A mixed-method evaluation of the feasibility and acceptability of a telehealth-based parent-mediated intervention for children with autism spectrum disorder

Abstract

Research within the autism spectrum disorder field has called for the use of service delivery models that are able to more efficiently disseminate evidence-based practices into community settings. This study employed telehealth methods in order to deliver an Internet-based, parent training intervention for autism spectrum disorder, ImPACT Online. This study used mixed-methods analysis to create a more thorough understanding of parent experiences likely to influence the adoption and implementation of the program in community settings. Specific research questions included (1) What are parents’ perceptions of the online program? (2) How does ImPACT Online compare to other services that parents are accessing for their children? And (3) Do parents’ experience in, and perceptions of, the program differ based on whether they received a therapist-assisted version of the program? Results from 28 parents of a child with autism spectrum disorder indicate that parents saw improvements in their child’s social communication skills and their own competence during the course of the program, regardless of whether they received therapist assistance. However, qualitative interviews indicate that parents who received therapist assistance were more likely endorse the acceptability and observability of the program. These findings support the potential for Internet-based service delivery to more efficiently disseminate evidence-based parent training interventions for autism spectrum disorder.

Keywords

autism spectrum disorder mixed-methods analyses parent-mediated intervention telehealth

Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by pervasive deficits in social communication and the presence of restricted and repetitive behaviors (American Psychiatric Association (APA), 2013). Individuals with ASD often require intensive and comprehensive intervention across the lifespan (Lavelle et al., 2014; National Research Council (NRC), 2001). There has been a dramatic increase in the prevalence of ASD over the past two decades, with estimates of 1 in 68 children now receiving this specific diagnosis (Baio, 2014). Despite a growing number of evidence-based interventions available for young children with ASD, there has been a large disconnect in the effective dissemination of these interventions into community settings (Dingfelder and Mandell, 2011; Stahmer and Pellecchia, 2015). This disconnect has contributed to high levels of unmet service needs for individuals with ASD and their families (Bitterman et al., 2008; Chiri and Warfield, 2012; Kogan et al., 2008; Vohra et al., 2014) and has led researchers to emphasize the need for systematic research to improve methods of ASD service delivery (Dingfelder and Mandell, 2011; Stahmer and Pellecchia, 2015).

Training parents to implement intervention with their child is one ecologically valid way to improve service access. Research has shown that parents are able to learn evidence-based intervention strategies to fidelity, and parents’ use of these strategies can lead to improvement in child social communication skills (e.g. Aldred et al., 2004; Ingersoll and Wainer, 2013; Kaiser et al., 2010; Kasari et al., 2015; Wetherby et al., 2014), although not all studies have found robust effects on child outcomes (Green et al., 2010; Oosterling et al., 2010). Additional benefits of parent-mediated intervention include increases in the generalization and maintenance of child skill (Koegel et al., 1982; McConachie and Diggle, 2007), improvements in parent self-efficacy (Sofronoff and Farbotko, 2002), and reductions in parental stress (Tonge et al., 2006). Despite these benefits, research has demonstrated that parent-mediated interventions are underutilized in community settings, with less than 25% of parents using this intervention approach with their child with ASD (Hume et al., 2005; Thomas et al., 2007). Barriers to the dissemination of parent-mediated interventions include a shortage of trained professionals, limited financial resources and transportation, lack of child care, geographic isolation, lengthy waitlists, and extensive time commitments (Kazdin et al., 1997; Spoth and Redmond, 2000). These barriers are even more pronounced for low-income and rural families, which may explain the marked service use disparities noted with parent-mediated ASD interventions (Patten et al., 2012; Stahmer and Pellecchia, 2015). Indeed, parents of children with ASD from low socioeconomic backgrounds are more likely to report that parent-mediated interventions are an unmet health need (Pickard and Ingersoll, 2015). Thus, as research within the ASD field has begun to emphasize, there is a pressing need to re-think traditional service delivery models in order to improve access to evidence-based, parent-mediated interventions for ASD.

