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Feasibility of Delivering Parent-Implemented NDBI Interventions in Low Resource Regions: A Pilot Randomized Controlled Study



Background: This implementation feasibility study was conducted to determine whether an evidence-based parent -implemented distance-learning intervention model for young children at high likelihood of having ASD could be implemented at fidelity by Part C community providers and by parents in low resource communities. Methods: The study used a community academic partnership model to adapt an evidence-based intervention tested in the current pilot trial involving randomization by agency in four states and enrollment of 35 coaches and 34 parent-family dyads. After baseline data were gathered, providers in the experimental group received up to 12 hours of training while control providers received six webinars on early development. Six months of intervention with children-families then followed, concluding with data collection. Regression analyses were used to model outcomes of the coach behaviors, the parent fidelity ratings, and child outcomes. Results: A block design model-building approach was used to test the null model followed by the inclusion of group as a predictor, and finally the inclusion of the planned covariates. Model fit was examined using changes in R2 and F-statistic. As hypothesized, results demonstrated significant gains in (1) experimental provider fidelity of implementation compared to the control group; and (2) experimental parent fidelity of implementation compared to the control group. There were no significant differences between groups in child developmental scores. Conclusions: Even though the experimental parent group averaged less than 30 minutes weekly with providers in the 6 months, both providers and parents demonstrated statistically significant gains with moderate effect sizes compared to control groups. Since child changes in parent mediated models are dependent upon the parents’ ability to deliver the intervention, and since parent delivery is dependent upon providers who are coaching the parents, these results demonstrated that two of these three links of the chain were positively affected by the experimental implementation model. However, lack of significant differences in child group gains suggests that further work is needed on this model. Factors to consider include amount of contact with the provider, amount of practice children experience, amount of contact both providers and parents spend on training materials, and motivational strategies for parents, among others. Trial registration: Registry of Efficacy and Effectiveness Studies: #4360, registered 1xx, October, 2020 – Retrospectively registered, http://
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Feasibility of Delivering Parent-Implemented NDBI
Interventions in Low Resource Regions:A Pilot
Randomized Controlled Study
Sally J Rogers ( )
Aubyn Stahmer
Meagan Talbott
Gregory Young
Elizabeth Fuller
Melanie Pellecchia
University Pennsylvania
Angela Barber
University Alabama
Elizabeth Grith
University of Colorado Denver
Keywords: early intervention, ASD, parent implemented interventions, parent coaching, implementation
research, ESDM
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License
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Background:This implementation feasibility study was conducted to determine whether an evidence-
based parent -implemented distance-learning intervention model for young children at high likelihood of
having ASD could be implemented at delity by Part C community providers and by parents in low
resource communities.
Methods:The study used a community academic partnership model to adapt an evidence-based
intervention tested in the current pilot trial involving randomization by agency in four states and
enrollment of 35 coaches and 34 parent-family dyads. After baseline data were gathered, providers in the
experimental group received up to 12 hours of training while control providers received six webinars on
early development. Six months of intervention with children-families then followed, concluding with data
collection. Regression analyses were used to model outcomes of the coach behaviors, the parent delity
ratings, and child outcomes.
Results:A block design model-building approach was used to test the null model followed by the
inclusion of group as a predictor, and nally the inclusion of the planned covariates. Model t was
examined using changes in R2 and F-statistic.As hypothesized, results demonstrated signicant gains in
(1) experimental provider delity of implementation compared to the control group; and (2) experimental
parent delity of implementation compared to the control group.There were no signicant differences
between groups in child developmental scores.
Conclusions:Even though the experimental parent group averaged less than 30 minutes weekly with
providers in the 6 months, both providers and parents demonstrated statistically signicant gains with
moderate effect sizes compared to control groups.Since child changes in parent mediated models are
dependent upon the parents’ ability to deliver the intervention, and since parent delivery is dependent
upon providers who are coaching the parents, these results demonstrated that two of these three links of
the chain were positively affected by the experimental implementation model. However, lack of
signicant differences in child group gains suggests that further work is needed on this model. Factors to
consider include amount of contact with the provider, amount of practice children experience, amount of
contact both providers and parents spend on training materials, and motivational strategies for parents,
among others.
Trial registration: Registry of Ecacy and Effectiveness Studies: #4360, registered 1xx, October, 2020 –
Retrospectively registered, http://
Specic interventions for young children with or at high likelihood for autism spectrum disorders (ASD)
demonstrate powerful effects in reducing intellectual impairment, improving social communication and
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language development, and improving social skills, when initiated in early childhood (Fuller et al, 2020,
Fuller & Kaiser, 2019, Hampton & Kaiser, 2016, Sandbank et al., 2020). However, many of these
interventions are not implemented well within community settings due to technical aspects of the models,
delivery intensity, and precision of intervention methods. In fact, very few empirically supported models
for toddlers with ASD have demonstrated ecacy when assessed via community delivery with a recent
paper nding that children with ASD who receive intervention in community settings have less favorable
outcomes than children who receive intervention in clinical/University settings. (Nahmias et al., 2019).
This might be because the community systems that serve young children often involve low income and
culturally diverse areas and interventions have not been adapted to t the needs of families in these
areas. These characteristics, combined with low funding rates, low service intensity, and stang
diculties, make it dicult to implement evidence-based practices (EBP) at delity. Yet, PartC, the public
early intervention system for children under age three in the United States is, by its public and
noncategorical nature, the most likely source of early intervention (EI) for the nations young children with
signs of ASD.
The PartC philosophy focuses on having providers support parents to provide intervention for their child
during everyday activities. Children with ASD benet the most from interventions that include parents
(Hampton & Kaiser, 2016), and parent participation in EI is predictive of long-term outcomes (Kim, Bal, &
Lord, 2018). However, too seldom do PartC providers use evidence-based parent coaching methods.
PartC providers tend to provide direct intervention services to children (Campbell & Sawyer, 2007), which
allows for little carryover into daily life and does not realize the intent of PartC services for family
learning (Aranbarri, et al., 2017). PartC providers consider young children at high likelihood of ASD to be
the most dicult and discouraging children to serve, due to their intense intervention needs, diculty
engaging with the provider, and poor progress. Given the signicant cost of educating children with ASD
(Amendah, et al., 2011), and the importance of providing high-quality intervention at an early age, their
limited access to evidence-based practices (EBP) in PartC EI is a major concern.
Recently, there have been some attempts to move evidence-based, parent-implemented autism
interventions into early intervention systems with some early success (Stahmer, Rieth et al., 2019; Rooks-
Ellis et al, 2020). Researchers have partnered with community providers to train them to use parent
coaching strategies to teach parents a Naturalistic Developmental Behavioral Intervention (NDBI;
Schreibman et al., 2015) that t the context of the community (Brookman-Frazee et al., 2012). These
interventions show promise for improving social communication outcomes in children with high
likelihood of having ASD, however, samples are small and more data are needed regarding how to
increase access to under resourced communities.
Efforts are still needed to scale out the use of evidence-based, parent implemented NDBI in low resource,
PartC agencies. In order to address this need we worked with research community collaboratives in six
states to adapt the Early Start Denver Model’s (ESDM) parent coaching strategies for use in low-intensity
settings with PartC providers having limited experience with autism. ESDM is one of the very few
comprehensive EI models that have been validated and replicated in multiple published, randomized trials
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(e.g., Dawson et al., 2010; Rogers et al., 2019). A recent meta-analysis of 12 controlled ESDM studies,
found signicant effects of ESDM on cognition and language compared to usual care groups, even
though most of the studies involved low-intensity (1 hour per week) or group services delivered by parents
or professionals (Fuller et al., 2020). Multiple studies have examined the effects on parents and children
of parent implemented ESDM (P-ESDM) and demonstrated parent delity to the techniques and
accelerated child learning in language, imitation and play (Vismara et al, 2009, 2010, 2011, 2012, 2013).
