651064

research-article2016
FOAXXX10.1177/1088357616651064Focus on Autism and Other Developmental DisabilitiesVismara et al.

Article
Focus on Autism and Other

Telehealth Parent Training in the Early

Developmental Disabilities
2018, Vol. 33(2) 67­–79
© Hammill Institute on Disabilities 2016
Start Denver Model: Results From a Reprints and permissions:
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Randomized Controlled Study DOI: 10.1177/1088357616651064

focus.sagepub.com

Laurie A. Vismara, PhD1, Carolyn E. B. McCormick, PhD1,

Amy L. Wagner, MEd, MS2, Katernia Monlux, MS1, Anna Nadhan, BS3,
and Gregory S. Young, PhD1

Abstract
Telehealth training may benefit parents’ use of early intervention for children with autism spectrum disorder (ASD).
This study is one of the few randomized trials to compare telehealth parent training in the Early Start Denver Model
(P-ESDM) with a community treatment-as-usual, early intervention program. Parents were randomized to 12 weekly 1.5-
hr videoconferencing sessions with website access to P-ESDM learning resources or to monthly 1.5-hr videoconferencing
sessions with website access to alternative resources to support their intervention. Telehealth training facilitated higher
parent fidelity gains and program satisfaction for more of the P-ESDM than the community group at the end of the 12-week
training and at follow-up. Children’s social communication skills improved for both groups regardless of parent fidelity.
Findings suggest the feasibility of telehealth training with improved parent intervention usage and satisfaction from the
program. However, the impact of these effects on children’s development over time is yet to be understood.

Keywords
autism spectrum disorders, parent training, early intervention

With the newest estimate of 1 in 68 children in the United parents’ understanding, retention, and use of early interven-
States with an autism spectrum disorder (ASD; Centers for tion with children with ASD (Baggett et al., 2010). Thus far,
Disease Control and Prevention, 2014), early intervention telehealth training ranges from DVD to online text and
has never been more critical to treat the intellectual, com- video modules for parents’ self-guided instruction, to live,
municative, and behavioral deficits that can interfere with two-way videoconferencing from their homes, school, or
later functioning (Mundy & Crowson, 1997). Parents, as other remote setting with a therapist (Boisvert, Lang,
their children’s first and most natural teacher, have the great- Andrianopoulos, & Boscardin, 2010; Wainer & Ingersoll,
est interest and influence on their long-term growth and 2011). For example, Jang et al. (2012) developed an e-learn-
development. Practice, theory, and research have all empha- ing or web-based training module to explain applied behav-
sized the importance and efficacy of parent-delivered inter- ior analysis procedures to parents. Nefdt, Koegel, Singer,
ventions for children with developmental difficulties early in and Gerber (2010) used a DVD-based self-directed distance-
life (Wallace & Rogers, 2010). Studies of parent–child inter- learning program of 14 training modules with text and audio
actions in ASD have also found that parents can effectively lecture and video examples to teach pivotal response train-
deliver interventions and effect desired child changes in ing (PRT), an evidence-based naturalistic intervention, to 27
problem behaviors, nonverbal and verbal communication,
and appropriate play and imitation skills (Anderson & 1
Dept. of Psychiatry and Behavioral Sciences, University of California,
Romanczyk, 1999; Hancock, Kaiser, & Delaney, 2002; Davis, MIND Institute, Sacramento, CA USA
Ingersoll & Gergans, 2007; Koegel, Bimbela, & Schreibman, 2
Dept. of Human Ecology, Human and Community Development,
1996; Koegel, Koegel, & Surratt, 1992; Laski, Charlop, & University of California, Davis, USA
3
Dept. of Neurology, Physiology, and Behavior, University of California,
Schreibman, 1988; McClannahan, Krantz, & McGee, 1982;
Davis, USA
Stahmer & Gist, 2001; Stahmer & Schreibman, 1992).
Through its interactive and multimedia platform, tele- Corresponding Author:
Laurie A. Vismara, 628 Fleet Street, Suite 827, Toronto, Ontario,
health or communication technologies can integrate princi-
Canada M5V 1A8.
ples of adult learning and instructional design to increase Email: laurie.vismara@gmail.com
68 Focus on Autism and Other Developmental Disabilities 33(2)