Telehealth, or the use of computer and Internet-based technologies to deliver health information, has the potential to address many barriers to parent-mediated interventions (Wainer and Ingersoll, 2014). Access to computer and Internet technology in the home and community (e.g. public libraries and Internet hot-spots) has grown dramatically over the past two decades (File and Ryan, 2014) and has allowed users to access instructional content from anywhere at any time. Telehealth technology permits interactive and individualized learning while also providing standardized service delivery models that can be implemented at fidelity (Baggett et al., 2009; Wainer and Ingersoll, 2014). The use of telehealth-based programs to provide instruction in evidence-based interventions has been explored across health-related disciplines, disorders, and treatment approaches with promising outcomes (Webb et al., 2010). Furthermore, research with other populations has suggested that some parents may prefer telehealth-based intervention programs to home-visiting programs, therapist-based programs, and parenting groups (Metzler et al., 2012). This preference for telehealth has been replicated in parents from economically depressed neighborhoods, who reported preferring the online delivery of a positive parenting program (Love et al., 2013). Therefore, telehealth-based service delivery models may offer a promising mechanism for increasing access to, and engagement with, ASD parent-mediated interventions in community settings.

Although there has been growing interest in extending telehealth to parent-mediated interventions for children with ASD, empirical evaluations of such programs are limited. Several recent studies have demonstrated the initial efficacy of telehealth-delivered parent-mediated interventions for increasing parent knowledge and the use of intervention strategies. For example, self-directed telehealth programs have been shown to increase parents’ knowledge of behavior management strategies for their children with ASD (Hamad et al., 2010; Jang et al., 2012). Additionally, both self-directed and therapist-assisted (TA) telehealth programs have been shown to increase parents’ use of intervention strategies to support their child’s social communication development (Nefdt et al., 2010; Vismara et al., 2013; Wainer and Ingersoll, 2014). This same research has also shown that parents’ use of these intervention strategies can lead to gains in child’s social skills (Ingersoll et al., in press).

These early studies have highlighted the initial efficacy of such programs, have demonstrated that parents generally report viewing the online programs positively (Wainer and Ingersoll, 2014), and being satisfied at program completion (Nefdt et al., 2010; Vismara et al., 2013). However, previous research has typically reported quantitative measures of program satisfaction and acceptability as secondary to those of efficacy. This narrow approach has not allowed for a thorough understanding of other factors that can influence the adoption and use of such programs within community settings.

There are many factors that could significantly compromise the dissemination of telehealth-delivered parent-mediated interventions for families of children with ASD, outside of treatment satisfaction and acceptability alone. Issues such as the reach, complexity, and relative advantage of an intervention/service delivery model, which can strongly affect the ultimate impact of interventions on public health, cannot be understood using traditional tests of efficacy and satisfaction. Highly efficacious programs that have a limited reach or low-quality implementation are not likely to have as large an impact on public health as those with less efficacy but larger reach or higher quality implementation (Glasgow et al., 1999). Therefore, it is important to evaluate a variety of program factors affecting the likelihood of dissemination, alongside more traditional evaluations of program efficacy, to understand the potential impact that telehealth parent-mediated interventions can have on access to care for families of children with ASD (Glasgow et al., 1999).

Dissemination science theories advocate that involving key stakeholders in the development and early evaluation of interventions can promote the adoption and use of novel health innovations in community settings (Chinman et al., 2004; Flaspohler et al., 2012; Wandersman et al., 2008).

Theories like Roger’s (2002, 2003) Diffusion of Innovations theory emphasize the notion that community members’ perceptions of the feasibility, observability, and acceptability of health innovations influence whether the innovations are ultimately adopted, implemented, and sustained within community settings. Mixed-methods input from key stakeholders is a critical and necessary step which allows for collaborative problem-solving regarding supports to enhance a health innovation’s perceived fit within community settings (Chinman et al., 2004; Flaspohler et al., 2012; Wandersman et al., 2008). Although telehealth parent-mediated intervention research to date has assessed treatment perceptions using quantitative measures, stakeholder’s perceptions of the intervention and service delivery model have yet to be examined as a primary outcome variable.

