INCREASING THE DISSEMINATION OF AN EVIDENCE-BASED ASD INTERVENTION
VIA A TELEHEALTH PARENT TRAINING PROGRAM

By
Allison L. Wainer

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Psychology- Doctor of Philosophy
2014

ABSTRACT
INCREASING THE DISSEMINATION OF AN EVIDENCE-BASED ASD INTERVENTION
VIA A TELEHEALTH PARENT TRAINING PROGRAM
By
Allison L. Wainer
Systematic research focused on developing and improving strategies for the
dissemination and implementation of evidence-based ASD services is essential. An innovative
and promising area of research is the use of telehealth programs to train parents of children with
ASD in evidence-based intervention techniques. A hybrid telehealth program, combining selfdirected internet-based instruction with remote coaching, was created to introduce parents of
children with ASD to an evidence-based imitation intervention. A single-subject multiplebaseline design study evaluated the effect of the program on changes in parent knowledge and
behavior, and changes in child behavior. Parents improved their knowledge and use of the
intervention techniques, and their children demonstrated concurrent increases in spontaneous
imitation skills. Parents also indicated that the intervention and telehealth service delivery model
were acceptable, useable, and effective. Results suggest that this hybrid telehealth program has
the potential to increase access to evidence-based ASD services.

This dissertation is dedicated to my parents, Drs. Beth Volin and Gary Wainer, whose endless
support and last minute trips to East Lansing have made this all possible.

iii

ACKNOWLEDGEMENTS

I would like to thank my mentor, Brooke Ingersoll, for her guidance, support, and
encouragement during this process and throughout my graduate training. I would also like to
thank my colleagues, especially Nikki Bonter and Natalie Berger, for their help with data
collection and video coding, and for their constant support and cheerleading. I am incredibly
grateful for all of the hard work put forth by the parents and children who participated in this
study; getting to know them has been the ultimate reward.

iv

TABLE OF CONTENTS

LIST OF TABLES ...........................................................................................................iiv
LIST OF FIGURES .........................................................................................................iiiv
INTRODUCTION ...........................................................................................................1
METHOD ........................................................................................................................10
Participants ...........................................................................................................10
Settings and Materials ..........................................................................................11
Experimental Design and Study Procedure .........................................................12
Baseline Phase .........................................................................................14
Self-Directed Phase ..................................................................................14
Intervention ......................................................................................14
Delivery Platform .............................................................................14
Program Structure.............................................................................14
Procedure ..........................................................................................15
Coaching Phase ........................................................................................16
Follow-up .................................................................................................17
Dependent Measures ............................................................................................17
Program Engagement ...............................................................................17
Parent Knowledge of RIT ........................................................................17
Fidelity of Implementation of RIT ...........................................................17
Child Imitation .........................................................................................18
Social Engagement and Affect.................................................................18
Parenting Sense of Competence...............................................................20
Parenting Stress ........................................................................................20
Treatment Acceptability.......................................................................................20
Inter-Observer Reliability ....................................................................................21
Missing Data ........................................................................................................21
Data Analysis .......................................................................................................21
RESULTS ........................................................................................................................23
Program Engagement ...........................................................................................23
Parent Knowledge of RIT ....................................................................................23
Fidelity of Implementation of RIT .......................................................................23
Child Imitation .....................................................................................................27
Social Engagement...............................................................................................30
Relationship between Parent Fidelity and Child Behavior ..................................32
Parenting Sense of Competence & Parenting Stress............................................34
Treatment Acceptability.......................................................................................36
DISCUSSION ..................................................................................................................39
v

Summary ..............................................................................................................45
APPENDICES .................................................................................................................46
Appendix A-Online RIT Fidelity Form ...............................................................47
Appendix B-Online RIT Imitation Scoring Form ................................................49
Appendix C-Social Engagement and Affect Rating Scales .................................50
Appendix D-Modified Behavioral Intervention Rating Scale .............................53
REFERENCES ................................................................................................................55

vi

LIST OF TABLES

Table 1. Participant characteristics ..................................................................................11
Table 2. Behavioral definitions ........................................................................................19
Table 3. Mean Parenting Sense of Competence and Parenting Stress Scores ................ 34
Table 4. Individual Participant Scores on the RIT Knowledge Quiz, Parenting Sense of
Competence Scale, and Family Impact Questionnaire………………………………… 35
Table 5. Treatment Acceptability ....................................................................................37