primary caregivers of children with ASD. Similarly, Wainer secondary changes in children’s social communication as a
and Ingersoll (2013) developed a self-guided, online instruc- result of parent-implementation. We predicted that greater
tional program of audio- and video-based modules, short fidelity, website engagement, and program satisfaction gains
comprehension quizzes, and video clips of adult–child inter- would occur for P-ESDM than community-treated parents,
actions for rating accurate use of reciprocal imitation train- which in turn would be more likely to facilitate gains in chil-
ing, an evidence-based intervention to increase imitation in dren’s social communication skills.
children with ASD (Ingersoll, 2010; Ingersoll, Lewis, &
Kroman, 2007; Ingersoll & Schreibman, 2006). Enhancing
Interactions is a web-based tutorial developed by Kobak Materials and Method
et al. (2011) intended for parents to enhance their child’s Participants
social communication and decrease problem behaviors
within everyday routines. Sixty-one parents contacted the first author to participate
Other studies have primarily focused on videoconferenc- from the center’s website (52%) or from referrals (48%).
ing or live two-way communication over the Internet to pro- Eligibility required (a) children between 18 and 48 months
vide behavioral consultation services in a very effective of age, (b) a diagnosis of ASD from the Autism Diagnostic
manner compared with on-site coaching (Gibson, Pennington, Observation Schedule (ADOS; Lord, Rutter, DiLavore, &
Stenhoff, & Hopper, 2010; Machalicek et al., 2009; Suess Risi, 2002) by a licensed psychologist or physician, (c) one
et al., 2014; Wacker et al., 2013a, 2013b). To date, their work parent fluent in English and able to participate in all ses-
has demonstrated that applied behavioral analysis procedures sions, and (d) Internet in the home. Figure 1 shows the
such as functional analysis or functional communication recruitment, dropout, and retention process, resulting in 24
training are adaptable to most applied situations through vid- parents and their children (i.e., 14 in treatment, 10 in control)
eoconferencing training to parents, teachers, and other educa- who completed at minimum pre- and post-assessments.
tional and professional staff and are rated as highly acceptable
in lieu of traditional in-person sessions. Thus far, findings
generated from telehealth training suggest high parent satis-
Design and Procedure
faction, improved understanding of the content, and child Data were collected between 2011 and 2012. All research
improvement in the targeted area(s) of intervention (Baharav activities were approved by the university’s institutional
& Reiser, 2010; Jang et al., 2012; Kobak et al., 2011; Nefdt review board (IRB) and adhered to the Health Insurance
et al., 2010; Vismara, McCormick, Young, Nadhan, & Portability and Accountability Act (HIPAA) in response to
Monlux, 2013; Vismara, Young, & Rogers, 2012; Wainer & privacy, security, and electronic transaction guidelines.
Ingersoll, 2013). Videoconferencing sessions occurred through the Citrix
The current study adds to this literature with a compari- program GoToMeeting® in accordance with HIPAA to pro-
son of how two groups of parents engaged with telehealth tect the confidentiality and integrity of families’ health
training to augment their use of an intervention model with- information through a combination of encryption, strong
out traditional, in-person therapist-delivered coaching. access control, and other protection methods. Parents con-
Parents in the Early Start Denver Model parent coaching nected from their home with a laptop, tablet, or computer
program (P-ESDM; Rogers, Dawson, & Vismara, 2012) and web-camera. Children were randomized in clusters of
were taught the same developmental, relationship-based four to ensure that two were assigned to each group using a
principles as the ESDM therapist-implemented model using computer algorithm based on three pre-specified blocks: 18
videoconferencing sessions and website learning tools. to 30 months or 30 to 48 months, gender, and ADOS total
Previous publications of P-ESDM learning data demonstrate cutoff scores of <12 or 12+. Randomization was conducted
parents’ ability to deliver the set of responsive, sensitive and monitored by the last author who had no contact with
interactive strategies from center-based and telehealth train- the families or involvement with the intervention delivery
ing resources associated with increased child social commu- or assessment testing. Block assignment attempted to maxi-
nication skills (Rogers, Estes, et al., 2012; Rogers et al., mize equal samples in both groups (prior to attrition) and
2014; Vismara, Colombi, & Rogers, 2009; Vismara et al., not contribute to cohort effects or limit our resource capac-
2013; Vismara et al., 2012). Parents in the comparison group ity to serve families.
received videoconferencing sessions and website resources Parent–child assessments were collected at baseline, at
geared to treatment-as-usual services accessed from within the end of the 12-week treatment, and at another 12-week
their communities as part of the Birth to Three Services, Part follow-up period. At each point, parents were asked to play
C federal requirements. The two groups were evaluated at with their child as they normally would do so in two 5-min
three time points on primary outcome measures of parents’ play periods to evaluate parent fidelity performance and
fidelity with the P-ESDM and their engagement and satis- child social communication skills in each activity. Parents
faction with the telehealth training resources followed by were asked to carry out one activity with preferred toys or
Vismara et al. 69

Figure 1. Participant recruitment, enrollment, randomization, and retention.

