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Telehealth and Direct Parent Training (DPT): A Strategy to Improve Healthcare Access and Outcomes for Children with Autism Spectrum Disorder (ASD)

Telehealth and Direct Parent Training (DPT): A Strategy to Improve Healthcare Access and Outcomes for Children with Autism Spectrum Disorder (ASD)

Olusolape Agunbiade

University of Suffolk, Lagos, Nigeria

DOI: https://dx.doi.org/10.47772/IJRISS.2024.8110045

Received: 12 October 2024; Revised: 30 October 2024; Accepted: 04 November 2024; Published: 30 November 2024

ABSTRACT

Direct Parent Training (DPT) programs combined with telehealth have gained recognition as a promising approach to improving outcomes for children with autism, offering accessible and flexible intervention options for families across diverse settings. This study employs a mixed-methods analysis, integrating both quantitative and qualitative evidence to evaluate the effectiveness of this intervention modality to improve outcomes. The analysis focuses on three core areas to assess the efficacy of telehealth and DPT as a combined delivery approach:

1. Comparative Effects: Examining the comparative effects of telehealth versus no intervention or standard care, and telehealth combined with Direct Parent Training (DPT).

2. Influencing Factors: Identifying specific factors and nuances related to children with autism, their families, and providers that impact intervention effectiveness.

3. Design and Implementation Standards: Establishing essential design and implementation standards for training modalities to optimize outcomes for both parents and children.

Findings from this research highlights that fidelity—the degree to which the intervention is delivered as intended—is the single most critical factor in predicting and enhancing intervention outcomes when utilizing telehealth and DPT. This emphasis on fidelity suggests that consistent, high-quality implementation is essential to maximizing the potential of telehealth and DPT as a transformative tool for supporting children with autism and their families to improve outcomes.

INTRODUCTION

Global health policies increasingly aim to improve access and equity, yet stark disparities persist, especially for children with Autism Spectrum Disorder (ASD). The COVID-19 pandemic spotlighted these inequities as healthcare systems deprioritized ASD services to address immediate critical care needs (Oakley et al., 2021). ASD, a complex neurodevelopmental disorder affecting social interaction and behavior, occurs in 0.3-4% of the population, with boys being four times more likely to be diagnosed than girls (Ritchie, 2022). Today, more than 53 million children live with neurodevelopmental disorders worldwide and low and middle-income countries (LMICs) face profound challenges in providing early identification and intervention services due to resource constraints (Ahmed et al., 2022).

Barriers to ASD care are extensive, stemming from issues like the absence of universal healthcare, strained doctor-patient ratios, and limited data infrastructure. These factors leave families waiting up to three years for diagnosis or intervention in countries like the United States and the United Kingdom (Weale, 2020; Kerridge, 2021). The financial toll is substantial, with the lifetime cost of supporting a child with ASD ranging from 1.4to2.4 million. Many uninsured families must bear significant out-of-pocket expenses as a result (Wetherby et al., 2018; Buescher et al., 2014). As these costs rise, there is an urgent need to close the gap between evidence-based interventions and real-world access which ensure that children with ASD receive the support essential for their development at lower costs to their families (Hebbeler et al., 2012; Wetherby et al., 2018).

Research into telehealth-delivered parent training has emerged as a promising solution to bridge these gaps. Telehealth can extend the reach of ASD services, providing a cost-effective and time-efficient alternative to traditional care models by reducing travel and enabling remote intervention. Studies show that telehealth, when implemented with fidelity to evidence-based practices, can improve parent-child interactions. In some cases, it may reduce symptoms of autism (Matsumura et al., 2022). However, the success of these programs hinges on a critical factor: fidelity. Fidelity is the degree to which interventions adhere to their design and protocols, and is pivotal in achieving the intended outcomes. Studies emphasize tthat maintaining high fidelity combined with adapting interventions to fit each child’s unique needs is central to effective ASD care, with family engagement playing a crucial role (Tabatabaei et al., 2022b; Deb et al., 2022).

Despite the wide range of ASD treatments, telehealth-based parent training stands out as a viable approach for reaching underserved and remote populations. Such programs equip parents with tools to manage their child’s behaviors to reduce reliance on in-person visits and creating a more sustainable model for ongoing support. This accessibility has shown particular promise for families who may lack access to private treatment options, providing an alternative that cuts costs and extends care beyond geographic barriers (Stavropoulos et al., 2022; Stuckey & Domingues-Montanari, 2017). Moreover, telehealth has demonstrated a diagnostic reliability of 80-91% in identifying neurodevelopmental conditions and has proven effective in reducing travel costs and facilitating cross-border healthcare (Stavropoulos et al., 2022; Stuckey & Domingues-Montanari, 2017).

The promise of telehealth and parent training in ASD care is substantial, yet it also highlights the need for further research, particularly in understanding how to maintain fidelity while adapting these programs to diverse cultural and socioeconomic contexts. Achieving long-term, consistent outcomes requires standardizing telehealth practices to ensure efficacy and sustainability across varied environments. As digital health technologies continue to evolve, they present an invaluable pathway to reducing wait times, cutting intervention costs, and delivering high-quality ASD care worldwide (Badawy & Radovic, 2020; Valentine et al., 2020). This research aims to explore the factors that ensure telehealth and parent training can reliably improve outcomes and to provide a roadmap for optimizing ASD interventions across diverse populations.

Research Aim

To determine the comparative effect of telehealth on standard care, this research will investigate critical aspects of digital interventions for children with autism by focusing on three objectives. First, it will assess the comparative effectiveness of telehealth interventions versus traditional care or no intervention in improving outcomes for children with autism. Second, it will examine how individual characteristics—such as the specific traits of children with autism, family dynamics, or provider attributes—may influence the success of these interventions. Lastly, the research will explore strategies for designing and implementing digital interventions that maximize therapeutic outcomes and engagement, offering evidence-based recommendations for optimizing care delivery to this population.

