (i.e.,

participant independently engages with the interactive

program) or therapist-assisted (i.e., participant receives

additional guidance from a professional as part of the

program). Self-directed programs have greater dissemina-

tion potential as they do not require a trained professional

and can typically be administered at a reduced cost.

However, therapist-assisted CBT telehealth programs typ-

ically lead to better patient outcomes than self-directed

programs (Andersson and Cuijpers 2009; Spek et al. 2007).

This finding may be particularly relevant for telehealth

PMIs, as research suggests that parent coaching is impor-

tant for increasing parents’ fidelity of implementation

(Kaminski et al. 2008).

Empirical evaluations of telehealth PMI programs for

children with ASD are limited. Several uncontrolled stud-

ies have demonstrated the feasibility, acceptability, and

initial effectiveness (i.e., gains in parent knowledge) of

self-directed telehealth PMI programs (Hamad et al. 2010;

Jang et al. 2012; Kobak et al. 2011). A small RCT (n = 27)

found that parents who received a DVD-based self-directed

program made greater gains in their use of pivotal response

treatment (PRT) strategies, provided more language

opportunities, and were rated as displaying greater parent

confidence during a 10-min parent–child observation in the

home than parents in a no-treatment control group (Nefdt

et al. 2009). In addition, their children demonstrated

greater gains in their rate of functional verbal utterances

during the parent–child interaction. A single-case design

study (n = 3) demonstrated that parents improved their use

of reciprocal imitation training (RIT) strategies after

completing a web-based self-directed program (Wainer and

Ingersoll 2013), and their children increased their rate of

imitative toy play during parent–child interactions.

Importantly, parents in both studies indicated that coaching

from a professional would have been beneficial.

Several single-case design studies have examined the

efficacy of therapist-assisted telehealth PMI programs for

children with ASD. Across two studies, Vismara and

colleagues examined the ability of a DVD-based (n = 8) or

web-based tutorial (n = 9) in conjunction with weekly

coaching sessions via video-conferencing to teach parents

to use the Early Start Denver Model (ESDM) (Vismara

et al. 2012, 2013). Parents in both studies increased their

use of the ESDM intervention strategies and positively

altered their engagement styles during parent–child inter-

actions in response to the program. Furthermore, their

children demonstrated gains in functional verbal utterances

and imitative play actions. To evaluate the relative con-

tributions of self-directed instruction and therapist assis-

tance on parent learning, Wainer and Ingersoll (2015)

conducted a second study (n = 5) that measured parents’

use of RIT at baseline, after a self-directed web-based

tutorial, and then again after receiving coaching via video-

conferencing. Similar to their previous study (Wainer and

Ingersoll 2013), all parents improved their use of RIT

strategies during parent–child interactions in response to

the self-directed program, but roughly a third showed

additional benefit from remote coaching. In addition, most

children demonstrated gains in imitative play with the

onset of treatment; however, child gains were most robust

when parents received coaching.

These preliminary findings suggest telehealth PMI pro-

grams are acceptable to parents of children with ASD, and

can improve parent knowledge and intervention use and

child social communication skills. To date, no studies have

conducted a head-to-head comparison of self-directed and

therapist-assisted telehealth PMI. Data thus far suggest

therapist assistance may be necessary for some, but not all

parents to implement interventions with fidelity. A better

understanding of the contributions of self-directed

instruction and therapist assistance will make it possible to

develop more cost-effective delivery models in which

services are offered at different levels of intensity,

depending on family needs (i.e., stepped-care) (Phaneuf

and McIntyre 2011; Steever 2011). Pilot studies enhance

the likelihood of success of randomized controlled trials

(RCT) (e.g., Campbell et al. 2007). Thus, the goal of this

pilot study was to compare the effect of self-directed and

therapist-assisted delivery models of ImPACT Online, a

telehealth PMI program that targets social communication

using a naturalistic, developmental-behavioral intervention

(NDBI) (Schreibman et al. 2015), on key parent and child

outcomes in preparation for a fully powered RCT.