Note. ESDM = Early Start Denver Model.
70 Focus on Autism and Other Developmental Disabilities 33(2)

materials that were a part of the child’s usual play routines and child behaviors that could be taught, as well as website
at home, as determined by the family, and the second with a resources to try before the next session.
familiar social or physical game typically played by the par- Parents accessed the website, esdmanywhere.org, from a
ent and child but without the use of any materials or toys. 128-bit encrypted software program, featuring a (a) schedul-
Research assistants independently rated and compared 33% ing calendar; (b) email for parent–therapist communication;
of scored probes in random order in addition to reliability (c) multimedia program to upload files; (d) online posts
checks with the first author on 15% of dependent measures. among parents; (e) goal tracking program to record daily
Raters were blind to the study’s hypotheses and group practice of the P-ESDM topics, child behaviors taught, and
assignment. activities used; (f) modules with text instruction, video
examples, practice exercises, and FAQs; and (g) a resource
P-ESDM intervention. The P-ESDM (Rogers, Dawson, & center of website links and tool kits on (i) Individualized
Vismara, 2012) follows the same science of applied behav- Education Programs, (ii) early intervention models and effi-
ior analysis and developmental, relationship-based inter- cacy research, (iii) advocacy information, (iv) community
vention of the ESDM (Rogers & Dawson, 2010). Its content events, (v) daily life issues, and (vi) family support systems.
and approach to parent training develops moments of learn- Therapists viewed parents’ website activity so as to stay
ing inside the daily interactions and activities that make up informed and communicate about their usage in between
a young child’s life so as to teach and strengthen different sessions.
areas of development. These everyday moments, whether
involving a snack at the kitchen table, playing with the gar- Comparison group. Parents randomized to this group
den hose, getting dressed, or looking at a picture book, pro- received monthly instead of weekly 1.5-hr videoconferenc-
vide opportunities to teach and strengthen children’s ing sessions and unlimited access to the website minus the
developmental skills. The P-ESDM videoconferencing ses- P-ESDM content. Parents’ participation was geared to
sions and website intended to teach parents how to use the understand their engagement patterns with the technology,
10 topics to target multiple skills across different areas of their interaction style with their children, and child changes
development within any particular activity. These topics are across measured outcome variables as a result of treatment-
attention and motivation, sensory social routines, joint as-usual, community-delivered services compared with the
activity routines, nonverbal communication, imitation, joint P-ESDM. Parents reported that community services primar-
attention, speech development, functional and symbolic ily consisted of direct intervention programs, including in-
play skills, and the teaching techniques and learning contin- home instruction of applied behavior analysis and
gencies of applied behavior analysis (see the appendix). center-based speech-therapy sessions, followed by similar
The 12-week, 1.5-hr videoconferencing sessions began services coupled with occupational therapy sessions embed-
with the parents sharing their experience using the last ded within children’s educational programs.
P-ESDM topic introduced, discussed, and practiced during Parents’ videoconferencing sessions and website resources
the previous session or in the case of the first session, shar- focused exclusively on the existing content of their children’s
ing their overall insight about which P-ESDM topic(s) intervention programs rather than introducing the P-ESDM
seemed more or less relevant to their learning needs. Parents intervention and coaching curriculum. In each videoconfer-
were then asked to share an example of using the P-ESDM encing session, parents had the option to share learning goals
topic inside an activity with the child or any strategy they from their child’s existing program(s), to discuss ways in
may have read about if it was the first session. Next, the which their family might support further practice, and to use
parent and therapist reflected about the positive ways in the website features related to their learning needs. The web-
which the parent applied the topic to support the child’s site resources offered information about (a) the rights and
social communication skills and ways in which the topic overall processes involved with Individualized Education
could be expanded or improved in the activity so as to pro- Programs; (b) evidence-based intervention approaches and
vide further learning opportunities and strengthen or aug- supporting research; (c) advocacy information; (d) autism-
ment the child’s behavior. As a next step, the parent may related community events; (e) family support networks; and
now want to know how to introduce other materials into the (f) tool kits to manage daily life and self-help issues such as
activity and ultimately transition away from only playing eating meals as a family, toilet training, doctor’s visits, and so
with the child’s highly favored materials. After the parent forth. The therapist’s intention was to support the teaching
and therapist discussed strategies to support continued use methods and learning goals of the family’s original interven-
with the last topic, the therapist introduced the new P-ESDM tion program(s) and not introduce new techniques that might
topic and coached the parent through several activities with interfere with progress. Once parents completed the 12-week
the child. The session ended with the parent setting goals of intervention and 3-month follow-up, they received access to
typical activities and moments in which to use the new topic the P-ESDM topic modules on the website. This transition
Vismara et al. 71