The primary aim of this research paper is to examine the growing body of evidence on the efficacy of Telehealth and parent training as an effective digital healthcare intervention for children with autism (Matsumura et. al, 2022). Preliminary research has identified a gap in knowledge relating to standardized indices and modalities that determine an efficacious outcome if telehealth and parent training are implemented in fidelity. This leads to questioning the basis for embedding it in evidence-based practices (Matsumura et. al, 2022). The aim of this paper will be tackled in threefold as outlined in the three questions objectives to answer one question: What is/are the appropriate modalities and the key indices to determine if parent-training combined with telehealth is an efficacious intervention to improve outcome for Autism. The research will aim to contribute to the growing body of existing literature on standardizing treatment and intervention for Autism.

Research Rationale

The efficacy of telehealth and parent training has been questioned in relation to its ability to meet the needs of children with autism spectrum disorder (ASD). Although telehealth and parent training are effective methods of treatment, they are not always tailored to meet the specific needs of children with ASD. This can be a significant problem, as children with ASD often require specialized care. As a result, Tabatabaei et al. (2022a, p. 526) suggests that telehealth and parent training may not always be effective in treating children with Autism. The findings raise important questions about the efficacy of this modality of treatment.

The justification of this study is that given the large number of families who could benefit from this type of service delivery model if it is efficacious. It is essential to examine the effectiveness of combining telehealth with parent training approach, in order to make sound decisions about its use (de Korte et al., 2022). There are significant bodies of evidence providing a strong rationale for continued investigation into the efficacy of telehealth and parent training for children with ASD based on variances in outcomes stemming from peripheral and external factors (Tabatabaei et al., 2022b, p. 526). This research paper will therefore seek to identify the indices required to assess the effectiveness of this novel approach.

This study represents an important first step in this process to provide valuable information and insights into understanding the indicators needed to determine if, and when telehealth in combination with parent training is an efficient treatment delivery model for families of children with ASD. Future research should build on these findings by examining the long-term effects.

LITERATURE REVIEW

Understanding Autism Spectrum Disorder (ASD) and the Need for Early Intervention

ASD is a neurodevelopmental condition marked by communication challenges and repetitive behaviors that varies greatly across individuals. Early interventions such as Applied Behavior Analysis (ABA) can significantly improve ASD-related outcomes, particularly in communication and social skills (Rodgers et al., 2021). Additionally, early therapy can be beneficial as it capitalizes on neuroplasticity, fostering substantial developmental gains.

However, treatment outcomes can vary due to individual factors like baseline abilities, timing, and family involvement, underscoring the need for personalized approaches. There is limited research on the long-term impact of early interventions which makes it difficult to assess their effectiveness over time. The rising global ASD prevalence (Zeidan, 2022) continues to highlight the reason to prioritize the need for scalable interventions that are adaptable to diverse ASD populations and family contexts.

Efficacy of Self-Directed Parent Training (SDPT) Programs for Behavioral Interventions

Parent training, especially Self-Directed Parent Training (SDPT) empowers families to provide consistent support at home for children with ASD. Popular interventions include ABA, Pivotal Response Training (PRT), and Social Skills Training (SST). Each focuses on improving social and adaptive behaviors. SDPT’s success can vary with parental education, stress levels, and household support with research showing that parents with higher education and literacy are more effective in implementing interventions, leading to better outcomes (Glenn et al., 2022; Dahiya et al., 2021; Yakubova & Chen, 2022). This presents the strong case for managing parental stress for consistency in training effectiveness.

There are, however, limitations to the current research available carried out in small sample sizes and inconsistent methodologies, which complicates cross-study comparisons. Most research have also been conducted in high-income countries. This limits the ability to generalize it to low- and middle-income countries (LMICs) where challenges such as low digital literacy can impact SDPT effectiveness. Expanding research to diverse regions will provide a more comprehensive understanding of SDPT’s impact on ASD outcomes

Bridging Gaps in Access and Care through Telehealth and SDPT

Integrating telehealth with SDPT has also shown potential in addressing ASD care access, particularly for remote communities. Telehealth connects families to specialized services, providing consistent support (Lindgren et al., 2016). During the COVID-19 pandemic, the effectiveness of telehealth enabled continuity of care was demonstrated in remote intervention delivery. Telehealth-based SDPT allows for flexible scheduling and reduces travel burdens, making treatment adherence easier for parents (Corona et al., 2022). The challenge though is that telehealth places greater responsibility on parents, who may often lack real-time specialist feedback which is more available in clinical settings. Additionally, factors like internet access and parental confidence in administering behavioral interventions affect telehealth success. These factors emphasize the need for adequate resources and ongoing support for families in telehealth-based SDPT.

Optimizing Outcomes and Addressing Gaps by Designing Digital Interventions for Children with Autism

Designing effective digital interventions such as telehealth and SDPT for ASD requires standardizing and measuring outcomes to evaluate true impact. Current studies vary significantly in intervention format, duration, and delivery, complicating direct comparisons and limiting outcome consistency (Tabatabaei et al., 2022). Standardized success metrics are essential for understanding what works across different settings, such as improvements in social communication, reduction in maladaptive behaviors, and parental stress relief. Long-term studies are needed to assess intervention sustainability, as improvements observed in the short term interventions may diminish without follow-up.

Furthermore, the cultural applicability of digital interventions remains underexplored. Most of the research available focuses on high-income countries, leaving gaps in understanding how digital interventions would perform in LMICs, where technological and educational barriers are rampant, and may affect access and effectiveness. Developing adaptable models that account for cultural and socioeconomic contexts will be key to making digital interventions equitable globally.