This study used parents as key stakeholders and a mixed-methods approach in order to examine parent perceptions of ImPACT Online, an interactive, telehealth program that teaches parents to promote their child’s social communication within the context of play and daily routines. This program was designed to be delivered as a self-directed intervention or with therapist assistance via web-based remote coaching. This study was conducted as part of a larger evaluation of the efficacy of the self-directed and TA versions of the program (Ingersoll et al., in press). A mixed-methods approach to data collection and analysis was used to allow for a more thorough understanding of the variables that might facilitate or impede the use of the two versions of ImPACT Online in community settings. Specific research questions for this study included (1) What are parents’ general perceptions of ImPACT Online? (2) How does ImPACT Online compare to other services that parents are accessing for their children? And (3) Do parents’ experience in, and perceptions of, ImPACT Online differ based on whether they received a TA or self-directed version of the program?

Method

Participants

A total of 28 parents of a child with ASD between the ages of 19 and 73 months (M = 43.26 months, standard deviation (SD) = 12.58 months) participated in this institutional review board (IRB)-approved intervention study. Informed consent was provided to all parents prior to participation. Child ASD diagnosis was confirmed using Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria and the Autism Diagnostic Observation Schedule (2nd edn., ADOS-II; Rutter et al., 2012). All participants were recruited online and from community providers. A total of 97% of parents were females, and 70.40% were married or living with a partner. Participant characteristics are presented in Table 1. For a more thorough description of the intake procedure, online program content, and program timeline, see Ingersoll et al. (in press).

Table 1.

Sample demographics.

Characteristic	Full sample (N = 28)		Qualitative sample (N = 10)
Characteristic	Mean (SD)	Percent	Mean (SD)	Percent
Primary caregiver
Gender (% female)		96.80		100.00
Marital status
Married/living with partner		75.80		60.00
Single, widowed, and divorced		24.20		40.00
Ethnicity
White/Caucasian	81.50%			80.00
Black/African American	7.40%			10.00
Hispanic	0%			0
Asian/Pacific Islander	0%			0
Biracial/other	7.40%			10.00
Parent education
High school degree or less	7.00%			10.00
Some college/specialized training	34.50%			30.00
Bachelor’s degree	37.50%			40.00
Graduate degree	12.50%			10.00
Child
Age	43.26 months (12.58)		46.70 months (12.56)
Gender (% male)	77.80%		70.00%

SD: standard deviation.

Procedures

All families completed a standardized battery of assessments of family demographics and parent and child functioning at intake. Children were matched on expressive language on the Mullen Scales of Early Learning (Mullen, 1995) and then randomly assigned to the self-directed (SD) or TA group using a coin flip. Parents in the SD group independently completed the online 12-lesson intervention program. Although parents in the TA group also gained access to the same online intervention program, they met with a therapist twice each week for 30 min over Skype to receive supplemental assistance in their knowledge and delivery of the intervention techniques. All parents completed a survey-based, quantitative evaluation of ImPACT Online at post-treatment along with other measures of parent and child functioning (not presented here). Prior to beginning ImPACT Online, 10 parents (5 from the SD group and 5 from the TA group) were randomly selected to complete a qualitative interview upon their completion of the program. Interviews were conducted remotely (i.e. phone or video conferencing) within 1 month of program completion. Interviews were audio-recorded, transcribed, and checked for accuracy by trained research assistants. Parents who participated in the interviews did not differ in age or education from those who did not (all ds < 0.20).

Measures

Socio-demographic information

Parents provided basic demographic information including primary caregiver age, gender, education level, marital status, zip code (county of residence), as well as the age and gender of their child with ASD.

Quantitative evaluation of program perceptions

All parents evaluated the ImPACT Online program using a 49-item quantitative survey examining (1) intervention acceptability, (2) perceived child social communication gains, (3) burden of the intervention on the family, and (4) frequency of program use. Parents rated their agreement with statements reflecting these domains on a 7-point Likert scale. Average ratings were calculated for each domain. Cronbach’s alpha indicated strong internal consistency across the entire measure (α = 0.89) and within each domain (α = 0.80–0.88).