vii

LIST OF FIGURES

Figure 1. Study phases and procedures ............................................................................13
Figure 2. Ratings of parents’ overall fidelity ...................................................................25
Figure 3. Parents’ average fidelity of individual RIT techniques across phase ...............26
Figure 4. Child spontaneous imitation rate ......................................................................29
Figure 5. Ratings of child coordinated joint engagement ...............................................31
Figure 6. Ratings of parent and child affect .....................................................................33
Figure 1A. Online RIT fidelity form................................................................................47
Figure 1B. Online RIT child imitation scoring form .......................................................49
Figure 1C. Coordinated join engagement rating scale .....................................................50
Figure 2C. Child affect rating scale .................................................................................51
Figure 3C. Parent affect rating scale ................................................................................52
Figure 1D. Modified behavioral intervention rating scale ...............................................53

viii

INTRODUCTION
Autism spectrum disorder (ASD) is a chronic and pervasive neurodevelopmental disorder
characterized by deficits in reciprocal social interaction, social communication, and the presence
of restricted and repetitive behaviors (American Psychiatric Association, 2013). Individuals with
ASD often require intensive and comprehensive intervention in these core areas of deficit, as
well as in additional areas of functioning (e.g., adaptive skills, behavior management), across the
life span (Maglione, Gans, Das, Timbie, & Kasari, 2012). There has been a dramatic increase in
the number of individuals receiving this diagnosis over the last two decades, with prevalence
rates reaching 1 in 88 (Centers for Disease Control and Prevention, 2012), and this population is
at a particularly high risk for experiencing unmet service needs (Kogan et al., 2008).
Importantly, the significant unmet service needs of individuals with ASD do not appear
to be due specifically to a lack of knowledge about effective intervention programs. Indeed, there
has been significant progress with respect to the development and validation of evidence-based
services across mental health disciplines (Herschell et al., 2009), including the ASD intervention
field (Lord et al., 2005). Over this period, the long-term prognosis of individuals with ASD has
improved considerably, particularly when children are identified, and appropriate intensive
treatment is started, early in life (Turner, Stone, Pozdol, & Coonrod, 2006). However, evidencebased ASD intervention programs linked with positive distal and proximal outcomes are often
not successfully transported to practice settings (Lord et al., 2005; Smith et al., 2007; Stahmer,
2007), in large part because of the incompatibility between services and delivery models studied
in research settings and those that are available and feasible in existing clinical settings (e.g.,
Dingfelder & Madnell, 2011; Kazdin, 2008). Thus, although the number of individuals requiring
ASD specific services has increased, there has not been corresponding growth in the availability

1

of evidence-based services, (Sperry, Whaley, Shaw, & Brame, 1999; Stahmer & Gist, 2001;
Symon, 2005). Taken together these issues highlight the need for systematic research focused on
developing and improving strategies for dissemination and implementation of evidence-based
ASD services.
Parent training programs have been found to be one cost-effective and ecologically valid
way to increase access to evidence-based ASD intervention. Numerous studies have established
that parents can be successfully trained in evidence-based strategies to improve socialcommunicative functioning in young children with ASD (e.g., Charlop & Trasowech, 1991;
Ingersoll & Gergans, 2007; Koegel, Bimbela, & Schreibman, 1996; Stahmer, 1995). Additional
benefits of parent training include increases in generalization and maintenance of child skill, a
reduction in parent stress, and increases in family leisure time (Koegel et al., 1996; Koegel,
Schreibman, Britten, Burke, & O’Neill, 1982). Yet, there continue to be barriers involved with
the dissemination of training to parents, including a shortage of trained professionals, limited
financial resources and transportation, lack of child care, geographic isolation, lengthy waitlists,
and extensive time commitments (Stahmer & Gist, 2001; Symon, 2001; Taylor, WebsterStratton, Feil, Broadbent, Widdop, & Severson, 2008). Thus, it is essential to consider the
adaptation of evidence-based interventions, including parent training programs, to nontraditional service delivery methods (Feil et al., 2008).
Telehealth and related technology-based applications have the potential to replace, or at
the very least augment, traditional service models to increase access to evidence-based services
from a distance (Baggett et al., 2010; U.S. Department of Education, 2010). Broadly defined,
telehealth is the “use of electronic information and telecommunications technologies to support
long-distance clinical health care, patient and professional health-related education, public health