Recommendations for Future Studies

Future research should investigate adaptable yet fidelity-centered models, recognizing the unique needs of each child and family. This approach would clarify intervention elements essential for successful outcomes across diverse settings. Additional research should investigate how to maintain fidelity in culturally and contextually adapted programs. Longitudinal studies could explore fidelity’s role in sustaining long-term benefits, and studies in varied settings would uncover factors that enhance intervention success. Future studies should also increase sample sizes and follow-up durations as suggested by Morelius et al. (2021) to enable more comprehensive analysis of data across settings.

Researchers may consider mixed-method designs to yield greater insights into the role of fidelity in multicultural contexts, capturing both quantitative and qualitative perspectives. Additionally, studies prioritizing child outcomes, rather than solely focusing on parental metrics, and standardizing fidelity approaches across interventions would provide clearer guidelines for impactful and consistent implementation across diverse settings.

In summary, future research should focus on three main areas to optimize digital interventions for ASD:

1. Comparative Effects of Telehealth vs. Standard Care: Evaluate improvements in child outcomes, comparing telehealth with no intervention or standard care. Standardized tools like ADOS and VABS should be used for accuracy.

2. Influential Characteristics of Participants and Providers: Assess child, family, and provider attributes that impact intervention success. Consider factors like age, ASD severity, and provider expertise.

3. Design and Implementation of Digital Interventions: Develop models optimizing digital intervention format and delivery, accounting for cultural adaptation and resource accessibility.

Methodology to Be Considered

Research Design:

a. Question 1 (Comparative Effects of Telehealth vs. No Intervention or Standard Care), a randomized controlled trial (RCT) can be employed to compare telehealth interventions with either standard care or no intervention. This design will control for confounding variables and provide robust comparisons between groups.

b. Question 2 (Characteristics Affecting Effectiveness), a mixed-methods design can be used, combining quantitative data on child outcomes with qualitative interviews from parents and providers. This will offer insights into how family, child, and provider characteristics influence the effectiveness of interventions.

c. Question 3 (Design and Implementation of Digital Interventions), a quasi-experimental design will be applied using multiple case studies across different cultural and socio-economic settings. This will allow for an examination of the short- and long-term efficacy of various digital intervention models.

Data Collection:

1. Standardized assessment tools like ADOS and VABS should be used to measure child outcomes.
2. Surveys and questionnaires, to be distributed to assess parent-reported stress, satisfaction, and engagement with the intervention.
3. Provider feedback logs should be collected to evaluate the fidelity of the intervention and any implementation challenges.
4. Digital usage data, such as app usage and frequency of telehealth sessions, can be used to track adherence to the intervention.

Sampling:

1. Question 1, stratified sampling will be employed to ensure a representative sample of children from diverse socio-economic and geographic backgrounds.

2. Question 2, purposive sampling will be used to include children with varying degrees of autism severity, family structures, and different levels of provider expertise.

3. Question 3, a multisite sampling approach will be adopted across regions, including both high- and low-income countries, to explore the cultural and contextual influences on digital intervention effectiveness.

RESEARCH METHODOLOGY

This chapter outlines the research methodology used to investigate the effectiveness of telehealth combined with Self-Directed Parent Training (SDPT) programs in improving outcomes for children with Autism Spectrum Disorder (ASD). The methodology reflects the thematic areas discussed in the literature review, guiding the selection of variables, sampling strategies, and data analysis techniques.

Research Design

The research employs a systematic literature review approach that focuses on secondary research to explore the efficacy of telehealth-delivered SDPT programs. Given the scope of the inquiry, the research design focuses on identifying existing frameworks, interventions, and outcomes from peer-reviewed studies and relevant secondary data sources. The systematic review will evaluate studies published from January 2020 to December 2022 to ensure the inclusion of the most up-to-date research, with older studies referenced only when foundational methods or best practices are relevant.

Variables and Thematic Areas

The thematic areas identified in Chapter 2 inform the choice of variables for this study. Each thematic area contributes to the conceptual framework used to evaluate the data:

I. Effectiveness of Telehealth (Theme: Access to Care)

1. Dependent Variable: Improvement in child outcomes (communication, behavior, social skills).
2. Independent Variable: Type of intervention (telehealth vs. in-person).
3. Measure: Changes in standardized assessment scores (e.g., Autism Diagnostic Observation Schedule (ADOS), Vineland Adaptive Behavior Scales).

II. Characteristics of Participants (Theme: Parent Training Efficacy)

1. Dependent Variable: Parental engagement and adherence to the program.
2. Independent Variable: Parent characteristics (literacy, education level, socio-economic status).
3. Measure: Parent-reported outcomes and levels of stress, anxiety, and satisfaction.

III. Design and Implementation of Digital Interventions (Theme: Optimizing Digital Tools)

1. Dependent Variable: Outcome improvements in children.
2. Independent Variable: Intervention modality (combination of telehealth with SDPT vs. SDPT alone).
3. Measure: Specific telehealth platform used, duration, and method of delivery (e.g., video conferencing, apps, or SMS).

IV. Cultural and Demographic Considerations (Theme: Cross-Cultural Efficacy)

1. Dependent Variable: Generalizability of findings across cultural contexts.
2. Independent Variable: Geographical location (Western vs. non-Western countries).
3. Measure: Comparative analysis of program efficacy between high-income and low- and middle-income countries (LMICs).

These variables guide the data extraction process and subsequent synthesis of findings in the review.

Research sampling

The sampling process involves identifying relevant peer-reviewed articles and studies based on the following inclusion criteria:

• Studies published in English between January 2020 and December 2022.

• Studies that focus on children aged 18 months to 13 years diagnosed with ASD.

• Research that investigates the use of telehealth in combination with SDPT programs for parents.

• Studies that report on key outcomes such as child behavioral improvements, parent stress levels, and intervention efficacy.

Exclusion criteria include:

• Studies focused solely on in-person interventions without a telehealth component.

• Publications that do not assess parent involvement in the intervention process.

• Editorials, opinion pieces, and non-peer-reviewed studies.

