Comparison of a Self-Directed and Therapist-Assisted Telehealth Parent Training Intervention for Children with ASD

Kate Shannon, MS, Natalie Berger, MA, Katherine Pickard, MA, Nikki Bonter, MSW, & Brooke Ingersoll, Ph.D.
Department of Psychology, Michigan State University
Supported by grant #RC063462 from the Department of Defenses Autism Research Program

There is growing interest in expanding telehealth to parent training for ASD, but
research is limited and little is known regarding the relative benefits of selfdirected vs. therapist-assisted models.

OBJECTIVES

Pilot RCT to compare the effect of self-directed and therapist-assisted formats of

ImPACT Online, telehealth-based parent-mediated intervention on parent and
child outcomes.

Parenting Stress
Positive Perceptions of Child

Narrated Slideshow

Parent Sense of Competence Scale

Manual

Family Impact Questionnaire - Negative and Social

Impact subscale items
Family Impact Questionnaire - Positive Impact
subscale items

3.5
3
2.5
2
1.5
1
Pre

Child Measures
Expressive Language Targets
Expressive Vocabulary

MacArthur-Bates Communicative Development

Inventory

Functional Communication

Scales-2nd

Vineland Adaptive Behavior

(VABS-II) Communication Domain

Social Skills

Video-Based Exercises

70

Gender
(% Female)

92%

Reflection Questions

60
55

Education
(% Less than College Degree)
Residence
(% Rural and/or MUA/P area)
Child Characteristics
Gender
(% Female)

54%
77%
Self-Directed
(n=13)

46.08
(13.18)

41.57
(12.24)

Nonverbal Mental Agea

(Months)

25.42
(13.92)

24.29
(9.38)

19.15
(9.63)

21.64
(10.74)

Verbal Mental
(Months)
aMullen

Agea

Scales of Early Learning

2.5

Average Rating

Post

Self-Directed
300
200
100

Pre

Parenting Stress (FIQ)

Functional Communication (VABS-II)

Self-Directed
Therapist-Assisted

Main effect of time, F(1, 25)

=6.53, p<.05, p2=.21. Both
groups improved to similar
degree.

Post

90
85

Main effect of time, F(1, 25) =6.10,

p<.05, p2=.20. Both groups
improved to a similar degree.

Video Library

Moderated Forum

Pre

Self-Directed
Therapist-Assisted

80
75
70

Self-Directed
Therapist-Assisted

1.5
1

0.5

Remote Coaching
Review and Problem-Solving

60

Post

Pre

Positive Perceptions of Child (FIQ)

2.5

Therapist-Assisted
(n=14)

Chronological Age
(Months)

0.5

65

64%

21%

0.5

36%

39%

Main effect of time, F(1, 25)

=18.53, p<.01, p2=.43. Both
groups improved to a similar
degree.

Post

1.5

Therapist-Assisted
(n=14)
100%

1.5

Expressive Vocabulary (MCDI)

Main effect of time, F(1, 25)=

10.98, p<.01, p2=.31. Both
groups improved to similar
degree.

65

Pre

Average Rating

Participants

27 children between 19 and 73 months and their mothers.

ASD diagnoses provided by community providers and confirmed using DSM-IV-TR

criteria and ADOS-2.
Procedure

Assessments of child and parent functioning, and a parent-child interaction were

administered at pre-treatment (see Table 1).

Children were matched on expressive language age on Mullen and randomly

assigned to the self-directed or therapist-assisted group (see Table 2).

Parents in both groups received ImPACT Online for up to 6 months (see Table 3).
Self-directed group: Parents completed 12 internet modules on their own
over the course of 4 months.
Therapist-assisted group: Parents completed 12 internet modules plus 2, 30min remote coaching sessions per week from coach for 12 weeks.

Assessments were re-administered at post-treatment.

Data Analysis

ITT analysis (missing data was carried forwarded)

Mixed model, repeated-measures ANOVA to compare the effect of self-directed

and therapist-assisted ImPACT Online on parent and child outcomes.

Parent Characteristics

40

Homework Plan

Self-Directed
Therapist-Assisted

Pre

45

TABLE 2: PARTICIPANT CHARACTERISTICS

Self-Directed
(n=13)

2.5

400

50

Edition

Vineland Adaptive Behavior Scales-2nd Edition

(VABS-II) Social Domain

Self-Directed
Therapist-Assisted

75

Self-Check Quiz

Main effect of time, F(1, 25)=31.33,

p<.01, p2=.56. Both groups
improved.
Marginal interaction, F(1, 25)=3.38,
p=.078, p2=.12. Therapist-assisted
group had marginally greater gains
than self-directed group.

Parent Self-Efficacy (PSOC)

METHOD

Post

80

Frequency of language targets during parent-child

interaction

Main effect of time, F(1, 25)=65.78,

p<.01, p2=.72. Both groups
improved.
Interaction, F(1, 25)= 10.76, p<.01,
p2=.30. Therapist-assisted group
made greater gains than selfdirected group.

Rate per minute

Parent Self-Efficacy

Self-Directed Interactive Modules

Number of Words
Produced

Telehealth, the provision of health information over the internet, can increase
service access at a reduced cost.

Parent Fidelity

Self-Directed
Therapist-Assisted

4.5

Standard Score

Access to parent-mediated intervention services is often limited in rural and

under-resourced areas.

Behavioral rating during parent-child interaction (10min Play and Snack Routine)

Expressive Language Targets (PCI)

Parent Fidelity (PCI)

Post

Social Skills (VABS-II)

Main effect of time, F(1, 25)=13.31,

p<.01, p2=.35.
Interaction, F(1, 25)=8.27, p<.01,
p2=.25. Therapist-assisted group
made gains, but self-directed group
did not.

90

Interaction, F(1, 25) =4.97, p<.05,

p2=.17. Therapist-assisted group
made gains, but self-directed
group did not.

85

Standard Score

Parent-mediated intervention for children with ASD can improve both parent and
child functioning.

Adapted from Project ImPACT (Ingersoll & Dvortcsak, 2010)

Total Score

Parent Measures

Average Fidelity Rating

BACKGROUND

RESULTS CHILD OUTCOMES

RESULTS PARENT OUTCOMES

TABLE 3: ImPACT ONLINE

TABLE 1: OUTCOME MEASURES

80

Self-Directed
Therapist-Assisted

75
70
65
60

0
Pre

Pre

Post

Post

Coaching and Feedback

CONCLUSIONS
Both approaches show promise for increasing parents use of evidence-based intervention techniques to promote their childs social communication.
The self-directed program was effective for improving parent fidelity of implementation, parent self-efficacy, parenting stress, and child language. However, therapist
assistance via remote coaching provided an added benefit for improving parent fidelity and some aspects of child language. Gains in parent positive perceptions of
their child and child social skills were only observed in the therapist-assisted group. A full scale efficacy trial with a control group is warranted.
Additional research that can identify parents who are most likely to need remote coaching would assist in the development of a stepped care model that can increase
parent access to evidence-based services in underserved communities.