2

and health administration” (Office for Advancement of Telehealth). There are numerous benefits
associated with the use of telehealth programs, including providing a cost-effective means for
intervention to be accessed from anywhere at any time (Baggett et al., 2010). There is increasing
evidence that such programs can reduce patient and provider costs and increase provider system
coverage relative to traditional in-person service delivery models (Gros et al., 2013). Telehealth
programs make it possible to sustain highly standardized instruction and maintain fidelity of
program implementation, while also supporting individualized learning (Hollon et al., 2002;
Mandel, Bigelow, & Lutzker, 1998). Users are able to interact directly with the instructional
content through video, animation, and active learning tasks (e.g., quizzes) (Weingardt, 2004), as
well as with other individuals, including expert clinicians, via email and teleconferencing
mechanisms (Ingersoll & Wainer, 2013). Importantly, the number of individuals with access to
internet-based and computerized technologies has grown considerably in recent years (File,
2013). The percentage of U.S. households with a computer has increased from 8.2% in 1984, to
61.8% in 2003, to nearly 76% in 2011, while the percentage of US household with internet
access has gone from 18% in 1997, to 54.7% in 2003, to nearly 72% in 2011 (File, 2013).
Furthermore, as of 2007, nearly 83% of adults were able to access the internet from home, work,
or elsewhere (US Census Bureau 2009). Finally, telehealth services are becoming increasingly
more common with over 3,000 U.S. sites using distance-based service delivery models to
provide patient care (American Telemedicine Association). The use of telehealth programs to
provide services has been explored across health-related disciplines, disorders, and evidencebased treatment approaches (see Gros et al., 2013 for a review). Such telehealth programs may
serve a role in the direct delivery of evidence-based interventions, as well as in training service
providers to use evidence-based intervention strategies in in-person practice settings. Benefits of

3

telehealth technology, together with interest in such programs across health-related fields, and
rapid increases in consumer access to computer and internet technology, suggest that telehealth
applications may serve as a promising alternative service-delivery model to increase the reach of,
and access to, evidence-based ASD interventions, including ASD parent training programs.
Initial studies of telehealth-based parent training programs have indicated that parents of
typically developing children can be taught evidence-based adaptive parenting and behavior
management techniques via this service delivery mechanism (e.g., Baggett et al., 2010; Feil et
al., 2008; Kacir & Gordon, 1999; MacKenzie & Hilgedick, 1999). For example, Kacir and
Gordon (1999) adapted the parent training program, Parenting Adolescents Wisely, to a brief
self-directed interactive laserdisc program. The laserdisc program used audio, video and text to
deliver training and feedback, and was found to be effective in reducing child problem behaviors
and improving parent knowledge and use of adaptive parenting skills. MacKenzie and Hilgedick
(1999) created the Computer-Assisted Parenting Program (CAPP) to teach parents effective
behavior management techniques. This program utilized a number of technology-based
applications including computer simulation, written instruction, and multiple-choice questions
with immediate corrective feedback; use of the program resulted in increases in parents’ use of
behavioral management strategies and increases in parental involvement.
Although the number of studies exploring the use of telehealth and related technological
applications to train parents of children with ASD in evidence-based intervention has grown over
the past several years, empirical evaluations of such programs are limited. Several studies have
demonstrated that parents of children with ASD find such training programs to be feasible,
useable, acceptable, and effective in increasing knowledge about evidence-based intervention
procedures (e.g., Hamad, Serna, Morrison, & Fleming, 2010; Howroyd & Peeters, 2007; Jang et

4

al., 2012), yet only recently have researchers begun to evaluate the impact of these training
programs on parents’ fidelity of implementation. Examination of the effect of telehealth
programs on parent fidelity is critical because parent training interventions are, by definition,
multi-level. Thus, the “success” of an intervention can be affected by the transfer of information
from the telehealth program to the parent, and by the parent’s application of the techniques with
the children. Most parent training interventions include several different intervention strategies
and it is often unclear which elements of the intervention are most responsible for influencing
child behavior. Therefore, a failure to find treatment effects after the use of a telehealth program
could be due to problems in information transfer and/or to a set of ineffective intervention
strategies. As such, the collection of parent and child behavioral data is critical for developing a
more detailed understanding of the effectiveness of interventions and the systems used to deliver
them.
Initial examinations of the effect of telehealth programs on parent behavior suggest that
parents can learn to implement intervention techniques with fidelity. Nefdt and colleagues (2010)
examined a DVD-based self-directed training program to teach parents evidence-based
motivational techniques from pivotal response training (PRT). The program consisted of 14
training modules with information presented via text and audio lecture, and short video examples
of each technique; parents also engaged in brief active learning tasks such as comprehension
quizzes and rating of fidelity of implementation of other adults’ use of the techniques. Results
from this study suggested that parents were able to implement PRT strategies with fidelity,
provided their children with more language opportunities, and displayed greater confidence in
parent-child interactions. Importantly, some parents indicated that immediate feedback or
coaching from an expert clinician would have been a helpful addition to the program (Nefdt et