also marked the end of tracking their website engagement for child interest and engagement. Parents with scores of 4 or
data analyses. higher in each play condition at post-treatment and follow-
up were considered at fidelity. Inter-rater agreement was
Therapist training. Sessions were delivered by the first defined as raters’ scores falling within 1 point on the Likert-
and third author and another therapist, all trained by the type scale for each item. The weighted kappa between rat-
model’s developers. Training protocols used with families ers was .75.
were reviewed and approved by the IRB prior to conduct-
ing the study. The therapists followed a set of ethical and Program website use. Electronic tracking recorded the num-
practice guidelines developed in prior research using online ber of logins and amount of time viewing each website tool
forums to deliver intervention (see Trepal, Haberstroh, once parents completed their final baseline assessment
Duffey, & Evans, 2007 for more information), as well as until their last follow-up assessment. Amount of time view-
a manualized fidelity checklist on recommended coaching ing each website tool was calculated by subtracting the dif-
practices (i.e., collaboration, active listening, self-reflec- ference between the time stamps associated with each click
tion, contextual and nonjudgmental feedback) for work- or navigation from one web page to the next. Time spent
ing with and supporting parents through family-centered refreshing the web page, logging back into the website, or
practice (Hanft, Rush, & Shelden, 2004; Rush & Shelden, leaving a web page open for more than two standard devia-
2005, 2011). All videoconferencing sessions were recorded tions above the mean amount of parents’ view time (M = 5
and at least two sessions per parent were chosen at random min, 50 s, SD = 34 min, 57 s) were excluded from our
and coded using the fidelity checklists by unassigned thera- analyses.
pists with strong inter-rater agreement (intraclass correla-
tion coefficient [ICC] = .86) and therapist fidelity at 80% Program satisfaction. Parents completed a 20-item, 6-point
or higher. questionnaire ranging from 0 (not used) to 1 (strongly dis-
agree) through 5 (strongly agree) on (a) the website’s ease
of use (two items), (b) its intervention content and learning
Dependent Measures tools (14 items), (c) therapist support during sessions (two
The study conducted blind observation coding and analyses items), and (d) parents’ confidence to teach new skills to
at the start of the study and at the completion of the 12-week children and to pass on this information to other caretakers
intervention and 3-month follow-up. Primary outcome (two items). Parent scores were averaged to create a total
measures included group differences in parents’ P-ESDM score. Parents also reported on the benefits and limitations
fidelity use, website usage, and program satisfaction fol- of the website and training experience in an open-ended
lowed by secondary changes in children’s social communi- format.
cation skills as a result of parent-implementation.
Social communication behaviors. (a) Spontaneous, unprompted
functional verbal utterances of single words or approxima-
Primary Outcome Measures tions (not echoic or unintelligible utterances) directed to the
P-ESDM fidelity. The P-ESDM fidelity tool evaluates the parent with body orientation to request or comment about an
same 13 intervention skills used by therapists based on item or action; (b) imitative functional, related play actions
scores of 1 (i.e., no competence) to 5 (i.e., high competence; on objects and manual actions without objects done within 3
Rogers & Dawson, 2010). These skills define the child- s of the parent’s modeled action; and (c) unprompted, non-
centered, responsive interaction style of the model includ- verbal joint attention behaviors of eye gaze alternation with
ing (a) management of child attention; (b-c) quality of or without gestures directed to the parent to share interest or
behavioral teaching (use of clear antecedent-behavior-con- enjoyment in the activity. Analysis codes for all behaviors
sequence events and efficient teaching strategies embedded were summed across both parent–child play sessions per
in the play); (d) adult ability to modulate child affect and time point and calculated into a rate per minute to account
arousal; (e) management of unwanted behaviors using posi- for differences in duration of videotaped probes. The mean
tive approaches; (f) quality of dyadic engagement; (g) giv- ICC for frequency of behaviors was .77 (.11), with a range of
ing child choices and optimizing child motivation for .60 to .91.
participation in activity; (h) parent display of positive
affect; (i) parent sensitivity and responsivity to child com-
Results
munications; (j) parent use of multiple and varied commu-
nicative functions; (k) appropriateness of parent language P-ESDM fidelity. Parent fidelity was analyzed within a series
for child’s language level; (l) parent use of flexible joint of binomial generalized linear models. Model effects (i.e.,
activity routines with theme and variation in activities; and group assignment, assessment phase, group by time interac-
(m) smooth transitions between activities that maximize tion, and parent–child characteristics) were tested using
72 Focus on Autism and Other Developmental Disabilities 33(2)

Table 1. Parent–Child Descriptives.

Treatment group

P-ESDM (N = 14) Community (N = 10)

M (SD) M (SD)
Child’s age at enrollment (months) 31.9 (10.4) 27.20 (7.9)
Additional services before the study
Direct services 53.23 (64.54) 118.39 (235.51)
School services 100.83 (216.31) 121.67 (195.35)
Parenting classes/seminars 0.92 (2.23) 0 (0)
Additional services during treatment
Direct services 58.07 (81.20) 158.30 (93.38)
School services 66.67 (130.52) 80.56 (187.89)
Parenting classes/seminars 1.50 (5.20) 0 (0)
Additional services during follow-up
Direct services 59.25 (67.3) 222.04 (219.00)
School services 23.92 (55.97) 66.25 (159.26)
Parenting classes/seminars 0 (0) 0 (0)
Total hours of services 312.38 (331.70) 661.64 (657.99)
N (%) N (%)
Child’s gender
Male 11 (78.6) 6 (60)
Female 3 (21.4) 4 (40.0)
Child’s ethnicity
Hispanic 1 (92.9) 3 (30)
Non-Hispanic 13 (7.1) 7 (70)
Parent’s gender
Male 3 (21.4) 2 (20.0)
Female 11 (78.6) 8 (80.0)
Family income
Less than US$75,000 8 (57.1) 4 (40.0)
US$75,000 or more 6 (42.9) 6 (60.0)
Parent’s education
High school 0 (0.0) 2 (20.0)
Some college 2 (14.3) 2 (20.0)
College degree 6 (42.9) 3 (30.0)
Graduate degree 6 (42.9) 3 (30.0)
Parent’s employment
Not employed outside the home 8 (57.1) 5 (50.0)
Part- or full-time employment 6 (42.9) 5 (50.0)
Parent’s Internet use
Low Internet use 7 (50.0) 6 (60.0)
High Internet use 7 (50.0) 4 (40.0)