ESDM was collaboratively adapted for under resourced PartC communities by a multidisciplinary group
of providers, funding agency representatives, parents, and researchers who provided feedback after
review of ESDM manuals and other written materials. Adaptations involved greatly shortening and
streamlining training materials and providing them asynchronously via distance learning; simplifying and
shortening procedures for developing short term intervention objectives and progress monitoring tools,
and creating video modules that described and illustrated the key strategies for parents to use with
children through cartoons and parent -child videos. Additional adaptations addressed (1) community
values (rural Colorado, rural Alabama, rural California, Montana, Arizona, and urban Philadelphia); (2) the
limited time PartC providers have for learning, planning, and data collection, (3) the need to reach
families with attractive and practical brief audio-visual learning materials that could be accessed through
their phones, (4) the need to use a ipped classroom educational approach grounded in the principles of
adult learning for exible provider training, (5) methods for integrating ESDM approaches within the
existing PartC Individual Family Support Plan (IFSP) and delivery approaches, and (6) the very limited
service intensity delivered in these communities (as low as one one-hour visit per month). The resulting
model was named the Community ESDM, or C-ESDM.
We used an iterative process to develop both the C-ESDM provider training approach and the parent
learning materials from three sources: (1) experimental data using component analysis to examine key
components of ESDM, (2) survey data from a multi-state, multi-level survey aimed at better
understanding PartC services (Aranbarri et al., in preparation), and (3) ongoing discussions with our
implementation teams. The provider training program included methods of measuring child, parent and
provider progress, provider training materials, on-line parent lessons and materials. The on-line materials,
“Help is in Your Hands” (HIIYH;, include four modules with 4 lessons per
module focused on narrated video examples of families using the strategies during daily routines at
home. Modules cover the following topics: (1) Increasing Children’s Attention to People (Positioning;
Following the leader; Finding and making attention magnets; Child comfort zone); (2) Increasing
Children’s Communication (Talking bodies; Responding to child body language; Gestures and sounds;
Following and leading); (3) Creating Joint Activity Routines (Building Joint Activities in Four Easy Steps;
Variations on the theme; Joint activity routines without toys); (4) ABCs of learning (A = antecedents; B = 
behavior; C = Consequences). All provider training activities and parent coaching materials were made
available on-line and also covered during twice monthly one-hour provider interactive webinars.
The current study used a small randomized trial to test the feasibility and promise of the adapted model
for use with PartC providers and families who had a young child with social communication challenges
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considered at high likelihood of a future autism diagnosis. This study aims to test the effects of this low
intensity training approach for PartC providers on three groups: (1) providers’ use of parent coaching
strategies, (2) parents’ use of interactive strategies, and (3) toddlers’ developmental skills.
The current pilot study examined the effectiveness of C-ESDM delivered in PartC systems across 4
states: Alabama, California, Colorado, and Pennsylvania. Recruitment began at the agency level, with
providers nested within agencies, and families recruited from participating providers’ caseloads. Agencies
were recruited via outreach from University partners in each state. Eligible agencies served children 0–3
through their state’s PartC Program. Video calls were scheduled with all potential providers at an agency,
wherein study details were described. Interested providers were subsequently contacted by study staff
and formally screened via phone or video call. Each agency was randomized to either the Community
Early Start Denver Model (C-ESDM) or an active comparison group (All About Young Children; AAYC)
immediately upon enrollment, using a matched pair, cluster-randomization procedure. After enrolling,
providers recruited eligible families from their existing caseload. A study yer and recruitment video were
available to provide interested families more study details. Interested families were contacted by the
study coordinator via phone and eligible families consented and enrolled electronically. The current study
focused on evaluating the impact of C-ESDM on 3 levels: providers’ use of parent coaching strategies,
parents’ use of interactive strategies, and toddlers’ developmental level.
Thirteen agencies, 35 providers (all female), and 34 families enrolled in the project. Seven agencies (14
providers) were randomized to the C-ESDM and six agencies (17 providers) were randomized to the
comparison group. One agency (with two providers) and an additional provider at a different agency
withdrew after assignment to the comparison group before providing any demographic or intake data.
One provider (C-ESDM) provided intake and demographic data but withdrew before attending any
webinars. One provider (comparison group) withdrew after completing demographic information but did
not provide an intake session. In all, this left a nal sample of 32 providers reporting demographic
information and 31 providers with at least one provider delity data point. (See Table1 for demographic
information about providers.
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Table 1
Provider Demographic Characteristics, by State and Group, shown as percentages of the group.
Measure State Treatment Group
 AL
 = 4)
 = 8)
 = 11)
 = 9)
 = 14)
 = 18)
Provider Race/Ethnicity (%)
White 50 75 100.0 100 92.9 83.3
Black/African-American 50 - - - - 11.1
Prefer not to answer - 25 - - 7.1 5.6
Hispanic or Latina - 25 - - 14.3 -
Highest Education (%)
Associate - - 9.1 11.1 14.3 -
 Bachelor - 25 9.1 33.3 21.4 16.7
Master 100 62.5 81.8 55.6 64.3 77.8
Doctorate - 12.5 - -  5.6
Typical Intensity of Services Provided
1–2 hours per month 100 50 - - - 44.4
3–5 hours per month - 50 90.9 100 85.7 55.6
More than 5 hours per month - - 9.1 - 14.2 -
Agency eligibility criteria included: 1) agency receives some PartC funding; 2) agency serves low income
families (dened as below the state mean income; 3) agency provides low-intensity services (fewer than
15 hours per week); 4) agency has at least two providers without previous ESDM training willing to
participate in the study. Provider eligibility criteria included: 1) employed as an early interventionist at a
participating agency; 2) no previous training in ESDM; 43 serving or will serve one or more children with
social-communication delays with high likelihood of ASD. Providers’ formal titles varied, but most were
credentialed professionals working as early educators (early childhood special educators, special
instructors or developmental interventionists) or allied health specialists (Speech-Language Pathologists,
Physical and Occupational Therapists). Inclusion criteria for families and children included: 1) child
chronological age between 12 and 30months at study intake; 2) child’s provider is concerned about
possible ASD and child meets risk criteria on either the Modied Checklist for Autism in Toddlers, Revised
(M-CHAT-R; Robins, Fein, Barton, & Green, 2001) or Infant-Toddler Checklist (ITC; Wetherby & Prizant,
2003); 3) child is ambulatory with unimpaired hand use; 4) child does not have signicant motor, medical,
vision, or hearing problems or genetic conditions associated with ASD; 5) child receives fewer than 10
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hours per week of early intervention (including the EI agency and other intervention sources such as
applied behavior analysis); 6) English is used at least 60% of the time in the home and parent is able to
consent and complete questionnaires in English; 7) participating caregiver is child’s legal guardian; 8)
participating caregiver is willing to attend scheduled intervention sessions with participating provider; 9)
parent has not previously received ASD-specic parent coaching; 10) family income is below the state
mean. In response to recruitment challenges, eligibility criteria for children and families were changed
midway through the study to allow for 1) increased family income ( in the last year we removed all
income restrictions and 2) removal of requirement involving (1) provider concerns about ASD risk and (2)
requirement that children meet ASD risk criteria on a screening tool. Even so, the enrolled children did in
fact show ASD risk on screeners. Four children were screened using the ITC; all met concerns criteria.
