J Autism Dev Disord (2016) 46:2275–2284
DOI 10.1007/s10803-016-2755-z
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
Ó 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
& Brooke Ingersoll
ingers19@msu.edu
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
•
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-
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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
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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
J Autism Dev Disord (2016) 46:2275–2284 2277

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.
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.

Design and Procedure Parent Outcomes Measures

Families were administered standardized assessments at Parent Intervention Fidelity

pre-treatment in the lab and family home. Children were
matched within 3 months on expressive language age on Parents were videotaped during a parent–child interaction
the Mullen Scales of Early Learning (MSEL; Mullen 1995) (PCI) in the family home at pre-treatment, post-treatment,
and randomly assigned to the self-directed (n = 13) or and 3-month follow-up. They were asked to: (1) play with

Table 1 Participant flow

through the study Enrollment
Assessed for eligibility (n=29)

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

Randomized (n=28)

Allocation
Allocated to self-directed group (n=13) Allocated to therapist-assisted group (n=15)
Received allocated intervention (n=13) Received allocated intervention (n=15)
Did not receive allocated intervention (n=0) Did not receive allocated intervention (n=0)

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

Analysis
Analysed (n=13) Analysed (n=14)
Excluded from analysis (n=0) Excluded from analysis (family took 14
months to complete due to crisis) (n=1)

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Table 2 Participant demographic information

Group Test statistic p value
Self-directed (n = 13) Therapist-assisted (n = 14)

Parent characteristics
Gender (% female) 92 % 100 % 1.12a .29
Education (% less than college degree) 54 % 36 % .90a .34
a
Marital status (% not married) 8% 29 % 1.95 .16
Employment status (% not employed) 46 % 29 % .65a .42
Residence in underserved area 77 % 64 % .52a .47
Child characteristics
Gender (% female) 39 % 21 % .94a .33
a
Race/ethnicity (% minority) 8% 36 % 3.06 .08
Chronological age (Mos.) 46.08 (13.18) 41.57 (12.24) -.71b .48
Nonverbal mental age (Mos.) 25.42 (13.92) 24.29 (9.38) -.25b .80
Verbal mental age (Mos.) 19.15 (9.63) 21.64 (10.74) .63b .53
Outside intervention (Hrs/wk)c 13.62 (10.96) 12.38 (9.70) -.31b .76
a
Chi-square
b
t test
c
Average of hours received at pre- and post-treatment

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).
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

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
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).

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MacArthur-Bates Communicative Development Inventory Group Assignment

(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.
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 Users receive weekly ‘‘Tip of the Week’’ emails that provide tips for implementing the intervention techniques along
Emails 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 (g2p) F (g2p)

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- 74.77 (13.79) 74.23 (10.42) 75.07 (7.77) 77.00 (11.14) .26 (.01) .83 (.03)
II)
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,
g2p = .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, g2p = .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,
g2p = .29, and a marginally significant time X group
interaction, F(1, 21) = 3.38, p = .08, g2p = .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.
2281
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
123
J Autism Dev Disord (2016) 46:2275–2284
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 (g2p = .08) and child lan-
guage targets (g2p = .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
J Autism Dev Disord (2016) 46:2275–2284
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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