5

al., 2010). Wainer and Ingersoll (2013a) piloted a web-based self-directed telehealth program to
train new therapists and parents in reciprocal imitation training (RIT; Ingersoll & Schreibman,
2006), an evidence-based intervention to improve imitation skills in children with ASD. The
program consisted of five modules and instructional content was delivered over narrated
slideshows augmented with video examples and written descriptions of the techniques.
Participants completed short comprehension quizzes and rated others’ implementation of the RIT
techniques. Results suggested that undergraduate therapists and parents were able to learn about,
and increase their use of RIT techniques after utilizing the self-directed training modules.
However, one third of the participants in both groups required additional live, in-person,
feedback and coaching in order to achieve fidelity of implementation. Moreover, parents who did
not receive feedback indicated that contact with a coach would have been helpful. Findings from
both of these studies suggest that the addition of an interactive remote coaching component may
be a desired, and for some a critical, element of successful telehealth parent training programs.
Indeed, recent research has begun to explore the use of teleconferencing technology to
provide feedback and support to parents of children with ASD from a distance (Baharav &
Reiser 2010; Vismara, McCormick, Young, Nadhan, & Monlux, in press; Vismara, Young, &
Rogers, 2012). For example, Baharav & Reiser (2010) utilized streaming internet technology to
provide live feedback and coaching to parents implementing in-home speech and language
therapy. Results from this pilot study support the feasibility and effectiveness of remote coaching
conducted via teleconferencing technology for parents of children with ASD attempting to
implement evidence-based intervention in their homes (Baharav & Reiser, 2010).
Recognizing the potential for combining remote coaching with technology-based
instruction, Vismara and colleagues (Vismara et al., 2012, Vismara et al., in press) have explored

6

the use of “hybrid” telehealth programs to deliver the parent curriculum of the Early Start
Denver Model (ESDM; Rogers & Dawson, 2010; P-ESDM, Rogers et al., 2012) an evidencebased comprehensive ASD intervention program. Both DVD-delivered instructional content and
web-based instructional content, in conjunction with weekly video-conferencing coaching
sessions, have been examined as potential mechanisms for delivering the parent training
(Vismara et al., 2012, Vismara et al., in press). In both studies parents engaged in self-guided
instruction (via a DVD or website) and then participated in weekly hour, or hour and a half,
remote coaching sessions with an expert therapist. Results suggested that parents were able to
implement the intervention strategies with fidelity and alter their engagement styles to be more
attentive and responsive to their children after the hybrid telehealth programs. Furthermore,
children in both studies demonstrated gains in important social communicative behaviors (e.g.,
language, imitative behaviors) as their parents participated in the telehealth programs (Vismara
et al., 2012; Vismara et at., in press).
Findings from this nascent body of literature provide initial evidence for the feasibility
and effectiveness of telehealth programs to serve as alternative models for delivering training in
evidence-based intervention strategies to parents of children with ASD. The research described
above highlights the diversity of technology and technology-related applications, each with
benefits and limitations, currently available for incorporation into telehealth programs. For
example, self-directed telehealth programs seem to be effective for increasing participant
knowledge and may offer a cost-effective way to significantly increase the reach of parent
training programs. Theoretically, once a self-directed telehealth program is developed, few
resources should be necessary to enroll participants and to maintain the program. Yet, previous
research suggests that self-directed programs may not provide enough support for some parents