Twenty-ve of the remaining children were screened using the M-CHAT-R and scored with “high” or
“moderate” ASD concerns. There were no statistically signicant differences between the intervention and
comparison groups related to sociodemographics (proportion non-white, maternal education greater than
high school, or income of $50,000 or more). Demographic characteristics of parents and children in each
state are presented in Table2.
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Table 2
Child and Family Participant Demographic Characteristics, by State and Group
Measure State Treatment Group
 AL
 = 6)
 = 8)
 = 13)
 = 7)
 = 14)
 = 20)
Child Age at Enrollment (M,
SD) 25.02,
4.58 24.98,
4.42 26.84,
3.77 25.51,
2.85 26.8,
2.35 25.11,
Child Sex (% male) 83.3 37.5 69.2 100 71.4 70.0
Child Race/Ethnicity (%)
White 16.7 100 76.9 28.6 64.3 60.0
Black/African-American 83.3 - 15.4 42.9 28.6 30.0
 Asian - - - 14.3 - 5.0
 Multiple - - 7.7 14.3 7.1 5.0
Hispanic or Latino - 25 23.1 42.9 28.6 20.0
Maternal Education (%)
 High
School/GED/Vocational 16.7 62.5 23.1 57.1 42.9 35.0
Some College 16.7 25 46.2 28.6 28.6 35.0
College Degree 16.7 - 30.8 14.3 28.6 10.0
Graduate Degree 50 12.5 - - - 20.0
Family Income (M, SD) 43,966;
Training Procedures
Intervention Group. The C-ESDM intervention delivery consisted of ve components: 1. providers’ real-time
webinars with trained ESDM parent coaches and in self-study, 2. providers’ group procedural learning
through video review with the coach, 3. parents’ real-time learning during parent coaching with their
providers, 4. parents’ independent learning through HIIYH videos and materials including parent manual,
and 5. child learning through interactions with their parents within everyday activities.
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Core learning materials:
1. Parent manual “An Early Start for your Child with Autism” (Rogers et al., 2012);
2. Website “Help Is in Your Hands” with its narratives, videos, and exercises
3. Provider video materials, training sessions and tools on the Help Is in Your Hand website;
4. Parent Refrigerator Lists, which cover the main topic of each week’s intervention session;
5. P-ESDM Parent Fidelity of Implementation Scale;
6. P-ESDM Coaching Fidelity of Implementation Scale;
7. Coach’s list of child objectives from the child’s IFSP broken down into 4–5 learning steps;
8. Child session data sheet capturing progress through objectives and learning steps.
C-ESDM providers received access to learning materials, webinars, and video coaching via telehealth in
the C-ESDM strategies and in how to coach parents to implement these strategies. The training program
included the materials listed above: methods of measuring child, parent and provider progress, provider
training materials, and on-line parent lessons and materials. Prior to training, providers completed brief
on-line knowledge assessments related to understanding of adult learning principles, early signs of
autism, and parent coaching strategies. If they did not receive a score of 80% or better they reviewed brief
videos introducing these concepts prior to beginning training. They also reviewed a brief introduction to
the parent materials.
Providers attended four weekly telehealth group meetings that included a concept presentation, video
examples, and discussions with 3–4 other providers from their agency. Meeting leaders were certied
ESDM trainers who had developed the C-ESDM procedures and materials. Session topics included: (1) an
introduction to HIIYH and Parent Coaching; (2) Parent Coaching structure and strategies; (3) building
specic treatment objectives from IFSP goals and simple tracking methods for child progress; and (4)
supporting parent learning. Each meeting included both didactic information as well as interactive
activities related to the topic. Between session activities included practice using materials provided (e.g.,
coding intervention delity; practicing with data collection). Once providers completed the initial webinar,
they began to use HIIYH with an enrolled family and met monthly for group supervision with their meeting
leader. Enrolled parents received access to the HIIYH parent materials and the ESDM parent manual and
providers could use any of the video and written materials and strategies during their PartC early
intervention sessions with enrolled families.
Comparison group. The comparison group received directions to access publicly available online
modules (All About Young Children: AAYC, CA Dept Ed 2013; of high quality
covering early developmental milestones from birth to 60 months in 5 domains: 1) social-emotional
development, 2) language development and literacy; 3) number sense; 4) physical development; and 5)
approaches to learning. The website included videos with examples of strategies to promote child
development that could be viewed by providers and parents. Providers in the comparison group met
monthly (for 6 months) via telehealth with a leader (developmental psychology PhD and early childhood
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specialist) who reviewed the materials covered and provided structured discussion on each topic but did
not offer concrete suggestions for either parent coaching strategies or child interaction strategies.
Providers could use the materials in their PartC intervention in any way they wished.
Assessment Procedures
Provider Assessments. Providers completed online questionnaires and session videos at study enrollment
and exit (6 months later, or whenever their nal family completed intervention). The initial provider video
was taken of a session with a consented PartC family who was receiving ongoing intervention with that
provider, in order to sample provider’s typical parent-coaching strategies used. During a PartC
intervention session. After training and initiation of intervention with the project children enrolled in
experimental or comparison groups, providers recorded each intervention session on a project-supplied
iPad and uploaded the session videos to a secure, HIPAA-compliant website. The nal video uploaded by
each provider was selected as their “exit” video. Note that families/children in provider initial videos were
not necessarily the same families/children that providers worked with and lmed for the exit videos.
Raters naïve to timepoint coded provider delity from each intake and exit video. Analysis of provider
change in delity focused on the initial and the last available session of the provider with the target child.
The mean number of weeks between the provider initial and exit intervention sessions was 17.23 weeks
(SD 7.03), which did not differ between the groups (
 > .49). To track number of hours delivered, providers
were asked to complete weekly online questionnaires indicating whether a session was scheduled with
each family and whether it took place as scheduled.
Parent and Child Assessments
We reached out to our University partners (participating in the research community partnership that
developed C-ESDM) in each state for help with child assessments and recruited seven assessors (all
female), including graduate students (n = 1) and early intervention professionals (n = 6) working in their
local communities. These assessors were hired as contractors (not participants) for the project and were
naïve to provider group assignment. The study team sent each assessor a kit with a recording device,
forms and necessary toys and stimuli to complete the assessments. The child assessments included two
primary components: 1) A parent-child interaction and; 2) the ESDM Infant-Toddler Curriculum Checklist
(IT-CC; Rogers et al., 2020 described below). For the parent-child interaction, the assessor asked the parent
to play with their child in their typical way, rst without any objects and then with toys either from home
or from a selection of toys the assessor brought to support the curriculum assessment. The parent-child
interaction lasted up to 20 minutes. The assessor then completed the IT-CC, described in detail below.
Each assessment was digitally recorded for later scoring of parent and child behaviors. In addition to
these live interactions, some parent measures were completed online by the parents. For the very few
parents who did not complete the on-line measures, the assessors provided the surveys as paper and
pencil measures.
Assessor training procedures included one initial telehealth training with a project member on the
assessment procedures. Providers then submitted practice tapes for feedback on administration and
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scoring until they reached delity benchmarks specied for the IT-CC. Following this training, assessors
began seeing families. Family contact information was provided to assessors via secure, HIPAA-
compliant messaging, and assessors contacted families directly to schedule at a time that was mutually
convenient. Assessments were scheduled in families’ homes and lasted approximately 1.5 hours.
Assessors scored the IT-CC live at the time of assessment administration and submitted copies of their
scores and videos of the assessment sessions via a secure website so that their scores could be checked
for accuracy by a trained member of the research team. If an item was missing or incomplete, the
assessor was contacted directly by the Project Coordinator to clarify.