Note. P-ESDM = parent training in the Early Start Denver Model.

Wald chi-square tests. As shown in Table 2, no one met comparison group, there was no significant change from
fidelity during baseline and therefore only post and follow- post to follow-up, χ2(1) = 0.93, p = .33, or an interaction
up time points were included in the model to enhance con- between time point and group, χ2(1) = .73, p = .33. Multiple
vergence. At post-treatment, five out of 14 P-ESDM parents parent and child characteristics as shown in Table 1 were
met fidelity compared with only two out of the eight com- tested within the model of fidelity. Gender was the only
parison parents, χ2(1) = 4.73, p < .05. Four additional variable with a significant effect and was therefore main-
P-ESDM parents versus none in the comparison group met tained in the model. Female caregivers were more likely to
fidelity 3 months later at follow-up. In spite of the improved meet fidelity than male caregivers, χ2(1) = 3.93, p < .05.
skill usage among parents in the P-ESDM over the
Vismara et al. 73

Table 2. Parent Outcome Measures.

P-ESDM Community

Pre Post Follow-up Pre Post Follow-up

Website engagement time
M (SD)
ESDM topic modules — 5:01:44 (2:38:22) 1:14:56 (2:55:14) — — —
Goal tracking — 2:42:51 (2:51:37) 0:38:25 (0:56:43) — 0:25:18 (0:45:21) 0:17:23 (0:26:03)
Internal email — 0:55:19 (1:10:16) 0:08:16 (0:12:09) — 0:12:21 (0:16:30) 0:00:57 (0:00:46)
Autism resources — 0:09:42 (0:24:48) 0:18:30 (0:23:59) — 0:21:08 (0:27:05) 0:29:52 (0:37:13)
Message board — 0:06:32 (0:10:17) 0:12:36 (0:16:27) — 0:14:19 (0:26:07) 0:06:49 (0:11:00)
Media sharing — 0:09:55 (0:17:26) 0:00:33 (0:00:19) — 0:00:24 (0:00:13) 0:00:39 (0:00:05)
Calendar — 0:01:15 (0:01:37) 0:01:03 (0:00:38) — 0:02:21 (0:02:19) 0:00:44 (0:00:05)
P-ESDM fidelity
N met criteria 0 5 9 0 2 2
N did not meet criteria 14 9 5 10 8 8

Note. P-ESDM = parent training in the Early Start Denver Model.

Figure 2. Group engagement time on website.

Note. P-ESDM = parent training in the Early Start Denver Model.

Program website use. Analyses used a linear mixed model In Table 2, P-ESDM parents interacted most often with the
approach. Separate models were run for total time, time on topic modules and more so than the resource center for
each feature with main effects of time and group, and a community parents during post-treatment and not follow-
group by time interaction. P-ESDM parents were more up, F(1, 27.5) = 12.39, p < .01. This model had a significant
likely to use the website than community parents, F(1, 33.9) interaction effect, F(1, 27.5) = 6.47, p < .05. P-ESDM par-
= 21.69, p < .001, and more so during post-treatment than ents also spent more time emailing their therapist, F(1,
follow-up, F(1, 33.9) = 11.69, p < .01, as shown in Figure 2. 24.5) = 5.16, p < .05, and recording intervention usage and
74 Focus on Autism and Other Developmental Disabilities 33(2)