7

to be able to implement evidence-based intervention techniques with fidelity (e.g., Wainer &
Ingersoll, 2013a). The provision of remote coaching via video-conferencing technology may
serve as an additional support to help parents implement evidence-based intervention techniques
with fidelity. However, remote coaching programs require more time and financial resources at
organizational, clinician, and family levels, than do self-directed programs. Thus, an important
step in developing, evaluating, and eventually disseminating telehealth programs is to understand
the unique contributions of self-directed and remote interactive components in supporting parent
learning and child outcomes. A more nuanced appreciation of the contributions offered by each
component will make it possible to develop more cost-effective delivery models where services
are offered at varying levels of intensity, depending on specific needs of the family. Indeed,
suggestions for the redesign of service delivery systems to models of stepped-care have been
made not only in the ASD intervention field (Phaneuf & McIntyre, 2011; Steever, 2011), but also
in the behavioral health field more generally (O’Donohue & Draper, 2011).
The current study sought to examine the use of a hybrid telehealth program to introduce
parents of children with ASD to an evidence-based imitation intervention, Reciprocal imitation
training (RIT). RIT, as implemented by therapists and parents, has been shown to increase
spontaneous imitation skills, in addition to other early social-communication skills such as joint
attention, in young children with ASD (Ingersoll, 2010; Ingersoll & Gergans, 2007; Ingersoll &
Schreibman, 2006). Furthermore, a recent pilot study suggested the feasibility of a self-directed
telehealth program to train individuals in the use of these intervention strategies (Wainer &
Ingersoll, 2013a). The current study sought to expand on this pilot work by examining parent and
child outcomes in response to the use of a hybrid telehealth program combining self-directed
instruction with subsequent interactive remote coaching sessions.

8

The first goal of the current study was to assess the degree to which parents could learn
about and effectively implement RIT after engaging in the self-directed and coaching portions of
the telehealth program. The second goal of the current study was to evaluate the impact of parent
participation on child behavior, including child imitation skills and joint engagement.
Additionally, the degree to which parent use of the intervention techniques were related to child
behaviors within the interaction were examined in an attempt to identify which parent behaviors
most strongly influence child outcomes. A final goal of the study was to assess the acceptability
of this hybrid telehealth service delivery model to parents.

9

METHOD
Participants
Five young boys with ASD and their parents participated in the current study. Inclusion
criteria included: (a) children between the ages of 24 – 72 months, (b) a diagnosis of autism
spectrum disorder by an independent licensed professional in the families’ community, (c)
internet access in the families’ homes throughout the duration of the study (hardware and an
internet connection were available at the request of the parent), (d) no previous participation in a
formal parent training study, (e) the same parent available for all baseline, data collection, and
coaching sessions, and (f) parent reports of deficits in social imitation skills. Seven families were
referred to the program from their local community-based diagnostic and service provision
centers. One family withdrew from participation after two baseline sessions due to the high rates
of social imitation reported by the parents and observed by the research staff. The other family
dropped out of the study after 6 baseline sessions, but did not provide an explanation for their
withdrawal. In total, five children and their mothers completed the entire study.
At intake, child chronological age ranged from 29 to 59 months. All parents completed
the Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003) to obtain a
measure of autism severity and the Vineland Adaptive Behavior Scales survey interview to
obtain a measure of child adaptive behaviors (Sparrow, Cicchetti, & Balla, 2005). Families were
specifically recruited from areas distant from the main study site, with all participants residing in
Ontario, Canada (over 300 miles from the main study site) during study participation. Families
from diverse ethnic and cultural backgrounds were represented in the current study. Four of the
parents indicated countries of origins other than Canada or the United States and three of the

10

families cited that in addition to English, other languages (e.g., Bengali, Spanish) were spoken in
the home. See Table 1 for a description of parent-child characteristics.
Table 1
Participant characteristics
Parent
Education

Parent
Employment

Marital
Status

Child
Age
(mo.)

Child
Ethnicity

ASD
Severity

Dyad
1

Graduate
Degree

Not
Employed

59

Dyad
2

Not
Employed

Asian/
Pacific
Islander
MultiRacial

Dyad
3

Some
College/
Special
Training
Graduate
Degree

Dyad
4

Graduate
Degree

Finance

Dyad
5

Graduate
Degree

Technology

Married,
living
with
partner
Single,
living
with
partner
Married,
living
with
partner
Married,
living
with
partner
Married,
living
with
partner

Asian/
Pacific
Islander
White,
NonHispanic
Hispanic

Finance

42

29

40

41

Vineland
Soc.