The search strategy was executed using major databases such as PubMed, JSTOR, Google Scholar, and ScienceDirect. Boolean operators were used to combine search terms such as “Autism Spectrum Disorder,” “Telehealth,” “Parent Training,” “Efficacy,” and “Standardization” to ensure comprehensive coverage.

Data Collection and Quality Analysis

The data collection method involved a two-phase screening process:

1. Title and Abstract Screening: Articles were reviewed to determine their relevance to the study based on the inclusion criteria.

2. Full-Text Review: Full-text articles were analyzed to ensure alignment with the research objectives and thematic areas.

The quality of the secondary data was assessed using a content analysis method, aided by Atlas.ti software to extract actionable insights. Studies were evaluated for their methodological rigor, including the use of valid and reliable outcome measures, and their ethical adherence.

Quality of Data:

The data was assessed for risk of bias, including sample size, follow-up periods, and research design. Studies were included only if they had low to moderate risk of bias and reported results clearly.

Description and sources of secondary data selected

All relevant studies were conducted using Boolean operators such as “AND” and “OR” with the keywords such as “Autism Spectrum Disorders,” “Autism,” “Parent Training”, “Efficacy,” “Telehealth,” “Intervention,” “Modalities,” “Standardisation” (Table 1), in electronic databases such as Directory of Open Access Journals (DOAJ), JSTOR, PubMed, Google Scholar and Science Direct. Manual searching was also carried out in relevant journals, checking the reference list of articles, expert sources, and grey literature from 1 Jan 2020 to 30 Dec 2022.

Search Strategy Terms and Combinations

Table 1 Search Strategy Terms and Combinations

Search Terms
1 Autism/ or Autism Spectrum Disorder/ or Telehealth/ or Parent Training/
2 or Efficacy/ or Intervention/ or treatment/ or modalities/ or Standardization/ or intervention
3 (2021* or 2022*)
4 S1 AND S2 AND S3
5 Telehealth

Research Content Analysis


Figure 1 (Content Analysis using Atlas.ti)

Ethical Considerations

Ethical standards were strictly adhered to by selecting studies that ensured participant consent and adhered to the principles of beneficence, non-maleficence, and respect for autonomy. The research prioritizes the privacy and safety of participants involved in the primary studies reviewed. Only peer-reviewed articles that met these standards were included in this review.

Data Validity and Reliability

The selected studies utilized rigorous research methods that ensured the constructs related to autism interventions were well-defined and aligned with the objectives of the review. This careful selection of research design enhanced the precision and relevance of the findings to the field of autism spectrum disorder (ASD). To ensure content validity, the review prioritized studies authored by experts with established credentials in ASD research. This approach guaranteed that the studies included were grounded in scientifically sound theories and practices specific to autism interventions to strengthen the credibility of the data.

Reliability was a critical focus in the review process. A robust validation screening was conducted, where each study was independently reviewed by multiple researchers. This process ensured that the selection of studies was both systematic and unbiased. The validation screening yielded an 80-90% agreement rate among researchers, which is indicative of a high level of consistency in the review process. Any discrepancies or disagreements in the data selection were resolved through in-depth discussions and consensus among the researchers. This method of cross-checking and resolving conflicts not only enhanced the reliability of the data but also ensured that the final set of studies was representative of the best available evidence on telehealth and parent training interventions for children with autism.

Limitations

The studies in this review used varied analysis methods and timeframes, which complicates result comparisons. Some focused on specific populations or regions, limiting generalizability. For example, Wainer and Ingersoll (2013) examined fidelity in ASD parent training but did not address telehealth’s impact on fidelity or how interventions could adapt to individual family needs, crucial given the diversity within the ASD population.

Tabatabaei et al. (2022) highlighted fidelity documentation gaps, making it challenging to assess program effectiveness, and noted the predominance of Western-centric studies, limiting cross-cultural applicability. Many studies also had small sample sizes, reducing statistical power. Self-report measures were commonly used, introducing bias, as in Dahiya et al. (2022), where studies with few participants did not assess long-term intervention effects, questioning their real-world applicability.

SUMMARY OF RESEARCH FINDINGS

The current study sought to address the effectiveness of parent-mediated interventions in combination with Telehealth for Autism. A literature review was conducted to answer these questions. The format of research findings presented vary based on the study design, data collection methods, and purpose of the study. This section is a compilation of different formats of research findings were guided by the following research questions:

(1) What is the outcome of autism intervention in the case of telehealth vs. no telehealth?
(2) What are the effects of exogenous and endogenic factors on Self-Directed Parent Training (SDPT) programs and on autism outcomes?
(3) What standard modalities of Direct Parent Training (DPT) and telehealth can optimize autism interventions?

Research Findings

(A) Comparative Effects of Telehealth vs. No Telehealth in Autism Interventions

The research underscores telehealth’s effectiveness in autism care, comparable to traditional in-person methods, especially in Direct Parent Training (DPT) programs. According to Tabatabaei et al. (2022), telehealth significantly improves child behavior, communication, and parent-child interactions, reducing parental stress. Individual telehealth interventions showed 86.48% efficacy, while in-person achieved 81.25%. Telehealth is particularly beneficial in low- and middle-income countries (LMICs), providing an accessible alternative where in-person services may be limited (Dahiya et al., 2022).

(B) Impact of External and Internal Factors on SDPT Outcomes

SDPT efficacy depends on both external (family dynamics, child characteristics) and internal (program fidelity) factors. Studies reveal that a child’s age and symptom severity, along with parental literacy and engagement can influence outcomes (Kobak et al., 2020; Ruiz-Baques et al., 2018). Fidelity, or adherence to program guidelines, emerged as a key success factor, with telehealth’s real-time feedback enhancing compliance. Programs with high fidelity saw a 90% reduction in problematic behaviors (Bird et al., 2019).