children’s learning progress than community parents, F(1, community treated parents met fidelity. When examined 3
27.7) = 7.00, p = .01. months later at follow-up, 64% of P-ESDM parents met
fidelity in contrast to no fidelity change among the commu-
Program satisfaction. P-ESDM parents reported significantly nity treated parents. This study contributes to the few ran-
higher satisfaction and confidence from their sessions and domized controlled trials that tested parents’ direct ability,
website usage than community parents, F(1, 24) = 11.16, rather than mere knowledge, of how to use an intervention
p < .01. They were more likely to notice positive changes in with their child from telehealth training. Furthermore, the
their children’s behavior and to feel encouraged by their parent gains reported here are in contrast to Rogers, Estes,
intervention usage online tracking of progress. Community et al.’s (2012) randomized controlled findings that showed
parents focused on the website resources related to teaching no fidelity difference among center-based P-ESDM training
self-help and coping skills to children. Both groups posi- to treatment-as-usual community early intervention.
tively rated videoconferencing sessions and felt well-sup- Although it was not the scope of this study to compare tele-
ported by their therapists. Community parents regretted not health with center-based training, Rogers, Estes, et al.
having weekly sessions as a result of how helpful and pro- (2012) discussed the importance of providing parents with
ductive they found the time with their therapist. Both groups additional learning resources and opportunities for practice
wished for more time throughout to use the website and the in order for low-intensity training approaches to produce
option to communicate directly with other enrolled parents. noticeable behavioral changes. For some parents, telehealth
Two P-ESDM parents reported occasional technical diffi- may provide additional supports when the clinician can
culty when they could not log into or use certain features of observe direct interaction skills from the families’ home and
the website. flexible learning options are available online at any time of
day. It will be an important direction in future research to
Social communication behaviors. The analysis used a linear compare the learning benefits with drawbacks of telehealth
mixed model approach. Separate models were run for each versus traditional, in-person training.
variable with main effects of group assignment, assessment However, the findings also raise important questions of
phase, and a group-by-time point interaction. Chronological why not all P-ESDM treated parents benefited and why
age, gender, and total community-delivered intervention similar fidelity gains occurred for at least two of the com-
hours were also tested within the models as covariates. Age munity parents. What we know from the heterogeneity in
was the only significant covariate within the model of spon- ASD suggests that any specific intervention may lead to
taneous communication, F(1, 69.9) = 18.99, p < .001, in beneficial outcomes in some children but not others. The
which older children tended to produce more spontaneous same can be said with teaching parents to deliver complex
communication. Overall, children in the P-ESDM group intervention strategies intended to target multiple skill
produced higher rates of imitation, F(1, 64.5) = 4.83, p < domains in young children’s development. Not all parents
.05; P-ESDM M = 1.37, SD = 1.02, Community M = 0.91, may prefer to use or benefit from telehealth training and
SD = 0.78, and both groups increased their imitation across may require a more traditional and/or intensive approach to
time, F(2, 45.7) = 4.52, p < .05. There were no significant be effective with the intervention (Vismara et al., 2013).
interaction effects or covariates. There were also no signifi- Another consideration may relate to the coaching struc-
cant main effects, interaction effects, or covariates in the ture of the telehealth-delivered sessions. P-ESDM parents
model with initiated joint attention behaviors as the depen- were exposed to a new P-ESDM topic each week built on
dent variable. the understanding they could use earlier taught concepts
without difficulty. This pace may have been difficult for
some parents to manage. We also do not know whether par-
Discussion
ents need to be taught all P-ESDM topics to have a desirable
Early intervention models that are both effective and acces- effect on children’s learning. There are data from a few ran-
sible are becoming an ever pressing need as more children domized controlled studies suggesting that a skill-specific
with ASD are identified. Telehealth may help parents use curriculum may help parents not only improve that targeted
early intervention to further their children’s learning. The behavior but also contribute to other important skills to chil-
current study tested telehealth parent training in the dren’s development (Kasari, Freeman, & Paparella, 2006;
P-ESDM followed by secondary changes to children’s Kasari, Gulsrud, Freeman, Paparella, & Hellermann, 2012;
social communication compared with community early Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Schertz,
intervention. Odom, Baggett, & Sideris, 2013). A comparison of a skill-
At baseline, the two groups of parents did not differ focused curriculum with broader developmental content
across demographic variables presented in Table 1, and all such as the P-ESDM may help to explain how and in what
showed low levels of P-ESDM fidelity. At post-treatment, manner an intervention produces downstream effects from
36% of P-ESDM parents compared with 20% of
Vismara et al. 75