15

Vineland
Comm
.
65

13

67

68

20

64

89

21

79

72

24

52

65

61

Settings and Materials
All parents completed the telehealth program using their own or family members’ home
computers, web-cameras, and internet connections. All data collection and coaching sessions
took place in the home and were conducted over the internet-based, password-protected videoconferencing programs Skype (4 families) or Facetime (1 family). Families who did not have an
account with one of these videoconferencing programs prior to participation in the current study
were provided with instructions and assistance with program download and registration. All
11

sessions were recorded using commercially available screen-recording software. Prior to the first
baseline session, the parent and parent coach strategized about how to position the web-camera
for optimal viewing of the parent-child interactions in the homes. The families’ own toys and
materials were used during all data collection sessions.
Experimental Design and Study Procedure
An IRB approved, single-subject, multiple-baseline design was conducted across the five
parent-child dyads (Hersen & Barlow, 1976). Dyads were randomly assigned to between 4 and 9
baseline probes (Edgington, 1996). Although the initial study design called for the baseline phase
to be completed within 2 – 3 weeks so as not to delay access to the intervention, the duration of
baseline periods ranged from 2 to 7 weeks (M = 4.42 weeks) due to difficulties with scheduling
and problems with technology (e.g., family losing internet access in the home for several weeks).
There were four phases involved in the current study (see Figure 1). The first phase
consisted of a randomly assigned number of baseline probes as detailed above. The second phase
involved completion of the self-directed portion of the telehealth program and two subsequent
data collection probes (self-directed probes). The third phase of the study included three 30minute coaching sessions and three data collection probes (coaching probes). The fourth phase of
the study involved two follow-up data collection probes approximately one- and three-months
after the final coaching probe.

12

Figure 1
Study Phases and Procedures. For interpretation of the references to color in this and all other figures, the reader is referred to the
electronic version of this dissertation

4-9 Randomly
Assigned
Baseline
Sessions

Intake
Assessments

RIT
Knowledge
Quiz

Coaching
Session #1

One-Month
Follow Up

RIT
Knowledge
Quiz

Online RIT
Website

Data
Collection
Probe

Coaching
Session #2

Data
Collection
Probe

Data
Collection
Probe

Coaching
Session #3

Three-Month
Follow Up

Baseline
Phase

Data
Collection
Probe

Data
Collection
Probe

Three-Month
Follow Up
Assessments

13

Exit
Assessments

SelfDirected
Phase

Coaching
Phase

Follow Up
Phase

Baseline phase.
During baseline sessions parents were asked to interact with their child as they normally
would during play activities for 10-minutes. Parents were informed that the purpose of these
sessions was for the parent coach to develop an understanding of the child’s skills and the parentchild interaction style, and were not provided with any other instructions or feedback.
Self-directed phase.
Intervention.
The content of the self-directed telehealth intervention was adapted from reciprocal
imitation training (RIT), an evidence-based intervention aimed at increasing spontaneous
imitation skills in children with ASD (Ingersoll & Schreibman, 2006). Parents were taught to: 1)
set up their homes and environments for successful parent-child play interactions; 2)
contingently imitate their children’s actions with toys, gestures/body movements, and
vocalizations; 3) use simplified language to describe objects and actions around their children’s
focus of attention; and 4) use prompting and reinforcement strategies to elicit a nonverbal
imitative response (i.e., object or gesture imitation) from their children.
Delivery platform.
The self-directed portion of the telehealth program was delivered via a secure website
(referred to as Online RIT) developed specifically for the current study. Upon enrollment in the
study, participants were able to create a unique username and password for access to the Online
RIT website.
Program structure.
Instructional content in the self-direction portion of the program was presented in four
short lessons, each addressing one of the strategies listed above. Instruction was presented via

14

animated slideshows with text presented on screen and a concurrent audio lecture providing
more thorough explanations of the concepts. There was a corresponding printable PDF of a
written manual that expanded upon the information presented in the instructional slideshow for
each lesson. Participants also completed a homework plan and reflection questions for each
lesson wherein they indicated their plans for practicing and use of the techniques, and wrote
about implementation successes and challenges, respectively. In addition, two active learning
tasks were included in the lessons. The first task, termed the “self-check,” required participants
to complete several multiple choice questions related to information provided in the slideshow to
ensure comprehension of lesson content. In the second task, termed “exercises,” participants
viewed short clips of adult-child interactions and were asked to indicate whether or not the adult
was implementing a specific RIT technique correctly. Participants were provided with feedback
after each self-check and exercise question. There were a total of 40 possible instructional
components (e.g., slideshow, self-check questions, homework plan) across the four lessons.
The Online RIT website also included a Video Library in which users were able to view
10 longer video examples (approximately five minutes each) of RIT sessions with children at
different developmental levels. In addition, the website offered a resources page where
participants could access relevant references from the ASD intervention literature, as well as
links to additional online autism resources (e.g., a link to Autism Speaks’ website).
Procedure.
After the baseline period, parents were given access to the Online RIT website. Before
accessing the instructional content, all parents were asked to complete an RIT knowledge quiz to
assess general knowledge of naturalistic behavioral techniques and specific techniques involved
with the intervention. After finishing all four Online RIT lessons, parents completed the same