Method

Participants

Twenty-eight families of a child with ASD between the

ages of 19 and 73 months participated. Participants were

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recruited from agencies serving children with ASD. All

children met criteria for Autistic Disorder or PDD-NOS

based on DSM-IV criteria (American Psychiatric Associ-

ation 2000) and the ADOS-G or ADOS-2 (Lord et al.

2000). Parents had to be proficient in English, although

other languages could be spoken in the home. One family

who was assigned to the therapist-assisted group had to

suspend treatment after 2 months due to significant health

problems. After a 7-month break, the family finished the

program; however, the time between their pre- and post-

treatment assessments (14 months) was not comparable to

the other participants’. Thus, their data were not included

in the analyses. All parents gave informed consent under

the oversight of Michigan State University’s IRB.

Design and Procedure

Families were administered standardized assessments at

pre-treatment in the lab and family home. Children were

matched within 3 months on expressive language age on

the Mullen Scales of Early Learning (MSEL; Mullen 1995)

and randomly assigned to the self-directed (n = 13) or

therapist-assisted group (n = 14) using a coin flip.

Assessments were re-administered at post-treatment and

3-month follow-up in the family home. See Table 1 for

participant flow through the study.

Eligibility and Sample Characteristics Measures

Parents provided information on family and child demo-

graphics at pre-treatment. They also provided information

on hours per week of all non-study treatments at pre- and

post-treatment. Children were administered the ADOS-G

or ADOS-2 to determine study eligibility and the MSEL as

a measure of developmental functioning. See Table 2 for

participant demographic information.

Parent Outcomes Measures

Parent Intervention Fidelity

Parents were videotaped during a parent–child interaction

(PCI) in the family home at pre-treatment, post-treatment,

and 3-month follow-up. They were asked to: (1) play with

Table 1 Participant flow through the study Assessed for eligibility (n=29)

Excluded (n=1) Not meeting inclusion criteria (n=1) Declined to participate (n=0) Other reasons (n=0)

Analysed (n=13) Excluded from analysis (n=0)

Lost to follow-up (n=0) Discontinued intervention (did not have time; family crisis; began intensive program) (n=4)

Allocated to self-directed group (n=13) Received allocated intervention (n=13) Did not receive allocated intervention (n=0)

Lost to follow-up (n=0) Discontinued intervention (n=0)

Allocated to therapist-assisted group (n=15) Received allocated intervention (n=15) Did not receive allocated intervention (n=0)

Analysed (n=14) Excluded from analysis (family took 14

months to complete due to crisis) (n=1)

Allocation

Analysis

Follow-Up

Randomized (n=28)

Enrollment

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their child for 10 min; and (2) have a snack with their

child. Parent behavior was scored for correct use of the

intervention using the Project ImPACT fidelity checklist

(Ingersoll and Dvortcsak 2010). Fidelity ratings for the

play and snack routines were averaged to form an overall

fidelity rating for each time point. Reliability was calcu-

lated for 20 % of the observations using intra-class corre-

lation (ICC = .96, p \ .001).

Parent Sense of Competence Scale (PSOC)

Parents completed the PSOC (Gibaud-Wallston and Wan-

dersmann 1978) at pre- and post-treatment as a measure of

parent self-efficacy. Parents rated items from 1 (‘‘Strongly

agree’’) to 6 (‘‘Strongly disagree’’) with higher scores

indicative of higher parenting self-efficacy. Missing item

level data (\5 %) were imputed by using the participant’s average for the scale. Cronbach’s alpha was .85.

Family Impact Questionnaire (FIQ)

Parents completed the FIQ (Donenberg and Baker 1993) at

pre- and post-treatment as a measure of the impact of their

child on their family life. Parents endorse items on a

4-point scale, with higher scores indicating greater impact.

The average of the negative and social impact subscales

was used as a measure of parenting stress, and the positive

impact subscale was used as the measure of positive per-

ceptions of the child. Missing item level data (\5 %) were

imputed by using the participant’s average for the scale.