parents’ implementation to noticeable developmental out- tips. These results may help to uncover program character-
comes for children with ASD. istics associated with more effective online learning for par-
For the community treated group, two of the parents’ ents of children with ASD.
interaction skills naturally met the P-ESDM approach. It is There was no treatment effect for children’s social com-
not uncommon for other play-based intervention models to munication. The P-ESDM group demonstrated higher rates
follow children’s preferred interests and to use everyday of imitation; however, this group difference was consistent
activities to encourage learning. Parents may have observed across all time points and, therefore, cannot be attributed to
or received support on how to use similar strategies, given the intervention. Both groups increased their rates of imita-
that many Birth to Three Services adopt a family-centered tion at the same rate and older children demonstrated more
approach from the Part C federal requirements. spontaneous communication. Maturation across the
Parent gender was the only demographic related to fidel- 12-week intervention period may have acted as a confound-
ity. Mothers were more likely to reach the criterion for cor- ing variable and contributed to overall skill improvement
rect implementation of the P-ESDM than fathers. It is for both groups. The fact that children were already partici-
difficult to draw firm conclusions about this finding given pating in a number of community programs also made it
that more mothers than fathers enrolled in the study, and we difficult to tease out effects specific to the P-ESDM. Other
did not inquire or assess reasons for which parent chose to randomized controlled studies of parent-mediated interven-
participate. This has been the trend with parent training tions have reported similar results of parent behavior change
studies in which mothers tend to be the more common inter- but no overall group differences on children’s developmen-
vening parent. Research regarding parent training in ASD tal scores (Carter et al., 2011; Green et al., 2010; Oosterling
among fathers remains sparse for this reason. Parent train- et al., 2010; Siller, Hutman, & Sigman, 2013). The absence
ing studies that have focused on fathers suggest they can be of a treatment effect brings into question the role of at least
taught skills (i.e., following the child’s lead, imitation, ani- short-term parent training models on children’s direct
mation, narration, expectant waiting) similar to mothers for symptoms compared with more intensive, therapist-deliv-
interacting and promoting social reciprocity skills in their ered intervention. Rogers, Estes, et al. (2012) proposed that
children with autism (Bendixen et al., 2011; Elder et al., children whose parents take between 8 and 9 weeks to reach
2011). Further study is needed to test training methods with fidelity may not receive the “full dosage” of the interven-
fathers that will solicit and maintain their involvement and tion until the very end of the 12-week measurement period.
the extent to which strategies may need to be tailored to More time may need to pass for changes in parents’ skills to
reflect parental gender and roles. measurably affect child behaviors and to see noticeable
Although P-ESDM treated parents used the website gains in children’s development from parent-mediated
more often and with higher satisfaction, their engagement intervention. Further efforts are necessary to continue to
did not contribute to fidelity. While self-guided instruction improve the ability of early autism intervention programs to
may increase parents’ understanding of autism intervention support parents, given their greater risk for stress, depres-
(Granpeesheh et al., 2010; Hamad, Serna, Morrison, & sion, and feelings of isolation, as well as improve child out-
Fleming, 2010), how this knowledge transfers directly into come variables.
actual use of the skills is presently unknown. The literature Several study limitations are acknowledged. Although
on adult learning suggests that active participation and all diagnoses were made with the ADOS, there may have
comparing current performance with a standard set of skills been variations in how the protocols were administered by
is critical to understanding something new and becoming community practitioners, which raises the possibility for
good at it (Bransford, Brown, Cocking, & Donovan, 2000; inaccurate diagnoses. However, these are the families with
Donovan, Bransford, & Pellegrino, 1999; Knowles, 1984). whom the intervention is likely to be used in community
This may explain why parents spent the most time online settings, and therefore, including them potentially increases
using the P-ESDM topics, early intervention resources, and the ecological validity of the findings. Second, our study
goal tracking program. Interactive tools may help parents resources precluded us from offering weekly sessions to
process and make sense of the information if and when ther- both groups and from directly testing children with stan-
apist support (either direct or online) is limited or not avail- dardized measurements. A stronger research design would
able. Currently, we are comparing the standard version of include the same schedule of videoconferencing sessions
the P-ESDM website (as described in this study) with a new between groups to allow for more accurate comparison of
version in which the amount of topic information and abil- fidelity performance and potential gains from children.
ity to track and evaluate intervention usage depends on par- Third, we were unable to control for group differences in
ents’ progress with each topic. Based on how parents community programs and, as a result, the amount and type
identify and report experiences with each topic, the new of early intervention was highly diverse. Fourth, not all
version of the website customizes feedback to acknowledge P-ESDM treated parents met fidelity in spite of positive sat-
or support parents’ intervention practice with additional isfaction ratings with the training and program experience.
76 Focus on Autism and Other Developmental Disabilities 33(2)