15

RIT knowledge quiz. At this time, the parent coach also observed two, 10-minute parent-child
interactions. During these two self-directed data collection probes, parents were asked to practice
RIT without any coaching or feedback.
Coaching phase.
Participants received a total of three, 30-minute remote coaching sessions. The first
coaching session took place immediately after participants completed the second data collection
probe in the self-directed phase. The subsequent two coaching sessions began with a 10-minute
data collection probe, followed by 30-minutes of feedback and problem solving. The final data
collection probe was taken on a different day, after the third coaching session. Thus, this phase
of the study consisted of a total of three coaching sessions and three data collection probes.
During the 30-minute coaching sessions, the parent coach answered questions, engaged
in collaborative problem solving, and provided specific feedback about parents’ use of the RIT
techniques observed during the session. Parents were given the opportunity to integrate the
coach’s feedback and engage in additional practice. After each coaching session the parent coach
sent written feedback summarizing content covered in the session and suggesting portions of the
website that might be useful for the parent to review (e.g., specific videos in the video library,
exercises from a certain lesson). After the final coaching session, parents completed a set of exit
assessments and provided feedback about the intervention and telehealth service delivery model.
Adjustments were made to the coaching phase protocol for one family (Dyad 2) due to
problems with internet connectivity. Parent-child interactions were filmed offline and then
uploaded to a secure password protected digital file sharing program accessed from a computer
in another family member’s home. The parent coach reviewed the video, sent the parent written
feedback summarizing observations and suggestions, and conducted a follow-up phone

16

conversation to help the parent problem solve and answer any questions from the written
feedback. This procedure was followed for all three coaching sessions for Dyad 2.
Follow-up.
Follow-up data collection probes were conducted approximately one- and three-months
after the final coaching session for the majority of families. Due to difficulties with technology
and scheduling, the final data collection probe was collected approximately five months after the
last coaching session for Dyad 2.
All follow-up sessions began with a 10-minute data collection probe in which parents
were asked to practice RIT with their children. Next, the parent coach answered any questions
and engaged in collaborative problem solving with the parent. The coach did not provide specific
feedback, unless the parent reported concerns using the techniques or asked specific questions
about the techniques. At the three-month follow-up, participants completed an additional
feedback form addressing issues of implementation and sustainability.
Dependent Measures
Program engagement.
Parent use of the self-directed portion of the training program was tracked on the website.
Parent knowledge of RIT.
Changes in parent knowledge of RIT and naturalistic behavioral intervention techniques
were assessed with a 20-question online multiple-choice exam administered before and after
completing the self-directed portion of the telehealth program.
Fidelity of implementation of RIT.
Trained observers scored the parent-child interactions for parent fidelity of the RIT
intervention techniques using the RIT fidelity form (Ingersoll & Lalonde, 2010). Observers rated

17

the parents from one (low fidelity) to five (high fidelity) on Contingent Imitation, Linguistic
Mapping, Modeling, Prompting, Reinforcement, and Pacing. The final four dimensions were
averaged to create a Prompting Sequence score. Parent scores on Contingent Imitation,
Linguistic Mapping, and the Prompting Sequence were averaged to create an Overall Fidelity
score. See Table 2 for behavioral definitions and Appendix A for a copy of the RIT fidelity
form.
Child imitation.
Trained observers scored the parent-child interactions for child spontaneous imitation.
Rate per minute of spontaneous imitation was calculated by dividing the number of spontaneous
imitative responses demonstrated by the child by the number of minutes of the session. See Table
2 for behavioral definitions and Appendix B for a copy of the RIT imitation scoring form.
Social engagement and affect.
Trained observers scored the parent-child interactions for episodes of coordinated joint
engagement and parent and child affect using an adapted version of the rating scale for the
Communication Play Protocol (Adamson & Bakeman, 1998; Adamson, Bakeman, Deckner, &
Brooke Nelson, 2012). Observers rated child behavior on a scale from 1 (no episodes) to 7
(frequent and rich episodes) on Coordinated Joint Engagement. To be considered “in” an
episode of joint engagement, the child needed to be attending to the same object and/or event as
the caregiver. Observers also rated Parent Affect on a scale from 1 (tense, disruptive, or
affectively flat to the point of being expressionless and subsequently very hard to read) to 7
(smoothly modulated, appropriate, and serves to enhance other modes of communication) and
Child Affect on a scale from 1 (disruptive, highly inappropriate, or very flat and constricted
affect) to 7 (affect is smoothly modulated, appropriate, and serves to enhance other modes of