Cronbach’s alphas ranged from .86 to .92 for the parenting

stress items and from .81 to .86 for the positive impact

subscale.

Child Outcome Measures

Language Targets

The children’s use of language targets was scored during

the PCI at pre, post, and follow-up. Language that was at or

above the child’s targeted language level and used appro-

priately was scored using frequency counts and converted

to rate per minute. Language targets were determined at

intake based on the child’s spontaneous language during

standardized and observational assessments using Tager-

Flusberg et al. (2009) framework for defining spoken lan-

guage benchmarks for children with ASD. Language acts

were scored if they were at or above the child’s current

expressive language phase, which included word approxi-

mations for children at the preverbal communication stage,

single words for children at the first words stage, phrase

speech for children at the word combinations stage, and

grammatically correct sentences for children at the sen-

tences stage. Both prompted and spontaneous use of lan-

guage targets was scored. Data from the play and snack

routines were averaged to form an overall rate of language

targets for each time point. Reliability was calculated for

25 % of the observations (ICC = .98, p \ .001).

Table 2 Participant demographic information

Group Test statistic p value

Self-directed (n = 13) Therapist-assisted (n = 14)

Parent characteristics

Gender (% female) 92 % 100 % 1.12 a

.29

Education (% less than college degree) 54 % 36 % .90 a

.34

Marital status (% not married) 8 % 29 % 1.95 a

.16

Employment status (% not employed) 46 % 29 % .65 a

.42

Residence in underserved area 77 % 64 % .52 a

.47

Child characteristics

Gender (% female) 39 % 21 % .94 a

.33

Race/ethnicity (% minority) 8 % 36 % 3.06 a

.08

Chronological age (Mos.) 46.08 (13.18) 41.57 (12.24) -.71 b

.48

Nonverbal mental age (Mos.) 25.42 (13.92) 24.29 (9.38) -.25 b

.80

Verbal mental age (Mos.) 19.15 (9.63) 21.64 (10.74) .63 b

.53

Outside intervention (Hrs/wk) c

13.62 (10.96) 12.38 (9.70) -.31 b

.76

a Chi-square

b t test

c Average of hours received at pre- and post-treatment

2278 J Autism Dev Disord (2016) 46:2275–2284

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MacArthur-Bates Communicative Development Inventory

(MCDI)

Parents completed the MCDI at pre and post as a measure

of their child’s expressive vocabulary (Fenson et al. 2006).

The total number of words reported as ‘‘understands and

says’’ (Words and Gestures Form) or ‘‘words produced’’

(Word and Sentences Form) was used. Test–retest relia-

bility of the MCDI is .95 (Fenson et al. 1994). The MCDI

was missing at pre-treatment for one participant.

Vineland Adaptive Behavior Scales, Second Edition

(VABS-II)

Parents were interviewed on the VABS-II at pre and post

(Sparrow et al. 2005). The VABS-II is a standardized

parent interview that assesses child adaptive functioning in

four domains: Communication, Socialization, Daily Living

Skills, and Motor Skills. Each domain yields a standard

score with a mean of 100 and a standard deviation of 15.

Test–retest reliability estimates range from .88 to .92 for

the domain scores. Given the focus of ImPACT Online

(social communication development), we expected

improvement in standard scores on the Social and Com-

munication domains indicating accelerated development.

As a comparison, we examined changes on the Daily

Living and Motor Skills domains, with no expectation for

improvement. The VABS was missing at post-treatment for

one participant.

Group Assignment

Self-Directed Group

The self-directed group received access to the secure,

password-protected, ImPACT Online website for

6 months. The content was adapted from Project ImPACT

(Ingersoll and Dvortcsak 2010), a NDBI-based PMI for

young children with ASD targeting social communication

development. The website contained 12, self-directed les-

sons; each took approximately 75 min to complete. Parents

were encouraged to complete one lesson per week and to

practice the intervention with their child between each

lesson. Parents were able to contact project staff for

assistance with technology-related problems, but received

no staff support in learning the intervention. See Table 3

for description of the ImPACT Online program

components.