(C) Standardizing Telehealth and DPT for Improved Outcomes

Standardization in telehealth and DPT is crucial, particularly to bridge the 26.68% efficacy gap between HICs and LMICs (Tabatabaei et al., 2022). Practical tools, such as video content, improved efficacy by 6.04%, emphasizing the need for interactive resources (Exhibit 9). Limited availability of program manuals suggests that structured protocols are essential for consistent and effective implementation (Dawson-Squibb et al., 2020).

Summary of Findings

The tables below synthesize key findings from each exhibit to offer a comprehensive understanding of telehealth and DPT intervention outcomes for children with ASD.

Key Findings on the Implications for Telehealth and DPT Interventions

Table 2: Key Findings on the Implications for Telehealth and DPT Interventions

Exhibits Key Findings Implications for Telehealth and DPT Interventions
Exhibit 1 Higher efficacy of telehealth over non-telehealth formats in DPT, particularly with mixed individual-group training Telehealth provides a viable alternative to in-person DPT, enhancing accessibility and reducing parental stress
Exhibit 2 Cost-effectiveness of telehealth interventions, particularly in LMICs Telehealth can mitigate financial and logistical barriers to autism care in underserved regions
Exhibit 3 Greater behavior reduction in children with telehealth DPT compared to in-person interventions High fidelity and remote monitoring enhance telehealth efficacy for ASD care
Exhibit 4–6 Variability in telehealth modalities and lack of fidelity reporting Need for standardized telehealth delivery to improve consistency and measurable outcomes
Exhibit 7 26.68% higher efficacy in HIC interventions vs. LMICs due to resource disparities Addressing regional disparities and adapting telehealth for cultural needs is essential for equitable care
Exhibit 8 Cultural preferences in LMICs, such as reluctance to allow external professionals in homes Regionalized telehealth designs can enhance program uptake and efficacy
Exhibit 9 6.04% efficacy improvement with practical content (e.g., videos) Interactive tools significantly enhance DPT outcomes, supporting the inclusion of practical resources
Exhibit 10 Limited availability of detailed program manuals Standardized, manualized telehealth protocols are critical for maintaining fidelity and ensuring effective program replication

Findings on Fidelity in Telehealth and Direct Parent Training (DPT) Interventions

Table 3: Summary of Literature Review Findings on Fidelity in Telehealth and Direct Parent Training (DPT) Interventions

Exhibit Description Key Finding Source
Exhibit 1 Results of parent training-based interventions based on the studied variables Telehealth significantly improves outcomes for Autism DPT programs. Efficacy increased from 81.25% to 86.48% when technology such as the internet, smartphones, or video conferencing was used. Parent-child communication and behavior showed marked improvement, as well as a reduction in parental stress. Tabatabaei et al., 2022
Exhibit 2 Costs of Autism Treatment When Delivered via Different Service Models The cost-effectiveness of telehealth and its accessibility make it a valuable alternative to in-person autism treatment. Telehealth reduces travel costs, logistical barriers, and allows better access to specialists, particularly in remote areas. Lindgren et al., 2016, p. 723
Exhibit 3 Results of parent training-based interventions in High-Income Countries (HICs) Interventions in HICs reported higher success rates (90% in individual formats). Telehealth was as effective as in-person sessions. In-home telehealth was particularly effective, with behavior improvement reaching up to 97.27%. Dawson-Squibb et al., 2020, p. 11
Exhibit 4 Results of parent training interventions based on studied variables in HICs Findings highlight the variability in training formats and delivery methods (individual vs. group). Individual interventions in home settings had the highest success rates, while group-based interventions showed reduced efficacy at 76.19%. Dawson-Squibb et al., 2020, p. 12
Exhibit 5 Results of parent training-based interventions based on studied variables In high-income settings, mixed-form interventions that combined individual and group training methods were found to yield positive results, but individual sessions remained more effective. Dawson-Squibb et al., 2020, p. 13
Exhibit 6 Results of parent training-based interventions based on studied variables Further evidence was provided on how interventions conducted in the home setting, compared to clinical settings, have higher efficacy. Telehealth conducted at home led to greater adherence to the program by parents. Dawson-Squibb et al., 2020, p. 14
Exhibit 7 Modalities of PET program delivery and background of trainers/facilitators Variability in program delivery (technology, trainer experience) and background of facilitators impacts the success of parent training programs. More experienced trainers and better delivery technologies led to higher success rates. Dawson-Squibb et al., 2020, p. 15
Exhibit 8 Research designs and theoretical constructs of outcome measurements used in PET programs Standardized research designs and outcome measurements in PET programs are lacking, which impacts the ability to consistently measure the success of these programs. Some programs reported improvements in behavior, but without standard metrics, these findings are inconsistent. Dawson-Squibb et al., 2020, p. 16
Exhibit 9 Research designs and theoretical constructs of outcome measurements used in PET programs Mixed-method research designs (quantitative and qualitative) show more comprehensive insights into autism interventions. Longitudinal studies were lacking, making it difficult to assess the long-term impact of interventions. Dawson-Squibb et al., 2020, p. 17
Exhibit 10 Lack of manualization in autism-directed Parent Training programs Many programs lacked formal manuals or guides, which affected fidelity. Standardized manuals would increase program effectiveness and ensure that interventions are delivered consistently. Dawson-Squibb et al., 2020, p. 18

Qualitative Findings: Factors that Influence Fidelity in Telehealth and Direct Parent Training (DPT) Interventions

Table 4: Qualitative Findings on Factors that Influence Fidelity in Telehealth and Direct Parent Training (DPT) Interventions

Measure Quantitative Evidence Summary of Findings
Fidelity Rate In home-based telehealth sessions, fidelity reached up to 97.27% compared to 91% in clinical settings (Lindgren et al., 2016) High fidelity in home settings correlates with improved adherence and outcomes, indicating home-based telehealth enhances fidelity.
Effectiveness with Monitoring Studies report 86.48% success rate when individual telehealth training is supported by real-time feedback (Tabatabaei et al., 2022) Real-time monitoring and feedback significantly improve fidelity, making interventions more effective for children with ASD.
Parental Adherence Video-based fidelity monitoring improved adherence rates by 90% (Bird et al., 2019) Video-based tools to monitor and guide parents enhance engagement and adherence, crucial for program success.
Comparative Efficacy 26.68% higher success in high-income countries (HICs) vs. low- and middle-income countries (LMICs) Fidelity issues in LMICs due to limited resources underscore the need for adaptable, context-aware telehealth solutions.
Efficacy of Interactive Tools Interactive tools (e.g., videos) increased efficacy by 6.04% over basic instruction (Bearrs et al., 2015) Incorporating practical components improves fidelity and program impact, enhancing both parental engagement and child outcomes.

