Comparative Efficacy of a Self-directed and Therapist-assisted Telehealth Parent Training Intervention for Children With ASD

Autism spectrum disorder (ASD) is a chronic and pervasive neurodevelopmental disorder characterized by deficits in social communication and the presence of restricted and repetitive behaviors. Individuals with ASD often require intensive and comprehensive intervention across the life span. There has been a dramatic increase in the number of individuals with this diagnosis over the last two decades, with current prevalence rates as high as 1 in 68. However, there has not been corresponding growth in the availability of evidence-based intervention services, contributing to high levels of unmet service needs for individuals with ASD and their families. The vast majority of families of children with ASD report receiving substantially fewer hours of services than recommended by the National Research Council. Furthermore, levels of unmet service needs are even higher for families residing in rural and medically underserved communities. Thus, systematic research focused on developing and improving strategies for dissemination and implementation of evidence-based ASD services is a high priority, particularly for chronically underserved communities.

Parent training programs are one cost-effective and ecologically valid way to increase access to evidence-based ASD intervention. Training parents to provide intervention themselves can increase the number of intervention hours a child receives and improve child outcomes. A number of studies have demonstrated that parents can learn to use evidence-based intervention strategies with a high degree of fidelity and their children experience gains in language and social communication development, decreases in disruptive behavior, and greater generalization and maintenance of child skill. These benefits are recognized by parents, who report parent training to be the most effective practice for promoting their child's overall development. Parent training also improves family quality of life by increasing parent self-efficacy and reducing parenting stress, which is particularly important given the high rate of stress and depression found in parents of children with ASD.

Despite these benefits, there continue to be barriers to the dissemination of training to parents. Formal parent training programs are rare in community-based early intervention settings for young children with ASD. For example, in a recent North Carolina survey, only 8% of parents of children with ASD under 4 reported receiving parent training. Barriers to the provision of parent training include a shortage of trained professionals, lengthy waitlists, limited financial resources and transportation, lack of child care, geographic isolation, and time limitations. These barriers may be even more pronounced for families who live in rural areas, for whom long distances, poor roads, and climatic barriers limit the ability of parents to receive services. Thus, it is essential to consider the adaptation of evidence-based parent training programs to non-traditional service delivery models to increase access to services.

Telehealth, or the provision of health services and information through the Internet and related technologies, has the potential to replace or, at the very least, augment traditional service models to increase access to evidence-based services. Users of telehealth programs are able to interact directly with instructional content through video, animation, and active learning tasks, as well as with other individuals, including expert clinicians, via email and teleconferencing systems. The number of individuals with access to internet-based technologies has grown considerably in recent years (File T, 2013), and it is now estimated that 75% of U.S. households have a home computer with high-speed internet, and nearly 87% of adults are able to access the internet from home, work, or elsewhere. Telehealth services are becoming increasingly common with over 3,000 U.S. sites using distance-based service delivery models to provide patient care.

Telehealth programs can reduce patient and provider costs and increase provider system coverage relative to traditional in-person service delivery models. Such programs have been shown to greatly improve care for patients with chronic diseases, such as diabetes, heart disease, and asthma, and increase access to evidence-based health promotion (i.e., smoking cessation, dietary change, physical activity), psychological (i.e., CBT for depression and anxiety), and parenting interventions. Patients are often very satisfied with the care they receive through telehealth services, and efficacy studies have found moderate to large effects of telehealth interventions on participant knowledge and behavior change. Further, several recent meta-analyses have found that CBT delivered via telehealth is as effective as traditional therapist-delivered intervention. Taken together, these data suggest that telehealth may serve as a promising alternative service delivery model to increase the dissemination of ASD parent training programs.