The entire process of recruiting and training providers and assessors, identifying and enrolling eligible
families and children, conducting the intervention, and gathering nal data took approximately one year.
Agencies were enrolled in rolling fashion and all the activities related to conducting the intervention study
other than coding and data analysis were completed in a two-year period.
Infant-Toddler Checklist (ITC; Wetherby & Prizant, 2003). The ITC is a 25-item checklist that assesses
infants’ language, communication, and play skills, and probes for parent concern. Empirically derived cut-
offs for concerns range are available for infants 6 through 24 months. The ITC was used as an eligibility
Modied Checklist for Autism, Revised (M-CHAT-R, Robins, Fein, Barton, & Green, 2001). Is a 20-item
checklist designed to screen for ASD. It provides empirically derived cut-offs for concern and referral
recommendations. The M-Chat was used as an eligibility screener.
ESDM Fidelity Checklist (Rogers & Dawson, 2010). The ESDM Fidelity Checklist consists of 12 items that
are each given a score between 1 and 5, with 5 representing more frequent and higher quality use of each
ESDM strategy and a total possible range of scores from 12 to 60. Trained coders naïve to group and
timepoint scored parents on the Fidelity Checklist from parent-child interactions lmed at the
assessments. Coders scored two routines from each assessment: one routine without toy play and one
with toy play. Routines had to last a minimum of one minute to be coded. Scores were averaged across
items for two routines for an average total delity rating. Twenty-nine percent of videos were
independently coded by both coders for reliability. Intraclass correlation coecients indicated high
reliability: ICC = 0.85 (CI:0.62–0.95).
Coaching Practices Rating Scale (CPRS, Rush & Shelden, 2011). A modied version of the Coaching
Practices Rating Scale (Rush & Shelden, 2011) was used to evaluate providerdelity of implementation.
Each of the 13 items were rated on a binary scale of present or absent, and these scores were summed
for a total of 13 possible points. These behaviors were rated by two coders naive to timepoint and group
assignment. Twenty percent of videos were independently coded by both coders for reliability. Intraclass
correlation coecients indicated high reliability: ICC = 0.92 (CI: 0.17–0.98).
Page 12/20
ESDM Infant-Toddler Curriculum Checklist (IT-CC; Rogers et al., 2020). The IT-CC is a criterion-based
measure of early development that spans the developmental range from 8 to 30 months and is adapted
from the Early Start Denver Model Curriculum Checklist (ESDM; Rogers & Dawson, 2010). The IT-CC
consists of 136 items organized in 9 developmental domains: Gestures Understood, Words Understood,
Gestures Produced, Words Produced, Joint Attention, Dyadic Engagement, Imitation, Cognition, and Play
Skills. Items are assessed during semi-structured play- and routines-based interactions carried out over
approximately 90 minutes using a standard set of play materials. Each IT-CC item is rated as ‘acquired’,
‘partial/prompted’, or ‘unable or unwilling’, based on child behavior during play-based interactions
throughout the entire assessment, as well as parent report. On the IT-CC, a score of ‘acquired’ on a given
item represents a mastery level of that skill and is credited. No other score receives credit. The Cognitive
domain was not utilized during the current study after pilot testing indicated the additional required
materials were too burdensome for assessors to travel with into families’ homes. Thus, nal scores for
this study consist of one point per ‘acquired’ item, for a total score out of 124 possible points, expressed
as a raw score (IT-CC Total Score). A team of gold-standard coders at the primary university site, naive to
timepoint and group assignment, scored the IT-CC from videos. Their scores were used for all analyses,
rather than the home assessors’ scores, because of the potential for assessors to become unblinded to
family/provider group assignment. Intraclass correlation coecients of assessors and gold standard
coding team indicated high reliability: ICC = 0.93 (CI: 0. 89 to 0.95).
A series of regression analyses were used to model outcomes of the coach behaviors, the parent delity
ratings, and child outcomes. Preliminary analyses revealed that there were no site differences on intake
variables (p 0.06). Therefore, a non-nested approach was taken. A block design model-building
approach was used to test the null model (accounting only for pretest), followed by the inclusion of group
as a predictor to address the primary research question, and nally the inclusion of the planned
covariates. Variables that were signicant predictors of outcome were retained in the model. Model t
was examined using changes in R2 and the F-statistic. The rst model tested the impact of the C-ESDM
training on the outcome of coaching behaviors. The providers’ initial level of Coaching Practices delity
and group assignment were included, in that order, to understand the effect of group assignment on
provider delity. The second model tested the impact of the C-ESDM intervention on parent delity. The
parent’s initial level of delity and group assignment were included, in that order, to understand the effect
of group assignment on parent delity. The third model tested the effect of the C-ESDM parent coaching
intervention on child outcomes. The child’s pretest score, group assignment, and changes in parent
delity were included in the model in that order, to understand the effect of group assignment and the
possible contribution of changes in the changes in parent delity on child outcomes. All interaction terms
between pretest variables and group assignment were examined. All statistical analyses were completed
using SPSS Statistics V. 26.
Page 13/20
Providers in both conditions attended an average of 78.36% of possible webinars/coaching contacts,
which did not differ by group (
(29) = 0.86,
 = 0.93). This translated to a mean of 9.71 hours of webinar
training/supervision sessions attended (SD = 2.11) by the C-ESDM group and 5.71 hours (SD = .47)
attended by the comparison group providers. Provider-reported weekly session attendance data indicated
no group differences in the number or proportion of family sessions completed (sessions completed:
MeanC−ESDM = 11.09, SDC−ESDM = 5.99, Meancomparison = 14.25, SDC−ESDM = 5.68, t(15.72) = 1.71,
 = 0.26;
percent sessions attended: MeanC−ESDM = 54.08%, SDC−ESDM = 20.28, Meancomparison = 64.33,%
SDcomparison = 12.66, t(16.73) = 1.35,
 = 0.19).
Coaching Outcomes
Regression analyses of coaching behaviors showed that initial coaching behavior rating was not
signicantly related to exit coaching behaviors (β = 0.24, se = 0.27, p = 0.38). To test the hypothesis that
inclusion in the C-ESDM intervention would result in the use of more coaching behaviors, group was
entered into the null model. Participation in the C-ESDM group predicted a signicant increase in
coaching behaviors compared to the control group (β= 4.30, se = 1.40, p = 0.007), with a signicant
improvement in model t (R2 change = 0.34, F = 9.39, p = 0.007). Observed means and standard errors for
three primary outcome variables are shown in Table3.
Table 3
Mean (SE) of outcome variables at initial and exit assessments.
C-ESDM Comparison (AAYC)
 Pre
(n = 20)
(n = 13)
(n = 12)
(n = 10)
Coaching Score 4.83 (0.62) 7.67 (0.74) 3.54 (0.93) 3.25 (1.20)
Parent Fidelity 3.24 (0.12) 3.66 (0.15) 3.21 (0.12) 3.15 (0.14)
Child IT-CC Total Score 41.40 (5.45) 59.85 (9.63) 44.75 (7.60) 62.50 (10.27)
ANOVAs showed no signicant differences between groups at intake (p0.24).
Parent Fidelity Outcomes
The C-ESDM group attended on average 11.09 sessions (sd.5.99), which was 54.08% of scheduled
sessions (SD 20.28%), and the comparison group attended on average 14.25 (SD = 5.68) sessions,
64.33% (SD = 12.66%) of scheduled sessions. The groups did not differ signicantly on number of
sessions (t = 1.71, df = 15.72. p = 0.26) or percentage of scheduled sessions (t = 1.35, df = 16.73, p = 0.19).