Therapist-Assisted Group

The therapist-assisted group was given access to the

ImPACT Online website for 6 months and was encouraged

to work through the program at the same pace as the self-

directed group. These parents also received 2, 30 min

coaching sessions per week (24 total) from a trained ther-

apist via video-conferencing. The first coaching session of

each week was used to clarify the lesson content and help

parents apply the information to their child. The second

Table 3 ImPACT online program components

Primary lesson components

Slideshow Users watch narrated slideshow with embedded video examples of techniques

Manual Users read the manual which provides a written description of lesson that corresponds to slideshow

Self-check Users answer comprehension check questions based on content of slideshow. The program provides automated positive

and corrective feedback

Exercises Users observe brief video clips and must indicate whether technique is implemented correctly or incorrectly. The

program provides automated positive and corrective feedback

Homework Users complete a homework plan that outlines techniques and activities in which to practice. These responses are

available to the coach for the therapist-assisted group

Reflection Users complete reflection questions based on their practice. These responses are available to the coach for the therapist-

assisted group

Supplemental components

Video library Users can observe longer videos of adults using the intervention techniques together with children at different language

levels

Forum Users can share information with other participants and post content-related questions and receive feedback from project

staff

Resources Users can access paper copies of all forms, additional information on the evidence-base for this intervention, and links to

relevant websites

Tip of the week

Emails

Users receive weekly ‘‘Tip of the Week’’ emails that provide tips for implementing the intervention techniques along

with a link to the program

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session of the week was used to provide parents with live

feedback on their intervention use with their child.

Coaching was provided by masters’ level therapists trained

to fidelity. Coaches used a fidelity checklist to rate their

fidelity to the coaching procedure at the end of each ses-

sion. Average self-assessed fidelity across sessions was

99.6 %. A random sample of 10 % of coaching sessions

were scored by independent raters for reliability using

exact agreement. Reliability for coaching fidelity was

97.8 %.

Results

Analytic Strategy

We used an Intention-to-Treat model (ITT) which requires

that all randomly assigned participants be compared on

outcomes regardless of adherence to treatment, reasons for

withdrawal, or missing responses (Moher et al. 2001).

Accordingly, we included all participants in the data

analysis, followed up participants who discontinued treat-

ment, and imputed missing data. Four parents, all in the

self-directed group, did not complete the program, which

represented a significant group difference in rate of pro-

gram completion, v2 (n = 27) = 5.06, p = .03. We obtained post-treatment data for these families on all

measures, with the exception of the VABS-II and PCI for

one family. The MCDI was missing for one child in the

therapist-assisted group at pre-treatment. We used partici-

pants’ data from the opposite point of treatment for the

missing data point. We collected follow-up 3-month PCI

data from the 23 parents who completed the program. For

these data, we conducted a completer analysis only.

Transformations were applied to non-normal data as

appropriate. VABS-II data remained non-normal after

multiple transformation attempts, potentially due to out-

liers. We report analyses for the VABS-II with non-normal

data as ANOVA is robust to this violation.

Independent t tests and Chi-square tests revealed no

statistically significant group differences on any pre-treat-

ment variables, although a marginally significant group

difference (p = .08) was observed in the percent of chil-

dren who were minorities. To determine the effect of the

intervention on parent and child outcomes, we conducted a

series of mixed-model repeated measures ANOVAs with

time (pre, post) as the within group variable and group

(self-directed, therapist-assisted) as the between group

variable. We conducted a second set of mixed-model

repeated measures ANOVAs on the follow-up PCI data

with time (pre, follow-up) and group as the within and

between group variables. Post hoc comparisons of simple

effects of significant interactions were conducted using

relevant t tests. See Table 4 for ANOVA results for out-

come variables.