Qualitative interviews

Parents randomly assigned to the qualitative interviews were asked to participate in a 30- to 45-min semi-structured interview that was divided into four sections: (1) overall perception of ImPACT Online and the intervention content, (2) perception of the feasibility of the ImPACT Online program, (3) experience of support during participation in ImPACT Online, and (4) program referral preferences. Each section of the interview began with broad probes about parents’ experience; depending on initial responses, narrower probes regarding both positive and negative aspects of the four interview topics were provided.

Data analysis

For the quantitative evaluation survey, descriptive statistics were computed for each domain and one-way analyses of variance (ANOVAs) were used to determine whether parents’ experience of the ImPACT Online differed based on service delivery format (SD vs TA).

The qualitative interviews were analyzed using both rapid evaluation and assessment methodology (REAM; McNall and Foster-Fishman, 2007) and grounded theory methodology (Corbin and Strauss, 1990; Strauss and Corbin, 1990; Walker and Myrick, 2006). As part of REAM, both primary investigators met at the completion of each interview to discuss the central themes that emerged from the interview and additional questions that could guide further data collection. This process was repeated until no new themes emerged from the interviews. The initial themes that emerged during REAM were used to expedite the determination of open codes during grounded theory analysis. In the first phase of grounded theory analysis (open coding), participant responses to each question were de-identified, compiled, and reviewed by the two investigators to condense the data into analyzable codes (Corbin and Strauss, 1990; Strauss and Corbin, 1990). During this process, the initial codes that emerged during REAM were validated and any additional codes missed during REAM were added. These open codes were collaboratively determined at the transcript’s manifest level, and were created based on constant comparative analysis, in which segments of the transcript were thoroughly compared for similarities and differences. Reliability was assessed after each investigator independently coded the transcripts and was calculated as percentage agreement on 30% of each transcript (Boyatzis, 1998). Analysis indicated good reliability, with agreement on 88.43% of codes. In the second phase, investigators used axial coding to relate the specific codes from the first phase into broader “subcategories” (Corbin and Strauss, 1990; Strauss and Corbin, 1990). During the third phase, selective coding was used to integrate all of the relationships between categories and subcategories into one, overarching phenomena. Critically, all coders were blind to child and family characteristics and intervention group during the entire coding process. Finally, relational and variational sampling was used to compare patterns of parent-reported experiences based on whether they were part of the SD or TA group (Strauss and Corbin, 1990).

Results

Quantitative evaluation of program perceptions

Participating parents’ quantitative evaluations of ImPACT Online are summarized in Table 2. Parents across both intervention groups rated ImPACT Online quite favorably, with average scores for all domains falling on the positive end of the scale. There were no group differences in the degree to which parents felt that participating in the ImPACT Online intervention placed an additional burden on their family (F(1, 25) = 0.67, p = 0.42, d = 0.32). Similarly, parents in both intervention groups reported spending relatively equal amounts of time accessing ImPACT Online (F(1, 25) = 1.63, p = 0.22, d = 0.52). Despite these similarities, quantitative results did reveal some differences across groups. Specifically, parents in the TA group found the intervention content to be more acceptable (F(1, 25) = 5.23, p = 0.03, d = 0.94). These parents also perceived significantly more improvements in their child’s social communication skills over the course of the program (F(1, 25) = 4.29, p = 0.05, d = 0.84).

Table 2.

Summary of quantitative program evaluations.

	Overall	Self-directed group	Therapist-assisted group	t value	p value
	M (SD)	M (SD)	M (SD)	t value	p value
Intervention acceptability	6.59 (0.58)	6.35 (0.73)	6.83 (0.25)	2.29	0.03
Child social communication gains	5.41 (1.24)	4.92 (0.40)	5.85 (0.87)	2.07	0.05
Burden of the intervention on the family (reverse)	5.72 (1.23)	5.51 (1.49)	5.90 (0.96)	0.82	0.42
Frequency of program use	6.36 (0.57)	6.22 (0.73)	6.49 (0.33)	1.28	0.21

SD: standard deviation.