Page 14/20
The results of the regression analyses showed that pretest parent delity was signicantly related to
posttest delity (β = 0.48, se = 0.22, p = 0.04). To test the hypothesis that inclusion in the C-ESDM
intervention would result in higher parent delity ratings, group was entered into the null model.
Participation in the C-ESDM group predicted a signicant increase in parent delity compared to the
control group (β= 0.520, se = 0.20, p = 0.02), with a signicant improvement in model t (R2 change = 
0.19, F = 6.40, p = 0.02).
Child Outcomes
The results of the regression analyses indicated that initial IT-CC total score was signicantly related to
exit score (β = 1.16, se = 0.14, p < 0.01). To test the hypothesis that inclusion in the C-ESDM intervention
would result in higher child scores, group was entered into the null model. Participation in the C-ESDM
group did not result in a signicantly greater change in child scores compared to the comparison group
(β= 1.17, se = 7.32, p = 0.87). Initial scores were signicantly related to exit scores (p < 0.01). Changes in
parent delity were not related to child outcomes (β = 5.49, se = 6.48, p = 0.40). Interactions between initial
variable data and group assignment were examined for all analyses but these interactions were not
Brief summary. This implementation feasibility study research-community partnership approach
(Brookman-Frazee et al., 2012) was designed and executed in order to determine whether an evidence-
based parent-implemented distance-learning intervention model for young children with or at high
likelihood of having ASD: (1) could be learned and implemented at delity by community providers after
very brief group training, (2) whether community providers could coach parents in ways that effectively
transmitted evidence based skills in an average of one contact per week or less, as measured by delity
of implementation measures, and (3) whether children of parents receiving the parent coaching model
would demonstrate positive benets in comparison to children whose parents received information on
child development only. The study used a three-phase model, beginning with input from community
partners in six sites. Phase two involved a component analysis of the parent model to determine which of
the strategies to emphasize, some pilot work to test the training and coaching intervention methods.
Phase three involved this pilot - controlled trial involving randomization by agency in four states and
enrollment of 35 coaches working in the PartC system and 34 parent-family dyads. Families of
qualifying children (based on social communicative delays and ASD risk) were enrolled by their EI
providers and initial baseline data on provider coaching, parent-child interactions, and child development
were gathered. Providers in the experimental group then received up to 12 hours of training via webinars,
group sessions, and asynchronous learning materials, followed by initiation of intervention with enrolled
families. Comparison group providers received six webinars on various aspects of early development,
followed by initiation of intervention with children-families.
Page 15/20
After approximately six months of intervention at whatever schedule the agency typically delivered
(ranged from 2 hours per week to 1 hour per month), video measures of provider interactions with the
dyad and videos of parent interactions with child were collected again as was developmental information
on children (collected by a naïve evaluator). Results demonstrated signicant gains in delity to the
coaching model of providers in the experimental group compared to those in the control group. Results
also demonstrated signicant gains in delity to the intervention strategies of parents in the experimental
groups compared to those in the comparison group, supporting the primary and secondary hypotheses of
the study. Gains in provider coaching delity were not related to baseline coaching scores; however, gains
in parent intervention delity were related to baseline delity scores. There were no signicant differences
between groups in child developmental scores.
This study focused on adaptation of a well-tested intervention to t the needs of public agencies,
providers, and families in four low resource areas across the country, chosen because these settings have
very limited services and the families often face many diculties in accessing high quality intervention
for their young children at risk for ASD. The sites involved both urban and rural settings in locations
where intensive services for young children with ASD were not available, nor was expertise in ASD present
in the agencies that participated. Involvement of community representatives in various sites allowed for
needed guidance about the needs, strengths, values and priorities of providers and families in each
region. Use of distance learning and self-instructional learning activities was necessary because of the
very limited time allowed by agencies for provider training and because of the geographic distances
involved. Providers in the C-ESDM group met in small groups with a project coach one hour every two
weeks for the rst three months of the project, tapering off to once monthly by month six. Community
providers delivered all interventions with parents and children; the project coaches never interacted with
the family nor did they provide direct coaching to the providers during sessions. To our knowledge, other
parent-mediated implementation studies have not relied on local providers to implement the experimental
intervention in low resource settings, nor have they relied on distance learning and such limited contact to
teach the intervention to the coaches. Even though the research project coaches averaged less than 30
minutes weekly in contact with the provider group over a 6 month period, and no time at all with the
parents, both providers and parents in the experimental group demonstrated statistically signicant gains
with moderate effect sizes compared to the comparison group. Since child changes in parent -mediated
models are dependent upon the parents’ ability to deliver the intervention, and since parent delivery is
dependent upon providers who are coaching the parents, these results demonstrated that both of these
links of the chain were positively affected by the implementation model being tested here.
However, lack of child change as measured by experimenter-administered measures suggests that further
work is needed on this model. Our group sizes were not large enough to analyze factors inuencing child
change. Factors to consider include amount of contact with the provider, amount of practice children
experience, amount of parent time spent on learning, and motivational strategies for parents. One of the
Page 16/20
settings we worked in provided only one hour per month of contact, and if illness, schedules, or holidays
required cancellation, no make-up sessions could be provided. Given our own ndings regarding weekly
parent-coaching visits (Rogers et al 2019), it is dicult to imagine that a parent could learn to embed
helpful strategies into natural routines and maintain new learning for a young child with autism
symptoms with only one hour per month of contact. Thus, follow-up research is needed to determine
what factors are necessary for changes in parent interaction strategies to permeate child behavioral
A recent replication of these methods, not yet published, in British Columbia, found similar positive results
in provider and parent delity, as well as signicant positive changes in parent questionnaire measures,
though not standardized measures, of child progress on multiple measures of development and
symptoms in the experimental group. Positive change measured on standardized measures from a
parent-mediated intervention is a very high bar. Very few low intensity parent-mediated models have
published positive child effects as measured by standardized developmental measures. However, since
change on standard scores is widely considered the most rigorous evidence of child improvement, and
since many studies of intensive autism intervention have shown that such change is possible, we nd it
important to continue to strive for this outcome as well.
Until replication of the C-ESDM model demonstrates positive child-level ndings, additional research is
needed to further develop and test this approach. However, the underlying principles – use of distance
technology to transmit strategies from existing ecacious models to community providers and to
parents - were both feasible and successful in this study, have been well documented in the literature
(Ashburner, Vickerstaff, Beetge, & Copley, 2016; Shire, Baker Worthman, Shih, & Kasari, 2020; Sutherland,
Trembath, & Roberts, 2018; Vismara et al., 2018; Vismara, Young, Stahmer, Grith, & Rogers, 2009; Wainer
& Ingersoll, 2015) and thus can be considered an evidence-based practice.
The data gathered from this pilot RCT, designed to determine the feasibility of enhancing use of evidence-
based early intervention practices for the youngest children with or at risk for ASD living in low resource
areas of the United States, suggests that provider evidence-based coaching practices can be signicantly
enhanced, with resulting signicant enhancements in parent use of evidence-based interaction practices
following implementation of low - cost distance learning activities and oversight for providers. Signicant
enhancement in parent interaction strategies occurred even though the experimental parent group
averaged less than 30 minutes weekly with providers over a 6- month period. Since child changes in
parent mediated models are dependent upon the parents’ ability to deliver the intervention, and since
parent delivery is dependent upon providers who are coaching the parents, these results demonstrated
that two of these three links of the chain were positively affected by the experimental implementation
model. However, lack of signicant differences in child group gains points out that further work is needed
to increase effectiveness of the model.