Parent Outcomes

There was a significant main effect of time for parent

fidelity, such that parents were rated higher on their use of

the intervention at post-treatment. There was also a sig-

nificant time X group interaction, indicating the therapist-

assisted group made greater gains in fidelity than the self-

directed group. Post-hoc tests of simple effects suggested

Table 4 ANOVA results for outcome variables

Outcome measure Self-directed group Therapist-assisted group Effects

Pre Post Pre Post Time Time X group

Mean (SD) Mean (SD) Mean (SD) Mean (SD) F (gp 2 ) F (gp

2 )

Parent fidelity (PCI) 1.77 (.67) 2.52 (.78) 1.62 (.37) 3.39 (.76) 65.78** (.72) 10.76** (.30)

Parent self-efficacy (PSOC) 53.23 (13.14) 58.62 (12.12) 54.60 (14.81) 61.43 (13.27) 10.98** (.31) .15 (.006)

Parenting stress (FIQ) 1.24 (.84) 1.04 (.61) 1.02 (.46) .69 (.30) 6.53* (.21) 2.18 (.08)

Parent positive perceptions (FIQ) 1.52 (.58) 1.60 (.50) 1.40 (.72) 2.06 (.56) 13.31** (.35) 8.27** (.25)

Child language targets (PCI) 1.36 (1.53) 1.95 (1.08) .65 (.52) 1.80 (1.00) 31.33** (.56) 2.84 ? (.10)

Child vocabulary (MCDI) 144.69 (146.21) 210.38 (187.46) 185.114 (202.17) 243.64 (237.94) 18.53** (.43) 1.17 (.05)

Child communication (VABS-II) 71.50 (15.57) 75.33 (12.40) 70.29 (11.28) 77.36 (13.79) 6.10* (.20) .68 (.03)

Child social skills (VABS-II) 71.00 (8.05) 70 .00 (7.56) 70.00 (6.95) 75.71 (9.07) 2.58 (.09) 4.94* (.17)

Child daily living skills (VABS-

II)

74.77 (13.79) 74.23 (10.42) 75.07 (7.77) 77.00 (11.14) .26 (.01) .83 (.03)

Child motor skills (VABS-II) 81.85 (11.47) 82.85 (9.74) 83.36 (8.87) 83.14 (11.27) .08 (.003) .18 (.007)

** \.01; * \.05; ? .10

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both groups had higher fidelity ratings at post- than pre-

treatment (ps \ .01), and at post-treatment, the therapist- assisted group was significantly higher than the self-di-

rected group (p \ .01). At follow-up, there was a signifi- cant main effect of time, F(1, 21) = 44.26, p \ .001, gp 2 = .68, suggesting that the benefits of the program on

parent fidelity maintained. The time X group interaction

was not significant, F(1, 21) = 1.17, p = .29, gp 2 = .05,

suggesting that the therapist-assisted group (M = 3.00,

SD = .66) no longer showed an advantage over the self-

directed group (M = 2.57, SD = 1.21) at follow-up,

although their mean fidelity ratings remained higher.

There was a significant main effect of time on parent

self-efficacy, such that parents in both groups rated them-

selves as more efficacious at post-treatment. There was no

significant effect of group or time X group interaction.

There was a main effect of time on parenting stress, such

that parents in both groups rated themselves as less stressed

at post-treatment, but no significant main effect of group or

time X group interaction. Finally, there was a significant

main effect of time and time X group interaction for pos-

itive perceptions of the child. Post-hoc tests suggested that

the therapist-assisted group had significant (p = .001) and

the self-directed group had marginally significant (p = .09)

increases in their positive perceptions of their child, and the

therapist-assisted group had significantly more positive

perceptions than the self-directed group at post-treatment

(p = .03).

Child Outcomes

There was a significant main effect of time on language

targets during the PCI, indicating improvement in child

language use over time. There was also a marginally sig-

nificant time X group interaction (p = .10), suggesting that

the children in the therapist-assisted group made margin-

ally more gains in their use of language targets than the

self-directed group. Post-hoc tests indicated children in

both groups exhibited significant gains in their language

targets from pre- to post-treatment (ps \ .05), but there were no differences between groups at post-treatment. At

follow-up, there was a significant main effect of time on

child language targets, F(1, 21) = 8.59, p = .008,

gp 2 = .29, and a marginally significant time X group

interaction, F(1, 21) = 3.38, p = .08, gp 2 = .14. Post-hoc

tests indicated language targets were higher at follow-up

(M = 1.71, SD = 1.28) than pre-treatment for the thera-

pist-assisted group (p = .003). The difference in language

targets from pre-treatment (M = 1.50, SD = 1.81) to fol-

low-up (M = 1.64, SD = 1.21) was not significant for the

self-directed group, although the trend was in the expected

direction. There were no group differences in language

targets at follow-up.