Qualitative reports of program perceptions

Qualitative themes and their frequency across intervention groups are summarized in Table 3. Many of the qualitative findings corroborated the quantitative results noted above. Critically, the discrepancies that did appear across the two methods could be explained by the more nuanced nature of the qualitative themes.

Table 3.

Frequency of each theme within both intervention groups.

Categories and subcategories	Therapist-assisted group (N = 5)	Self-directed group (N = 5)
Perceptions of acceptability
General positive experience	16	7
Individual differences in technique preference	13	6
Ease of learning ImPACT Online
Needed a background to learn the intervention	0	2
No background needed to learn intervention	4	0
Loved having a coach	16	0
Coach necessary later in the program as content became more challenging	8	5
Program content was easy	2	1
Familial support received during program	3	4
Support from therapists or professionals	0	4
Support from the research team	0	7
Support from therapist coach	16	0
Relative advantage
Accessed during periods of free time	5	4
Similar to other services being received	3	3
No other services	2	1
Free and/or flexible access	2	6
Parent and child outcomes
Child gains	9	6
Parent–child interaction gains	7	5
Continued use of program	7	6
Generalization of intervention techniques	6	4
Parent empowerment	4	3
Perceptions of barriers
Time barrier	6	10
Other barriers	3	7
No experienced barriers	2	3
Stressors while in the program	4	1
Stress associated with diagnosis	2	5
Website negative experience	6	2
Parent suggestions for dissemination
Wanting referral following diagnosis	8	4
Program as first source of intervention	1	3
Referral from diagnostician/pediatrician	5	2
Stress associated with diagnosis	2	5

Perceptions of the acceptability of ImPACT Online

Consistent with quantitative results, parents in both groups reported positive perceptions about the acceptability of the ImPACT Online intervention techniques:

It (the intervention techniques) was pretty straightforward. And you could read about them using know the manual, and you could listen to them too. I think it (the program) was set up to meet every different learning style. (TA mother)

I liked how you can use them (the intervention techniques) all day long in every activity. I found that they actually work with her. And I like the pyramid were there are steps and you are not pushing her too much, but you are teaching her. (SD mother)

Well you know, like I told my coach, all of the techniques were helpful it was just the timing for my child. You know, so I think it’s great to have all of that, you know, kind of in my tool bag, if you will. Then, when it’s appropriate for him, I can always pull it out. But I thought all of the interventions were great, even if it may not have worked for him at the moment. (TA mother)

However, substantial qualitative differences emerged regarding the frequency at which parents spontaneously endorsed the acceptability of the program, with parents in the TA group making these endorsements more than twice as often. These parents, relative to those in the SD group, were also twice as likely to discuss the specific intervention techniques that they felt benefited their child.

The ease of learning ImPACT Online

Qualitatively, both groups reported that the ImPACT Online intervention content was relatively easy to learn, particularly at the beginning of the program. However, as the program progressed, the intervention strategies taught to parents became somewhat more complex. As a result, parents in both groups indicted that the support of a coach would be essential as they progressed through the program and the complexity of the intervention increased:

I think we would have been okay up to a point and then at the end it would have been really, really tough putting it together, because that is when I really relied on the coach. (TA mother)

Maybe like a check-in that would have been nice. I think a lot of the beginning lessons were pretty simple, but once you got to the middle to the end [of] it a little more direction would have been good or just some direction here and there. (SD mother)

Regarding the intervention content, notable group differences emerged. Parents in the SD group reported that a background in child development and/or ASD intervention would be helpful for learning the intervention techniques. Parents in the TA group did not think that such a background was necessary to learn the intervention content. Instead, these parents reported that the support of the therapist coach greatly facilitated their learning of the intervention content:

It [a background] definitely didn’t seem like it was necessary. It started at a basic enough place. Anything seems to help as we go along learning and stuff like that but it definitely did not seem like it was something that you needed anything to start ’cause it kind of took you step by step. (TA mother)

Well, the coach is watching me as I’m doing it, and it was nice like having second eyes you know like okay he (child) is doing this so try this, and I would try it. It was something that I wouldn’t have thought of, you know, to do or to say. So, for me, it was that real time to do something differently. (TA mother)

Relative advantage of having remote access to ImPACT Online

Parents across both groups were in agreement when discussing how ImPACT Online fits with other services that they were accessing for their child. Parents indicated that the intervention techniques taught in ImPACT Online was similar to other intervention services that they were accessing for their child that specifically aimed at increasing their child’s social communication skills (i.e. Applied Behavior Analysis; Speech Language Therapy). Importantly, parents emphasized the relative advantage of having flexible access to ImPACT Online, as compared to other services that were delivered in person. This was particularly true for parents in the SD group, who were three times more likely to underscore the flexibility of the program as an advantage that made it unique from many of the other ASD services available within their community:

Because it’s just really hard with a lot of these other therapies and stuff. It’s just so hard to get an appointment that’s in the evenings or you know on the weekends. You know it just doesn’t happen so it’s hard to fit everything in, so at least you can you know learn how to do all this kind of stuff at home or wherever. (SD mother)

It wasn’t the lesson themselves were particularly time consuming because I found it very convenient that they were half a hour. Basically you could watch from start to finish in half a hour. It was easy for me and watch it on the computer while I was doing dishes or you know whatever so it was nice to be able to multitask while doing it so I found that to be the most helpful. (TA mother)

Parent and child outcomes

Parents across both intervention groups endorsed a number of benefits associated with participation in ImPACT Online. Specifically, parents across both groups reported, with a relatively similar frequency, that they felt empowered after learning the intervention techniques, that they were better able to interact and play with their child with ASD, and that they continued to use the intervention techniques after program completion:

And I mean it [ImPACT Online] is that foundation you know. Like okay let’s get some intervention, and from a family stand-point, I felt a little helpless. Like what do I do? And you know of course they have intervention outside of the home, going to this therapist and that, but when they come home a parent can be like I don’t have the knowledge. So, having something like this, I feel like I have power to really help my kid now. And that transition, you know that cycle doesn’t break when he steps in the house. You can continue to build upon what he’s learning. (TA mother)

Yeah, truthfully it helped me to interact more with him because most of the time I let him play by himself. (SD mother)

On the other hand, important group differences emerged regarding the frequency with which parents discussed child-focused gains. Parents in the TA group were 50% more likely to spontaneously report that their child made social communication gains during ImPACT Online and were equally more likely to emphasize the generalization of their use of the intervention strategies across a number of daily routines:

She was always really snuggly with me, but I definitely feel like we communicate better. Especially as soon as we started with the imitation. I think it was us showing that we were interested in communicating with her on her own terms. She was really excited about that. (TA mother)

He started out not talking, and was not going to play at all. You know, I would sit down and be like “let’s play” and he would just scream or just sit there and do nothing or like after 30 seconds he would get up and walk away. Now we go to do playtime and it’s like a half an hour passes and I’m like “Okay I’m done, I need a break!” (TA mother)

Perceptions of barriers associated with ImPACT Online

Although two parents in the TA group reported experiencing no barriers related to program participation, this was not the case for most other parents, who reported a number of barriers associated with ImPACT Online. However, differences emerged regarding the type of barriers that parents experienced. For example, only parents in the TA group indicated that they experienced difficulty having a stable connection with their therapist over Skype. Alternatively, parents in the SD group were nearly twice as likely to emphasize time requirements as a barrier to program participation and the need to have the ImPACT Online program accessible on tablets and smart phones:

Um, I think the only thing that would discourage people I guess would be taking the time to do it. I didn’t think it was that much time. I mean, it was just, what, about 40 minutes to go over it online a week. So that’s not bad for me. But beforehand I was like, you know, is this going to be a lot of work? Stuff like that. (TA mother)