Page 17/20
NDBI: naturalistic developmental-behavioral intervention; ASD: autism spectrum disorder; EI: early
intervention; EBP: evidence-based practice; ESDM: Early Start Denver Model; P-ESDM: parent-
implemented Early Start Denver Model; IFSP: Individualized Family Service Plan; C-ESDM: Community
Early Start Denver Model; HIIYH: Help Is In Your Hands; AAYC: All About Young Children; M-CHAT-R:
Modied Checklist for Autism in Toddlers, Revised; ITC: Infant-Toddler Checklist; IT-CC: Infant-Toddler
Curriculum Checklist; HIPAA: Health Insurance Portability Accountability Act; CPRS: Coaching Practices
Rating Scale.
Ethics approval and consent to participate: This study was approved by University of California Davis
Institutional Review Board Investigator: Rogers, Sally, PhD IRB ID: 780328-19. All providers and family
members gave consent to participate and to be videorecorded.
Consent for publication: not applicable
Availability of data and materials: The datasets and unpublished materials used and/or analyzed on this
study are available from the corresponding author on reasonable request.
Competing interests:
SJR receives royalties from Guilford Publishing Company for project manuals used in this study.
AS, MT, GY, EF, MP, AB,& EG: no competing interests
Funding: This research project was funded by a grant from the Institute for Education Science
(R324A150211 PI: Rogers) which covered all costs associated with the design and execution of this
study. Dr. Fuller’s time was supported by NIMH grant T32 MH07312. The project also received support
from the MIND Institute IDDRC, funded by the National Institute of Child Health and Human Development
(P50 HD103526 PI: Abbeduto).
Authors contributions: all authors read and approved the nal manuscript.
SJR: contributed to the design of the study, provided training to the C-ESDM providers, designed the HIIYH
website materials, helped choose measures and plan the analyses, and was the lead author on this paper.
AS: contributed to the design of the study, provided training to the C-ESDM providers, worked with Dr.
Rogers on development of the HIIYH materials, helped choose measures and develop the paper
introduction, provided input throughout the paper.
MT: delivered training to comparison group, trained assessors and supervised in-home assessments and
naïve coders, and contributed to data analysis, interpretation, and writing of this manuscript.
Page 18/20
GY: planned, supervised or conducted all analyses and contributed to methods and results sections of the
EF: contributed to the data analysis and write-up of the results
MP, AB, & EG: contributed community perspectives that guided that design and execution of the study
Acknowledgements The authors wish to acknowledge the tremendous contributions of MaryKate Miller to
the management of this study, our community partners in Alabama, California, Colorado, Montana, New
Mexico, and Pennsylvania for their input into the design and development of HIIYH, and the providers,
children and families who participated in the study.
Authors’ information – NI
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... Several of these studies found that coaching was effective in improving parent use of ESDM techniques and that child outcomes also improved in one or more domains (e.g., Vismara et al., 2009Vismara et al., , 2012Vismara et al., , 2013Waddington et al., 2021;Zhou et al., 2018). Other P-ESDM research found outcomes in favor of parent change but not child change (e.g., Rogers et al., 2019Rogers et al., , 2020Vismara et al., 2018). Finally, one P-ESDM study found no significant difference between coaching and control groups for either parent or child outcomes (Rogers et al., 2012a, b). ...
... Another limitation of the current body of ESDM research has to do with the inclusion/exclusion criteria applied to parents. Many studies excluded children whose primary caregiver met one of the following criteria: (a) self-reported substance abuse and/or significant mental illness (e.g., Rogers et al., 2012aRogers et al., , b, 2019; (b) lived farther than a specified distance from the University clinic that housed the study (e.g., Rogers et al., 2014Rogers et al., , 2019; and/or (c) did not meet various criteria for spoken and/or written English language ability (e.g., Rogers et al., 2020;Vismara et al., 2018). While none of these criteria is unreasonable in the context of a research efficacy study, they become untenable when applied to publicly-funded community services where families rightfully expect equitable access regardless of their child's diagnosis, their own language/literacy skills, and their ability to participate with regularity. ...
... In line with these efforts, Rogers et al. (2020) conducted a randomized feasibility trial aimed at addressing the need for preemptive autism supports in low-resourced rural and urban communities. Early intervention providers in participating community agencies were randomized to receive streamlined training in either a modified version of ESDM (called Community ESDM, C-ESDM) or a comparison intervention. ...
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A randomized feasibility trial of a parent coaching (PC) intervention was conducted across 16 community agencies in a Canadian province. Parents of toddlers with suspected autism were assigned to either a PC group (n = 24) or an enhanced community treatment (ECT) group (n = 25). PC participants received 24 weeks of coaching support from community service providers trained in the project. Children in both groups also received available community services and supplementary materials. PC children made significantly greater gains in word understanding and PC parents had significantly higher quality of life, satisfaction, and self-efficacy scores. Results are discussed in terms of the challenges of conducting feasibility studies in community settings and the lessons learned in the project.
... WHO-CST is a naturalistic behavioral intervention, and as such, implementation takes place during naturally occurring home and play routines requiring high levels of clinical judgment. In consequence, training of non-specialists might need more practice and coaching than more directive and structured interventions (82)(83)(84). Other studies have found that administrative support, the interactive nature of the training, and the compatibility of the training model with Facilitators' current practices facilitate the training process (54). ...
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Background For families with autistic children living in rural areas, limited access to services partly results from a shortage of providers and extensive travel time. Telehealth brings the possibility of implementing alternative delivery modalities of Parent Mediated Interventions (PMIs) with the potential to decrease barriers to accessing services. This study aimed to evaluate the feasibility and acceptability of implementing the World Health Organization-Caregivers Skills Training program (WHO-CST) via an online, synchronous group format in rural Missouri. Methods We used a mixed methods design to collect qualitative and quantitative data from caregivers and program facilitators at baseline and the end of the program, following the last home visit. Caregivers of 14 autistic children (3–7 years), residents of rural Missouri, completed nine virtual sessions and four virtual home visits. Results Four main themes emerged from the focus groups: changes resulting from the WHO-CST, beneficial aspects of the program, advantages and disadvantages of the online format, and challenges to implementing the WHO-CST via telehealth. The most liked activity was the demonstration (36%), and the least liked was the practice with other caregivers. From baseline to week 12, communication skills improved in both frequency ( p < 0.05) and impact ( p < 0.01), while atypical behaviors decreased ( p < 0.01). For caregivers' outcomes, only confidence in skills ( p < 0.05) and parental sense of competence ( p < 0.05) showed a positive change. Conclusion Our results support the feasibility of implementing the WHO-CST program via telehealth in a US rural setting. Caregivers found strategies easy to follow, incorporated the program into their family routines, and valued the group meetings that allowed them to connect with other families. A PMI such as the WHO-CST, with cultural and linguistic adaptations and greater accessibility via telehealth-plays an essential role in closing the treatment gap and empowering caregivers of autistic children.
... To address some of these concerns, NDBI researchers have examined the effectiveness of various streamlined approaches for training community-based providers via online instruction (e.g., Rogers et al., 2020;Rooks-Ellis et al., 2020;Vismara et al., 2009), in vivo instruction (e.g., Stahmer et al., 2020), or a combination of the two (e.g., Chang et al., 2016;Shire et al., 2017). Results have been mixed with regard to post-training fidelity. ...