On the MCDI and VABS-II Communication domain,

there was a main effect of time, but no effect of group or

time X group interaction, suggesting that children in both

groups improved their language skills on these measures

from pre- to post-treatment. On the VABS-II Social

domain, there were no main effects of time or group;

however, there was a significant time X group interaction.

Post-hoc tests suggested that the children in the therapist-

assisted group exhibited significant increases in their

standard scores (p = .04), while the children in the self-

directed group did not. At post-treatment, the therapist-

assisted group had marginally higher standard scores than

the self-directed group (p = .08).

No significant main effects of time or group and no

significant time X group interactions were observed for the

VABS-II Daily Living or Motor Skills domains.

Discussion

This pilot RCT compared the effect of a self-directed and a

therapist-assisted telehealth PMI for children with ASD on

parent and child outcomes. Parents in both groups

improved their fidelity. This finding suggests the self-di-

rected website was sufficient for increasing parent inter-

vention use and provides additional support for the benefits

of self-directed telehealth programs for increasing parents’

skills (Nefdt et al. 2009; Wainer and Ingersoll 2013).

However, parents in the therapist-assisted group made

greater gains in their use of the intervention. Similar

findings were observed regarding parents’ perceptions of

their child; parents in the therapist-assisted group had

greater increases in their positive perceptions of their child

than the self-directed group.

These findings are consistent with research on the ben-

efits of coaching in traditional PMI (Kaminski et al. 2008),

and suggest that coaching may be important for maximiz-

ing parent gains from telehealth PMI as well. Coaching

provides parents with feedback on their intervention use

and highlights its impact on their child’s behavior. Parents

who received coaching likely thus developed a greater

understanding of their child’s skills and a better apprecia-

tion for the impact of their own behavior on their child’s,

potentially improving their positive perceptions of their

child. Higher rates of program completion among the

therapist-assisted group may also have contributed to

observed group differences. Indeed, these parents were

significantly more likely to complete the program (100 %)

than parents in the self-directed group (69 %). Thus,

therapist assistance may be important not only for pro-

viding parents with feedback on their use of the interven-

tion and highlighting child skills, but also for encouraging

higher levels of engagement with the program in general,

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both of which may influence parent fidelity and/or positive

child perceptions. Given that program completion was

related to increases in parent fidelity (Ingersoll and Berger

2015), this is a distinct possibility. Either way, there

appears to be a benefit of therapist assistance on these two

parent outcomes. Additional research that can examine

which aspects of therapist assistance are most important

would be beneficial.

Improvements were also observed for parent self-effi-

cacy and parenting stress. This finding is important as

parents of children with ASD often experience lower self-

efficacy and higher stress than other parents (Hayes and

Watson 2013), and both are related to parent well-being

(Carter 2009; Karst and Hecke 2012). Interestingly, there

were no group differences in these parent outcomes. These

findings suggest that the self-directed program may be

sufficient for increasing parent well-being. Perhaps parents

who receive instruction in strategies to help their child

experience a greater sense of empowerment or agency,

regardless of instructional format. Indeed, parent empow-

erment and agency are associated with greater self-efficacy

and lower parenting stress in families of children with ASD

(Kuhn and Carter 2006). Future research that can identify

those components most likely to improve parent self-effi-

cacy and parenting stress would be informative. We also

found evidence for improvement in children’s social

communication skills. Although the groups did not differ in

the degree of improvement on the two parent-reported

language measures, the children in the therapist-assisted

group made marginally greater gains in their language

targets during the PCI than the self-directed group. These

findings suggest that both the self-directed and therapist-

assisted formats may be effective for increasing child

communication skills, although there may be a small

benefit of therapist assistance, as observed within the PCI.