Well, my husband works 12 hour shifts, and it’s me myself and I. I have no resources or people to come and give me a hand. I know in my head what I want my child to accomplish but for me to sit down there and take time to map out goals for her on the computer, I’m sorry I had to give it up. You just don’t have time. If your program was more like on the iPad quick things for parents to sit and watch and like, if your child is playing and its quiet, you can zip on that iPad and watch some instructions. (SD mother; withdrew during ImPACT Online participation)

I only have two days of the week that are really committed to my child, but there are parents who have more kids or whatever and want to go through this but need more time. They might not be able to do one lesson in one week, and maybe need the program spread out longer, so the only suggestion is to give them the option to not have to do one lesson one week. (TA mother)

Parent suggestions for program dissemination

At the conclusion of the interview, parents were asked when and how they would have liked to learn about ImPACT Online. Parents across both groups almost unanimously reported that the program should be made available to families right at the time of an ASD diagnosis or even earlier such as when “red flags” are raised for a child. This was particularly true for parents in the TA group, who were twice as likely to make this suggestion. Although there was acknowledgement of the stress associated with the diagnostic period, many indicated that access to a program like this would have helped empower them and provide them with direction during this difficult time:

At the time you’re overwhelmed … I was reaching out to anybody who listened to me, I just needed someone to reassure me basically, and I think that was the most important thing at the time. (SD mother; withdrew during ImPACT Online participation)

And so I mean it would have been helpful to be able to talk to our pediatrician or the doctors because everybody tells you that you have to start intervention and early intervention is key, but nobody gives you anything other than “well you need to do early intervention.” Well where the hell do you find that? (TA mother)

Discussion

This study used a mixed-methods approach to examine parents’ perception of ImPACT Online. It also sought to determine whether these perceptions differed based on whether parents received additional assistance from a therapist during program participation. In general, parents indicated a number of benefits associated with ImPACT Online including the relative simplicity of the program content, the unlimited access to the intervention program, and the child and parent gains made over the course of program participation. Despite reported positive experiences, parents indicated that the program content became more difficult to learn as the program progressed. Importantly, perceptions of the ImPACT Online program did differ depending on the specific service delivery model. Parents in the TA group reported that the therapist was essential for learning and applying the intervention content, while parents in the SD group indicated that a therapist would have made learning the intervention easier, particularly as the complexity of the intervention increased.

Many of the themes that emerged during this study mapped onto dissemination science theories such as Roger’s (2003) Diffusion of Innovations theory. Roger’s theory suggests that the passive diffusion of health interventions into community settings is influenced by the intervention’s compatibility, complexity, relative advantage, and observability (Rogers, 2002, 2003). Within this study, parents discussed the general acceptability of the intervention program (i.e. compatibility), the ease of learning the intervention content (i.e. complexity), the relative advantage of being able to flexibly access ImPACT Online, and the observable benefits associated with intervention participation (i.e. observability). These reported perceptions differed across intervention groups, with parents in the TA group generally reporting the program as being more compatible, less complex, and more observable than parents in the SD group.

Implications

Results from this study are crucial in that they suggest that evidence-based, parent-mediated interventions for ASD can be disseminated using telehealth, in a manner that is generally feasible, acceptable, and beneficial for parents. Importantly, although parents unanimously indicated the utility of having support from a therapist, parents in the SD group were also able to complete the ImPACT Online program. Taken together, results from this study lend further support for the use of Internet-based service delivery models to increase access to high-quality interventions for children with ASD (Vismara et al., 2013). Moreover, such service delivery models can help to eliminate many of the structural barriers associated with traditional clinic-based services, including the ability to provide parents with support without requiring transportation.