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This study evaluated the fidelity and effectiveness of a parent coach training program for toddlers at risk for autism spectrum disorder and identified factors required for successful training implementation under real-world conditions. Training addressed four tiers of clinical competence and was delivered to early intervention providers across 23 partner agencies in a large Canadian province. Results indicated that mean trainee fidelity scores were within the range reported in previous community-based training studies but there was considerable variability across trainees. Implementation facilitators included agency learning climate, leadership support, and trainee readiness for change. Implementation barriers included time/caseload demands and challenges related to technology learning and infrastructure. Results have implications for parent coach training in community settings.
... With this in mind, there has been growing interest to embed early ASD interventions within the EI system (Stahmer et al. 2017;Vivanti et al. 2018). Recent research has suggested that, when NDBIs are moved into the EI system, they are perceived as feasible and acceptable by EI providers and may have positive outcomes for families of young children with ASD and social communication delays, even if delivered at somewhat low intensity (Stahmer et al. 2017;Rogers et al. 2020a). This research has been foundational in building an understanding of how to translate NDBIs into systems naturally positioned to serve both children with a known diagnosis of ASD in addition to children with an increased likelihood of having ASD (Vivanti et al. 2018). ...
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Naturalistic developmental behavioral interventions (NDBIs) are evidence-based interventions for young children with autism spectrum disorder. There has been growing interest in implementing manualized NDBIs within the early intervention (EI) system without a clear understanding of how these programs and the broader strategies encompassed within them are already used by EI providers. This study examined the use of manualized NDBI programs and broader NDBI strategies within an EI system and factors that impacted their use. Eighty-eight EI providers completed a measure of NDBI program and strategy use. Thirty-three providers participated in a supplemental focus group or interview. Overall, providers described using broader NDBI strategies and the need to adapt manualized NDBI programs. Provider-, intervention-, and organization-level factors impacted their use of NDBI programs and strategies.
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Background and Aims Early intervention (EI) for young children with autism spectrum disorder (ASD) must be resource-efficient while remaining effective; thus, clinicians are challenged to create and implement useful methods. Clinical evidence from community-based interventions that include reliable diagnoses, individual EI programs, along with comprehensive descriptions of participants, procedures, and participant outcomes can inform practice, translational research, and local policy. Parent-mediated EI for toddlers with ASD can promote positive developmental outcomes and lifelong well-being, but evidence of successful community uptake of research-based EIs is somewhat limited. The community-based, parent-mediated, evidence-informed QuickStart EI program aims to encourage toddlers’ early social communication, social interactions, and relationship-building, in a community clinic setting. We aim to (1) describe our adaptations to the evidence-based Parent-Delivered Early Start Denver Model and (2) present promising findings for toddlers with or at risk for ASD and their families who received QuickStart. We also intend to motivate a similar study of EI in real-world situations to advance evidence-based practice and create relevant dialogue and questions for research. Methods Complete data were identified and analyzed for up to 89 toddlers diagnosed with, or at risk of, ASD. Pre- and post-intervention parent- or self-report data were analyzed using descriptive statistics and paired-sample t-tests, as appropriate. Pre-intervention measures included demographic information ( n = 89) and the Early Screening of Autism and Communication (ESAC; n = 89). Measures taken pre- and post-intervention included the Adaptive Behavior Assessment System-II ( n = 60), MacArthur-Bates Communication Development Inventories ( n = 58), and the parental sense of competence scale ( n = 62). The Measure of Processes of Care ( n = 60) was taken post-intervention. On enrollment, parents signed standard clinical agreements that included statements allowing their anonymous data to be analyzed for research. Results Using standardized parent/self-report measures, toddler gains were noted for social interaction, language, communication skills, and ASD symptoms, but not for parents’ feelings of competence. Parents identified QuickStart procedures as family centered (Measure of Processes of Care). Conclusions The QuickStart EI program, provided to toddlers and their families over 20 weeks in a community clinic, resulted in promising positive behavior and communication changes, as indicated on the parent-response measures, for a moderately large sample of toddlers. Implications This study adds to the literature by describing a new EI program with clear procedures by which clinicians can create, provide, and evaluate a readily accessible, community-based EI for toddlers with or at risk of ASD. Methodological limitations inherent to our study design that precluded a control group and necessitated a reliance on available parent-report data are carefully critiqued and discussed.
Lay abstract: Many early autism interventions teach parents therapeutic strategies to help them adjust their communication style with their children. Research has shown that this behaviour change in parents leads to improvements in child communication. It is, therefore, important to learn what factors support or hinder parents in their use of therapeutic strategies learned in such interventions. This study set out to interview parents who had participated in a research trial of the Paediatric Autism Communication Therapy-Generalised intervention. We interviewed 27 caregivers and explored their use of the strategies up to 2 years after the end of the research trial. Qualitative frameworks were used to inform interview questions and data analysis. These frameworks focused on a range of contextual factors, including parents' characteristics, their context and features of the intervention. Parents reported barriers and facilitators to using Paediatric Autism Communication Therapy-Generalised strategies across three themes: Motivating Factors; Opportunity and Support; Parent Characteristics. One of these themes, Motivating Factors, was further divided into the subthemes Compatibility and Buy-In and Alignment of Goals and Outcomes. Almost all parents reported continued use of the Paediatric Autism Communication Therapy-Generalised strategies. Facilitators included parental confidence in using the strategies and barriers included child's behaviour. Consideration of these factors can inform ways to better support parents in future autism interventions.
Lay abstract: Interventions to address core symptoms for young children on the autism spectrum have a strong and growing evidence base. Adapting and delivering evidence-based interventions to infants and toddlers with a high likelihood for autism is a logical next step. This systematic review and meta-analysis summarize the association between infant and toddler interventions and developmental and family outcomes. Results indicate that these early interventions are effective for improving parent implementation of core strategies, yet the effects do not readily translate to child outcomes. However, key studies demonstrate conditional results that indicate that parent implementation is associated with child outcome. Implications for research and practice toward building adaptive interventions that respond to parent implementation and changing child characteristics are discussed.
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This meta-analysis examined the effects of the Early Start Denver Model (ESDM) for young children with autism on developmental outcome measures. The 12 included studies reported results from 640 children with autism across 44 unique effect sizes. The aggregated effect size, calculated using a robust variance estimation meta-analysis, was 0.357 (p = 0.024), which is a moderate effect size with a statistically significant overall weighted averaged that favored participants who received the ESDM compared to children in control groups, with moderate heterogeneity across studies. This result was largely driven by improvements in cognition (g = 0.412) and language (g = 0.408). There were no significant effects observed for measures of autism symptomology, adaptive behavior, social communication, or restrictive and repetitive behaviors.
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Technology-enabled interventions have the potential to break through barriers related to travel time and access in rural and remote communities. Practitioner training to provide high-quality behavioral interventions for children with autism spectrum disorder (ASD) is typically resource intensive including multiday trainings and ongoing live coaching. Although technology-enabled training including video conference and video review may be more accessible, technology may also introduce unique challenges by increasing the coach’s reliance on verbal feedback and reducing their ability to use common strategies such as modeling and environmental arrangement. Therefore, it is not clear whether technology-enabled training will result in similar outcomes for interventionists or the children they serve. Secondary analyses of data from a randomized controlled intervention trial compared new interventionists receiving 3 months of face-to-face training (n = 16) to interventionists receiving remote training (n = 11) to deliver a social communication intervention with fifty children age 3–9 with ASD. No significant differences were found in fidelity after 3 months between interventionists receiving face-to-face versus those receiving remote training. Overall, interventionists made significant gains in fidelity and children made significant gains in initiations of joint attention, requests, and play diversity. This study provides preliminary support for the use of a technology-enabled interventionist training protocol.