Qualitative Finding: Outcomes of Environmental Factors and Variable Settings on Fidelity in Telehealth and Direct Parent Training (DPT) programs

Table 5: Qualitative Findings on Outcomes of Environmental Factors and Variable Settings on Fidelity in Telehealth and Direct Parent Training (DPT) programs

Factor Findings Relevance to Fidelity Source
Real-Time Support Engagement and adherence improved by 90% when real-time feedback was provided during telehealth sessions. Real-time monitoring reinforces fidelity by enabling immediate adjustments and guidance tailored to each parent-child pair. McGarry et al. (2020), Morelius et al. (2021)
Home vs. Clinical Settings Telehealth delivered at home showed a 97.27% reduction in problematic behaviors compared to 91% in clinical settings. The home environment enhances fidelity by providing a comfortable, familiar setting for children, promoting protocol adherence. Lindgren et al. (2016)
Standardization Challenges Lack of consistent program manuals led to variable fidelity and intervention efficacy across studies. Standardized protocols ensure fidelity by creating a consistent intervention framework applicable across various contexts. Dawson-Squibb et al. (2020)
Parent Engagement Parents who submitted videos or received regular feedback demonstrated higher adherence and engagement. Structured engagement practices, like video submission, support fidelity by reinforcing parental adherence to the intervention protocol. Bird et al. (2019)
Cultural Adaptation Telehealth efficacy was significantly higher in high-income countries (86.48%) compared to low-income settings (42.85%). Fidelity is supported by adapting program delivery to align with local cultural expectations and socio-economic conditions. Tabatabaei et al. (2022)
Practical Training Tools Video demonstrations increased parent engagement and adherence by 6.04% compared to passive instructional methods. Interactive tools, such as video demonstrations, reinforce fidelity by enhancing skill acquisition and implementation accuracy. Bearrs et al. (2015), cited in Tabatabaei (2022)

Key Findings

Overall, the key finding was that fidelity is essential to telehealth DPT success. Real-time monitoring, cultural adaptation, and standard guidelines help parents follow protocols accurately, leading to improvements in children’s communication, behavior, and social skills.

I. Tabatabaei et al. (2022) reviewed the effectiveness of Direct Parent Training (DPT) and telehealth interventions for children with Autism Spectrum Disorder (ASD), finding high efficacy in individually tailored telehealth programs, which achieved a 90% success rate, sometimes outperforming in-person sessions. Group-based telehealth was effective, but at a lower rate of 76.19%. Hybrid models that combined individual and group sessions balanced accessibility and effectiveness, indicating that customized approaches work best for each family’s unique needs.

II. Fidelity—parents’ adherence to program protocols—was key to DPT success. McGarry et al. (2020), cited by Morelius et al. (2021), found that programs with fidelity monitoring systems, like real-time video feedback, significantly boosted engagement, with efficacy rates over 90% in both telehealth and in-person settings. This shows that strong fidelity tracking in telehealth can achieve, and even surpass, traditional results.

III. Studies by Bird et al. (2019) and Lindgren et al. (2016) highlighted that delivering telehealth in the home environment boosted efficacy due to the comfort of familiar surroundings. Lindgren found a 97.27% reduction in problematic behaviors in home-based telehealth, compared to 91% in clinical settings, demonstrating telehealth’s flexibility and impact.

IV. A stark efficacy gap emerged between high-income countries (HICs) and low- and middle-income countries (LMICs), where telehealth DPT had an 86.48% success rate in HICs but only 42.85% in LMICs, largely due to limited technology, digital literacy, and cultural factors. This highlights the need for culturally and economically tailored telehealth programs in LMICs.

V. The lack of standardized telehealth DPT protocols was another barrier to consistent results, especially in LMICs with limited resources (Dawson-Squibb et al., 2020). Standardization could ensure reliable outcomes across populations and enable effective fidelity tracking. Programs using practical tools, like video demonstrations, showed higher efficacy (84.61%) than those using only instructional content (78.57%) (Bearrs et al., 2015; Tabatabaei et al., 2022), emphasizing the value of interactive elements for immediate application.

VI. While telehealth DPT shows promise, few studies have examined its long-term sustainability. Dawson-Squibb et al. (2020) noted a need for longitudinal research to see if behavioral and communication gains last, especially in LMICs where follow-up may be lacking. This suggests that ongoing support may be necessary for lasting benefits.

ANALYSIS / DISCUSSION OF RESEARCH FINDINGS

This analysis examines the effectiveness of telehealth and Direct Parent Training (DPT) for children with Autism Spectrum Disorder (ASD), focusing on standardized indices and modalities necessary to ensure reliable outcomes. A critical gap remains in understanding what standards can be applied globally, especially given the limitations imposed by cultural and technological disparities, particularly in low- and middle-income countries (LMICs) (Ryan, 2018). Diverse economic and infrastructural contexts, such as low internet penetration and limited healthcare resources affect access to telehealth, calling for adaptable, culturally aware interventions (Ryan, 2018). The research explored three main questions:

1. How does telehealth compare to standard or no interventions in ASD treatment?
2. What characteristics of children, families, or providers influence the effectiveness of these interventions?
3. How can digital interventions be designed to optimize outcomes for children with ASD and their families?