The use of both quantitative and qualitative analyses helped to clarify nuances of parents’ ImPACT Online experiences in a way that would have not been possible with standard quantitative measures of acceptability and satisfaction alone. As noted, many of the themes that emerged mapped onto variables specific to Roger’s (2003) Diffusion of Innovations theory. Critically, both quantitative and qualitative data depicted that parents’ perceptions of these variables differed as a function of whether they received therapist assistance. These group differences in the compatibility, complexity, relative advantage, and observability of ImPACT Online are important to consider, given that these variables have been shown to explain 49%–87% of the variance in how quickly an intervention is disseminated into community settings (Rogers, 1995). Thus, results from the mixed-methods approach employed in this study underscore the importance of receiving therapist assistance as a means to facilitate the dissemination of ImPACT Online into a greater array of community settings.

In addition to the implications associated with Roger’s Diffusion of Innovations theory, this study also assessed the barriers and limitations associated with the ImPACT Online program. These barriers included the time and technology necessary to complete the online program and were more frequently endorsed by parents in the SD group. Although most parents were able to overcome these barriers and complete the intervention program, three parents withdrew from ImPACT Online. A parent who did not complete the program indicated that the barriers such as those described above prompted her decision to withdraw. These important findings are consistent with research in other areas suggesting that perceptions of program participation barriers predict program dropout above and beyond socioeconomic status (Kazdin et al., 1997; Nock and Ferriter, 2005; Prinz and Miller, 1994; Spoth et al., 1999). Partnering with parents to qualitatively identify these barriers is critical as this information can be used to make modifications to enhance the fit of interventions within community settings (Chinman et al., 2004; Flaspohler et al., 2012; Stahmer and Pellecchia, 2015).

Limitations

There are several limitations to consider with this study. First, despite explicit attempts to reach families from a range of demographics, the study sample primarily consisted of parents with a college degree. Families needed to travel to the research site to complete assessments three to four times prior to beginning the program. As a result, the sample may include highly motivated families and/or those families who may have experienced fewer barriers during their participation. Therefore, the results from these specific interviews may not necessarily generalize to socioeconomically and ethnically diverse families. Future research employing qualitative research with this specific population is of critical importance.

Finally, this study leaves two questions unanswered. The first of these regards the role of parent-mediated intervention as it relates to a child’s overall treatment plan. Research to date does not support that parent-mediated interventions replace direct, therapist-implemented intervention (Bibby et al., 2002; Wetherby and Woods, 2006). However, parent-mediated interventions are considered to be an essential component of comprehensive intervention programs for children with ASD (Maglione et al., 2012; NRC, 2001). Given that many of the parents in this research study endorsed wanting to learn about ImPACT Online immediately following their child’s ASD diagnosis, disseminating the program to parents during the time that they are first initiating services for their child may serve as one effective way to ensure that parents have access to a piece of their intervention plan while they wait for other direct services to begin. The question next becomes who benefits most from parent-mediated interventions, and what level of support is necessary to maximize parent engagement and, subsequently, the likelihood of parents experiencing benefits? The creation of community-based partnerships with parents and providers will be fundamental in determining the varying levels of support that may need to be built into parent-mediated interventions in order to enhance family and child outcomes (Stahmer and Pellecchia, 2015). It is possible that parents with a greater amount of education and resources may benefit from learning the intervention strategies in a self-directed or online format. For other less resourced families, more flexible programs with live coaching and the potential for additional family supports may be necessary. Future research aimed at community-based partnerships will be an important piece of answering these questions.

Despite these limitations, this study represented an important step in advancing the understanding of the benefits and limitations of Internet-based service delivery models, particularly for parents of children with ASD. Despite the call to use mixed-methods research early in the intervention development process, this type of methodology has rarely been used within the ASD field. The use of mixed methodology in this study allowed for the most nuanced examination, to date, of variables that influence the adoption and implementation of Internet-based interventions for parents of a child with ASD. Therefore, in addition to providing information about online interventions and service delivery models, this study demonstrates the importance of mixed-methods research when designing an intervention to be efficiently disseminated to parents within community settings.

Footnotes

Funding

Funding was received from the Department of Defense Autism Research Program [grant #W81XWH-10-1-0586].

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