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In this comprehensive systematic review and meta-analysis of group design studies of nonpharmacological early interventions designed for young children with autism spectrum disorder (ASD), we report summary effects across 7 early intervention types (behavioral, developmental, naturalistic developmental behavioral intervention [NDBI], TEACCH, sensory-based, animal-assisted, and technology-based), and 15 outcome categories indexing core and related ASD symptoms. A total of 1,615 effect sizes were gathered from 130 independent participant samples. A total of 6,240 participants, who ranged in age from 0-8 years, are represented across the studies. We synthesized effects within intervention and outcome type using a robust variance estimation approach to account for the nesting of effect sizes within studies. We also tracked study quality indicators, and report an additional set of summary effect sizes that restrict included studies to those meeting prespecified quality indicators. Finally, we conducted moderator analyses to evaluate whether summary effects across intervention types were larger for proximal as compared with distal effects, and for context-bound as compared to generalized effects. We found that when study quality indicators were not taken into account, significant positive effects were found for behavioral, developmental, and NDBI intervention types. When effect size estimation was limited to studies with randomized controlled trial (RCT) designs, evidence of positive summary effects existed only for developmental and NDBI intervention types. This was also the case when outcomes measured by parent report were excluded. Finally, when effect estimation was limited to RCT designs and to outcomes for which there was no risk of detection bias, no intervention types showed significant effects on any outcome. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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This meta-analysis examined the effects of early interventions on social communication outcomes for young children with autism spectrum disorder. A systematic review of the literature included 1442 children (mean age 3.55 years) across 29 studies. The overall effect size of intervention on social communication outcomes was significant (g = 0.36). The age of the participants was related to the treatment effect size on social communication outcomes, with maximum benefits occurring at age 3.81 years. Results did not differ significantly depending on the person implementing the intervention. However, significantly larger effect sizes were observed in studies with context-bound outcome measures. The findings of this meta-analysis highlight the need for further research examining specific components of interventions associated with greater and more generalized gains.
Children living in geographically rural areas may have limited access to early, intensive evidence-based interventions suggesting children residing in these areas are less likely to experience positive outcomes than their urban-dwelling peers. Telehealth offers an option to rural families seeking early intervention by using communication technologies where providers are able to consult and deliver services in real-time over geographical distances. To our knowledge, no other study has examined the implementation of P-ESDM in rural natural environments within the framework of the state’s early intervention program. Using a multiple baseline design across participants, the current study investigated the effects of the parent-Early Start Denver Model implemented within a rural northeastern state’s existing IDEA Part C early intervention program. Parents demonstrated increased fidelity to intervention strategies and reported satisfaction with the program’s ease of implementation and observed child gains. Statistically significant pre-to post- change in children’s ASD symptomatology were reported for the domains of communication, social reciprocity and repetitive and restricted behaviors. Support for parent-mediated interventions, the importance of fidelity of implementation for sustainability of intervention strategies, and the need to explore telehealth as a viable service delivery option to improve developmental trajectories for toddlers with autism are discussed.
This study reports child and family outcomes from a community-based, quasi-experimental pilot trial of Project ImPACT for Toddlers that is a parent-mediated, naturalistic, developmental behavioral intervention for children with or at-risk for autism spectrum disorder developed through a research–community partnership. Community early interventionists delivered either Project ImPACT for Toddlers ( n = 10) or Usual Care ( n = 9) to families based on Part C assigned provider. Twenty-five families participated, with children averaging 22.76 months old ( SD = 5.06). Family and child measures were collected at intake, after 3 months of service, and after a 3-month follow-up. Results indicate significantly greater improvements in positive parent–child interactions for Project ImPACT for Toddlers than usual care families, as well as large, but non-significant, effect sizes for Project ImPACT for Toddlers families in children’s social and communication skills.
Objective: This single-blind, randomized, multisite, intent-to-treat study was designed to replicate and extend Dawson et al.'s (Pediatrics. 2010;125: e17-e23) randomized controlled trial testing the effects of the Early Start Denver Model (ESDM), an intensive play- and routines-based intervention delivered in natural settings. Method: A randomized controlled trial was conducted at 3 universities. One hundred eighteen children 14 to 24 months old with autism spectrum disorder were enrolled and randomly assigned to ESDM or community interventions for 27 months. Eighty-one children completed the full treatment course and all assessments; data from all 118 children were used in analyses. Children assigned to the ESDM intervention received 3 months of weekly parent coaching followed by 24 months of 15 hour per week (on average) 1:1 treatment weekly on average in homes or daycare settings from supervised therapy assistants while parents received coaching 4 hours monthly from a certified ESDM therapist. Results: For the primary analyses, there were time-by-group and time-by-group-by-site interactions for language outcome. In the significant 3-way interaction involving site, 2 sites showed a significant ESDM advantage and the third site showed no significant group differences. In the planned 2-way analysis that pooled data across all 3 sites, there was a significant advantage found for the ESDM group. For the secondary analyses, there were no significant differences between the ESDM and community groups involving developmental quotient, autism severity, or adaptive behavior. The treatment effect of group on language outcomes was not moderated by baseline developmental quotient, autism severity, or language. Conclusion: Results of the primary analysis provide a partial replication of Dawson et al.'s 2010 language findings. Clinical trial registration information: Intensive Intervention for Toddlers with Autism;; NCT00698997.
Purpose: Research interest in telehealth and autism spectrum disorder (ASD) has grown. There is a need to review the literature to allow speech-language pathologists (SLPs) and other service providers to consider applicability to their settings. The aim of this review was to examine the nature and outcomes of studies examining telehealth assessment and/or intervention in ASD. Method: A systematic search of the literature was undertaken, with 14 studies meeting inclusion criteria. The authors extracted information from each included article, including participant characteristics, technology used, measures and reported outcomes. Quality review of articles was undertaken. Result: The 284 participants with ASD across the 14 included studies ranged in age from 19 months to adulthood. The quality of the studies varied. A range of services were provided via telehealth, including diagnostic assessments, early intervention and language therapy. Results suggested that services delivered via telehealth were equivalent to services delivered face to face, and superior to comparison groups without telehealth sessions. Conclusion: The findings suggest there may be a range of benefits in using telehealth with individuals with ASD, their families, and teachers. Further research, however, is required particularly regarding the use of telehealth directly with children with ASD for assessment and intervention.
One in 68 children has been identified with Autism Spectrum Disorder (ASD), a disorder defined by 1) deficits in social-communication and social interactions and 2) restricted, repetitive patterns of behavior, interests or activities. Research has shown that children with ASD who receive high-quality early intervention (EI) services in university-based research trials can make large gains in cognitive, communication, and adaptive behaviors skills, with positive long term effects. However, less is known about the outcomes for the over 50,000 children who receive EI in community settings. This dissertation provides initial evidence of the current state of community-based EI for children with ASD. Chapter 1 presents a meta-analysis of cognitive, communication, social, and adaptive behavior outcomes for children with ASD in community-based EI programs, and demonstrates that the gains made in the community are much smaller than those observed in university-based trials. In Chapter 2, prospective, longitudinal data collected from a local EI system is studied to understand which characteristics of preschool EI predict cognitive gains for 79 preschoolers with ASD that received publicly-funded services in classroom placements. The best predictor of gains was the utilization of recommended intervention practices to support the development of social and peer relationships. Chapter 3 discusses measurement of executive functioning (EF) among preschoolers with ASD, as executive functioning skills likely play an important role in response to EI. However existing EF measures have not been validated for use with low-functioning, nonverbal preschoolers with ASD. Results are presented from the development and the validation of a battery of nonverbal, performance-based EF tasks. These measures can be utilized in future community-based treatment trials.