Perhaps the techniques parents did gain speak to the impor- Appendix (continued)
tance of isolating specific coaching tools and content that
help parents transfer knowledge into skilled practice. Strategies: Imitate child’s play, sounds/vocalizations, and
movements and encourage imitation back from child inside
Finally, the study involved a large number of middle-class,
toy play, songs, social games, and other daily activities.
well-educated parents who sought out the treatment, which Topic 6: Let’s get technical: How children learn
can be the trend with university research programs Goal: Teach the basic strategies of applied behavior analysis
(Brookman-Frazee, Vismara, Drahota, Stahmer, & for enhancing child learning.
Openden, 2009; Vismara et al., 2009). Strategies: Identify and use antecedent-behavior-
Traditionally, parent training has been one mechanism to consequence teaching principles for understanding child
facilitate the speedy implementation of evidence-based behavior and teaching new skills.
interventions given that many barriers make these services Topic 7: The joint attention triangle: Sharing interests with others
inefficient, inaccessible, and/or unaffordable to families Goal: Increase child’s interest to share objects and activities
with ASD (Baggett et al., 2010; Boisvert, et al., 2010; with others.
Fixsen, Blase, Naoom, & Wallace, 2009; Stahmer & Gist, Strategies: Give, show, and point to objects and pictures for
sharing comments and enjoyment.
2001; Wainer & Ingersoll, 2013). It will be necessary for
Topic 8: It’s playtime
future research to understand the advantages and appropri-
Goal: Increase learning opportunities in parent–child toy
ate role of telehealth parent training so as to eliminate or at play and support constructive, varied, and independent toy
the very least reduce these barriers. Parent training whether play.
provided in-person or remotely is not intended to replace or Strategies: Use play to build new skills, to practice skills
take over professionally delivered services. Rather, its pur- already developed, including social skills, and to create new
pose is to support and equip parents with the tools to inter- ways to play with toys independently and with others.
vene and create natural learning moments with their child in Topic 9: Let’s pretend
Goal: Develop child’s pretend play that is spontaneous,
Appendix creative, and flexible.
Strategies: Use imitation to teach animate play, symbolic
P-ESDM Topic Goals and Strategies.
substitution, and combinations of multiple symbolic play
Topic 1: Step into the spotlight: Capturing your child’s attention actions to make scenes from life activities.
Goal: Increase child’s attention on parent for learning. Topic 10: Moving into speech
Strategies: Identify and follow the child’s interests and Goal: Increase child’s use and understanding of speech
reduce outside distractions that may interfere with child’s through active engagement with people, their facial
ability to attend and participate in learning opportunities. expressions, and their gestures.
Topic 2: Find the smile: Having fun with sensory social routines Strategies: Develop vocal games to increase child’s sounds
Goal: Increase child’s positive affect and social communicative and build up child’s vocabulary with more opportunities for
behaviors during dyadic social games, songs, and social listening and responding to language.
exchanges. Note. P-ESDM = parent training in the Early Start Denver Model.
Strategies: Introduce and build a repertoire of sensory
social routines to optimize child’s energy level for learning.
Topic 3: It takes two to tango: Building back-and-forth interactions addition to or while waiting for more intensive services to
Goal: Increase opportunities for child learning within daily begin (Coolican, Smith, & Bryson, 2010; Stahmer & Gist,
play and caregiving activities. 2001; Vismara et al., 2009). Although further research is
Strategies: Create a four-part framework to building necessary to understand the benefits and limitations of tele-
joint activities and taking turns with the child; put simple health, its ability to potentially make parent training more
words to games, songs, and activities; create new learning available, easier to use, and less expensive is imperative to
opportunities with additional materials, actions, and steps to
supporting families with ASD.
the play; end the activity and transition together to the next
activity.
Topic 4: Talking bodies: The importance of nonverbal communication Acknowledgments
Goal: Increase child’s nonverbal communication skills for We wish to gratefully acknowledge the children and families who
promoting speech and language. participated in this study.
Strategies: Add gestures, facial expressions, and simple
language to family routines and identify communicative Authors’ Note
opportunities in which the child’s body language can be used
to express desires, feelings, and interests. Laurie A. Vismara, PhD, is now an adjunct professor at York
Topic 5: Do what I do: Helping your child learn by imitating University. Carolyn E. B. McCormick, PhD, is now a post-doc-
toral fellow at the Rhode Island Consortium for Autism Research
Goal: Increase child’s imitation of sounds, gestures, facial
expressions, actions, and words. and Treatment at Brown University. Katerina Monlux, MS, is now
at California State University, Northridge. Anna Nadhan, BS, is
(continued)
Vismara et al. 77

now a medical doctoral candidate at the Lewis Katz School of Centers for Disease Control and Prevention. (2014). Prevalence
Medicine. of autism spectrum disorder among children aged 8 years:
Autism and Developmental Disabilities Monitoring Network,
Declaration of Conflicting Interests 11 sites, United States, 2010. Morbidity and Mortality Weekly
Report, 63, 1–21.
The author(s) declared the following potential conflicts of interest
Coolican, J., Smith, I. M., & Bryson, S. E. (2010). Brief parent train-
with respect to the research, authorship, and/or publication of this
ing in pivotal response treatment for preschoolers with autism.
article: Laurie A. Vismara, PhD, is an author of the parent curricu-
Journal of Child Psychology and Psychiatry, 51, 1321–1330.
lum used in this study and receives royalties from the sale of this
Donovan, M. S., Bransford, J. D., & Pellegrino, J. W. (1999). How
book. No other conflicts of interest exist.
people learn: Bridging research and practice. Washington,
DC: National Academy Press.
Funding Elder, J. H., Donaldson, S. O., Kairalla, J., Valcante, G., Bendixen,
The author(s) disclosed receipt of the following financial support R., Ferdig, R., . . . Serrano, M. (2011). In-home training for
for the research, authorship, and/or publication of this article: This fathers of children with autism: A follow up study and evalu-
research was funded by Organization of Autism Research and the ation of four individual training components. Journal of Child
Joe P. Tupin grant from the University of California (UC), Davis, and Family Studies, 20, 263–271.
Department of Psychiatry and Behavioral Sciences awarded to Fixsen, D. L., Blase, K. A., Naoom, S. F., & Wallace, F. (2009).
Laurie A. Vismara. Core implementation components. Research on Social Work
Practice, 19, 531–540.
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