In contrast, only the therapist-assisted group made

improvements in their social skills on the VABS-II. Studies

examining parent-mediated social communication inter-

ventions for young children with ASD have more often

reported improvements in child language than social skills

(McConachie and Diggle 2007). Social skills may be less

amenable to treatment than language, and as such, therapist

assistance may be necessary to help parents improve their

child’s social development. For this study, we had only one

broad measure of social skills. Thus, it is possible that we

would have observed improvements in the self-directed

group as well, had we used a more sensitive measure or

examined specific skills. Future research that can determine

which social skills are most responsive to the intervention,

as well as the potential benefit of the self-directed program

on specific social skills is necessary.

A major limitation to this study is the small sample size

inherent in a pilot study. Our small sample and resultant

limited power may have contributed to our failure to

identify group differences in treatment response for several

of our outcome measures. For example, despite not

reaching significance, the effect sizes for the time X group

interactions for parenting stress (gp 2 = .08) and child lan-

guage targets (gp 2 = .10) were in the moderate range,

suggesting that with a larger sample size, these interactions

would likely have become significant. A power analysis

suggested that we would have needed a sample size of 60

to detect significant differences for effect sizes in this

range.

In addition, while we were able to establish an effect of

therapist assistance for those outcomes for which the

therapist-assisted group demonstrated greater improvement

than the self-directed group, without a no-treatment control

group, we cannot conclude that the improvements observed

in the self-directed group were a result of treatment. Sim-

ilarly, we cannot rule out maturation or placebo effects for

those outcomes for which both groups improved to the

same degree. We were, however, able to compare child

changes across VABS-II domains. As predicted, we found

improvements for only those domains targeted by the

program, suggesting that maturation or a placebo effect

(i.e., parent reporting bias) were unlikely solely responsible

for gains in child skills. However, additional research that

includes a web-based control is necessary to establish the

effect of both formats on parent and child functioning.

One additional limitation is that our treatment groups

differed in number of children from minority backgrounds,

with a larger number of minority children in the therapist-

assisted group (36 %) than the self-directed group (8 %). It

is not clear to what extent this might have impacted the

findings. Child minority status was not associated with rate

of parent program engagement (Ingersoll and Berger 2015)

for either group. However, it is possible that it might

impact other aspects of the treatment process. Future

research should examine the degree to which racial/ethnic

background and other demographic variables might affect

treatment response.

These data contribute to the growing empirical support

for the benefits of parent-mediated NDBIs on parent and

child outcomes (Schreibman et al. 2015), and provide

further support for the ability of telehealth to teach parents

to deliver these interventions (Nefdt et al. 2009; Vismara

et al. 2013; Wainer and Ingersoll 2015). These pilot data

suggest a potential role for both self-directed and therapist-

assisted programs for increasing parent access to evidence-

based interventions, and suggest the potential benefit of

supplementing telehealth interventions with therapist sup-

port. In addition, these data strongly support conducting a

fully powered comparative efficacy trial to examine

mediators and moderators of treatment. Such a study

should identify which outcomes are best targeted by each

2282 J Autism Dev Disord (2016) 46:2275–2284

123

format, as well as which parents and children benefit from

the different levels of care. The ultimate goal is to develop

a stepped-care model that can increase access to evidence-

based interventions, and reduce the high level of unmet

needs experienced by families of children with ASD.

Acknowledgments This project was supported by CDMRP Grant: #W81XWH-10-1-0586. The first author receives royalties from the

sale of the manual that was adapted for use in the online tutorial.

Royalities are donated to the research. We thank the families who

participated in this study.

Author Contributions BI conceived of the study, participated in its design and coordination and drafted the manuscript; ALW, NIB, and

KEP performed the measurement and participated in its design and

coordination and helped to draft the manuscript. NB performed the

measurement and participated in the study’s coordination. All authors

read and approved the final manuscript.

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