Findings Across Studies

This review analyzed parent training programs’ delivery across different settings and identified the significant influence of fidelity on intervention efficacy. Although no single method worked universally, fidelity—meaning adherence to the intended intervention design—consistently correlated with improved outcomes across diverse settings.

Fidelity emerged as a key indicator of program success, especially when factors like parent engagement, cultural nuances, and resource availability were considered. Key studies that support this focus on fidelity include:

Fidelity As a Key Indicator of Program Success

Table 6: Fidelity As a Key Indicator of Program Success

Author(s) Study Focus Key Findings on Fidelity
Dahiya et al. (2022) Telehealth efficacy in rural vs. urban areas Highlighted location-based variations in adherence, with fidelity impacted by regional differences in resources and access.
Dawson-Squibb et al. (2020) Parent training across different backgrounds Emphasized that fidelity varies across different parental backgrounds, influencing the effectiveness of training programs.
Lindgren et al. (2016) Cost-effectiveness of telehealth for ASD Found that fidelity was essential for reducing ASD-related behaviors at a lower cost, supporting telehealth as an efficient model.
Tabatabaei et al. (2022) Systematic review of ASD interventions Identified fidelity as a consistent success marker across interventions, essential for achieving reliable outcomes.
Wainer & Ingersoll (2013) ASD training effectiveness in telehealth Established fidelity as crucial to maintaining effectiveness in ASD telehealth training, ensuring consistent intervention delivery.

Fidelity as a Success Indicator in Telehealth and Parent Training

Fidelity in ASD interventions refers to delivering a program as it was designed, which is critical to achieving consistent outcomes (Tabatabaei et al., 2022). Wainer and Ingersoll (2013) highlight that fidelity ensures treatment consistency, even when challenges like varied family needs or communication limitations arise. Three following three factors are essential to maintaining fidelity: (1) Effective provider-parent communication, (2) maintaining integrity across contexts, and (3) adapting interventions.

According to Bellg et al. (2017), fidelity is a methodological strategy to maintain an intervention’s reliability and validity. Wilczynski (2017) found that evidence-based DPT programs were more effective when delivered with fidelity by trained professionals, emphasizing the need for precise intervention protocols.

Fidelity is also essential to measure DPT program effectiveness, serving as a control in ASD treatment regardless of shifting variables such as setting or socioeconomic status. Tabatabaei et al. (2022) stress that fidelity should remain constant in research to enable accurate program assessments. Challenges in maintaining fidelity, identified by Wainer and Ingersoll (2013), include:

1. Provider-Parent Communication: Providers may struggle to convey complex ASD intervention content to parents who lack relevant backgrounds.
2. Treatment Consistency Across Contexts: Adapting clinic-based interventions for home or group settings while maintaining fidelity can be challenging.
3. Family-Specific Adaptations: ASD interventions need customization due to the wide variation in ASD symptoms and family dynamics.

Technology-based parent training programs, particularly those delivered individually, were shown to be highly effective, with an average effect size of 0.90. Group-based programs also demonstrated positive results, achieving an effect size of 0.76, supporting the value of technology-enhanced training for caregivers (Kobak et al., 2011, cited in Morelius et al., 2021). In programs combining telehealth with parent training, fidelity rates improved significantly: 79% of parents scored ≥80% post-training, compared to 8% pre-training. Fidelity between parents and telehealth educators was adequate across studies, and most parents expressed satisfaction with the technology-based education programs.

McGarry (2020, cited in Morelius et al., 2021) noted that parents completing DPT programs via telehealth successfully learned and implemented strategies, partly due to video submissions of parent-child interactions, which were coded for fidelity. As compliance improved, fidelity rates reached 90%, showing significant gains in communication skills and appropriate language use. Initially, only one out of ten parents achieved full implementation, but by week five, nine out of eleven parents scored above 80%, indicating improved health knowledge and compliance over time.

Child outcomes also improved with telehealth-based parent training. Studies by Lindgren et al. (2016) and Dahiya et al. (2022) found that telehealth-delivered parent training effectively reduced autism symptoms, comparable to in-person training. Children showed reductions in problem behaviors, improved social skills, and better communication. These results are particularly valuable for families in remote areas or communities where cultural norms limit in-home services. Further, Dahiya et al. (2022) found a positive correlation between increased telehealth use and reduced autism symptoms, improved parent-child communication, and decreased child anxiety, showing telehealth’s potential in enhancing intervention access and effectiveness.
The data also revealed a strong correlation (-.814) between parent competence and reduced child behavior problems, suggesting that competent parents are better at managing these issues (Dahiya et al., 2022). These findings emphasize telehealth’s role as a feasible, effective method for improving treatment outcomes and child social communication in autism.

Unanticipated Findings

• Many studies lacked documentation on fidelity, making it difficult to measure program implementation accuracy (Tabatabaei et al., 2022).
• Most research emphasized parental outcomes (64.9%) over child outcomes (37.8%), revealing a need for more child-focused studies (Dawson-Squibb et al., 2020, Exhibit 13).
• Only 5.4% of interventions were delivered in multicultural contexts, with just one program designed for such settings. Quantitative methods dominated, with only a few using mixed or qualitative approaches (Dawson-Squibb et al., 2020).
• One-third of studies reviewed lacked data on the duration of parent training programs (Dawson-Squibb et al., 2020, p.16).
• Telehealth proved to be the most cost-effective model for delivering autism treatment compared to physician-based and community-based models (Lindgren et al., 2016, p.173, Exhibit 14).

CONCLUSION

This research highlights the potential of telehealth-delivered parent training in enhancing outcomes for children with autism, across settings. The findings indicate that the success of these interventions are hinged on a single, pivotal factor: fidelity. Fidelity serves as the backbone of effective telehealth programs, ensuring that interventions are implemented as intended to deliver consistent, high-quality outcomes. Through fidelity-focused practices such as remote monitoring, telehealth can empower parents to maintain intervention accuracy, receive timely support, and create real, measurable progress for their children.

To improve efficacy of telehealth interventions, they must be adapted to meet the unique needs of each child and actively involve family members, who are essential to reinforcing and maintaining treatment fidelity. Providers must also receive targeted training in telehealth technology and evidence-based ASD practices to support families in achieving the best outcomes. Fidelity serves not just as a measure of intervention quality but as a crucial safeguard, helping to prevent a drift on the implementation parameters, and to preserve the integrity of Direct Parent Training telehealth programs across settings.

As telehealth continues to revolutionize ASD care, fidelity should stand as the constant that bridges research and practice, to ensure equitable, effective interventions for children with autism worldwide. Fidelity should be emphasized to empower future interventions to be both flexible, robust and to provide families and providers with the essential tools to deliver efficacious, lasting and transformative results.

ACKNOWLEDGEMENTS

I dedicate this dissertation to my beautiful children, Daniella and Jaden, who have been the sole inspiration behind my passion and research for Autism. You are my heart.

I am grateful for my wonderful husband, Banji, who has been my partner and encourager through this journey. I also thank my wonderful sisters, my mother and my brother (you would have been so proud of me today) for their unbending love and for keeping me focused and always believing I can do it all. Most importantly, I thank my God- with you, I can achieve anything.

May this research pave the way to new discoveries for more effective ways to support children with Autism all over the world.

Student Statement

I confirm that the work presented is all my own work. Any other sources of information used have been clearly acknowledged or referenced. Permission to reproduce information has been sought and approved where appropriate.

Declaration Statement

The authors declare that there are no conflicts of interest regarding the publication of this dissertation.

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Terminology

ASD Autism Spectrum Disorder
ASIM Autism-Specific Intervention Model
ABA Applied behavior analysis
CAPM Comprehensive Autism Planning Model
DPT Directed parent training programs
DTT Discrete Trial Training
The SCERTS – Specific Intervention Model
HICs High-Income Countries
IBIs Behavioral interventions
LMIC Lower-Middle-Income-Countries
MATCH Modular Approach to Therapy for Children
RRBs Restricted and repetitive behaviors (RRBs)
PECS Picture Exchange Communication System
PRT Pivotal response training
SST Social skills training
SDPT Self-directed parent training programs

List of Exhibits

EXHIBIT DESCRIPTION PAGE
Exhibit 1 Results of parent training-based interventions based on the studied variables 38
Exhibit 2 Costs of Autism Treatment When Delivered via Different Service Models 41
Exhibit 3 Results of parent training-based interventions in High Income Countries (HICs) 43
Exhibit 4 Results of parent training interventions based on the studied variables in High Income Countries (HICs) 45
Exhibit 5 Results of parent training-based interventions based on the studied variables 46
Exhibit 6 Results of parent training-based interventions based on the studied variables 47
Exhibit 7 Modalities of PET programme delivery and (b) background of trainers/facilitator used to deliver PET programmes. 48
Exhibit 8 (a) Research designs and (b) theoretical constructs of outcome measurements used in the PET programmes) 49
Exhibit 9 Research designs and (b) theoretical constructs of outcome measurements used in the PET programmes. 49
Exhibit 10 Implementation-related factors examined in the Parent Education and Training programmes reviewed (n = 37) 50
Exhibit 11 Impact of variables on the effectiveness of parent training- interventions 63
Exhibit 12 Relationship between change in number of child problem behaviors on the ECBI and change in parent competence on the BPS 65
Exhibit 13 Theoretical Constructs of Parent Training outcome measurements 66
Exhibit 14 Cost of Treatment delivered via different Service Models 67

APPENDICES

Exhibit 1: Results of parent training-based interventions based on the studied variables

(Source: Tabatabaei et al. 2022)

Exhibit 2: Costs of Autism Treatment When Delivered via Different Service Models

Source : Lindgren et al. (2016, p. 723)

Exhibit 3: Results of parent training-based interventions in High Income Countries (HICs)

Source: Dawson-Squibb et al. (2020, p. 11)

Exhibit 4: Results of parent training interventions based on the studied variables in High Income Countries (HICs)

Source: Dawson-Squibb et al. (2020, p.12)

Exhibit 5: Results of parent training-based interventions based on the studied variables

Source: Dawson-Squibb et al. (2020, p. 13)

Exhibit 6: Results of parent training-based interventions based on the studied variables

Source: Dawson-Squibb et al. (2020, p. 14)

Exhibit 7: Modalities of PET programme delivery and (b) background of trainers/facilitator used to deliver PET programmes.

Source: Dawson-Squibb et al. (2020, p. 15)

Exhibit 8: (a) Research designs and (b) theoretical constructs of outcome measurements used in the PET programmes)

Source: Dawson-Squibb et al. (2020, p. 16)

Exhibit 9: Research designs and (b) theoretical constructs of outcome measurements used in the PET programmes.

Source: Dawson-Squibb et al. (2020, p. 17)

Exhibit 10: Lack of manualization in autism directed Parent Training programmes

Source: Dawson-Squibb et al. (2020, p. 18)

Exhibit 11: Impact of variables on the effectiveness of parent training- interventions

Source: Tabatabaei et al. (2022)

Exhibit 12: Relationship between change in number of child problem behaviors on the ECBI and change in parent competence on the BPS.

Source: Dahiya et al. (2022)

Exhibit 13: Theoretical constructs of Parent Training outcome measurements


Source: Dawson-Squibb et al, 2020, p.17)

Exhibit 14: Cost of Treatment delivered via different Service Mode


Source: Lindegren et al, 2016, p.173)

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