18

communication). See Table 2 for behavioral definitions and Appendix C for a copy of the social
engagement and affect rating scales.
Table 2
Behavioral definitions
RIT Fidelity Components
Contingent Imitation Following the child’s lead and imitating the
child’s actions with toys, body movements,
gestures, and vocalizations.
Linguistic Mapping The use of simple, descriptive, and repetitive
language around the child’s focus of attention.
Modeling Modeling an action for imitation around the
child’s focus of attention.
Prompting Using physical guidance or manipulation of
materials to encourage the child to imitate the
modeled action if the child does not
spontaneously imitate after the model.
Reinforcement Providing the child with praise and continued
access to the toys after both prompted and
spontaneous imitation.
Pacing Modeling an action of imitation once every one
to two minutes on average. Adjusts the rate of
models when necessary to keep the child
engaged.
The child imitates the adult’s model of an
Child Spontaneous Imitation
action with a toy or a gesture within 10-s of the
model. The child provides an imitative response
without physical guidance from, or material
manipulation by, the adult.
Child Social Engagement
Coordinated Joint Engagement Describes the quantity and quality of time the
child and caregiver are actively involve with the
same object and/or event, with the child
actively and repeatedly acknowledging the
caregiver’s participation in the interaction.
Affect
Caregiver Affect Assesses the caregiver’s affect and how it
influences the caregiver-child interaction.
Child Affect Assesses the way the child’s affective
expressions are integrated into the social
interaction with the caregiver.

19

Parenting sense of competence.
Changes in parent sense of competence from intake to completion of the hybrid telehealth
program were examined using the Parenting Sense of Competence Scale (PSOC; GibaudWallston & Wandersman, 1978). The PSOC is a 17-item questionnaire that asks about parenting
efficacy (perceived skills/knowledge about being a parent) and parenting satisfaction (value and
comfort associated with the parenting role). Parents were asked to rate items on a 6-point scale
ranging from (0) strongly agree to (5) strongly disagree.
Parenting stress.
Changes in parenting stress from intake to completion of the hybrid telehealth program
were evaluated using the Family Impact Questionnaire (FIQ; Donenberg & Baker, 1993). The
FIQ assess parents’ perceptions of a target child’s impact on their families relative to the impact
that most children have on their families. Parents were asked to rate agreement with items on a 4point scale ranging from Not At All (0) to Very Much (3). For the purposes of the current study
three of the six FIQ scales were used: Positive Feelings about Parenting, Negative Feelings about
Parenting, and Impact on Social Life.
Treatment Acceptability
Parents were asked to complete a modified version of the Behavioral Intervention Rating
Scale (BIRS; Elliott & Treuting, 1991) after the final coaching session to evaluate the feasibility,
acceptability, and effectiveness of the intervention program and service delivery model. For the
current study, the BIRS was modified to better reflect the goals of the intervention (e.g.,
acquisition of child imitation skills) and the components of the service delivery model (e.g.,
online self-directed instructional content, remote coaching). Parents were also asked to rate
additional items assessing the usability of the telehealth program using the same rating scale (see

20

Table 5 for additional items). Finally, parents were asked to indicate benefits and limitations of
the telehealth program in an open-ended format. See Appendix D for a copy of the modified
BIRS.
Parents also completed a feedback form at the 3-month follow up. They were asked about
their experiences with using the Online RIT website and the RIT intervention techniques over the
previous months. They were also asked to provide suggestions about how to support continued
use of the Online RIT website and the intervention strategies.
Inter-Observer Reliability
Approximately 25% of sessions were coded by a second independent rated who was
blind to intervention phase. Intraclass correlations were used to calculate reliability on parent
overall fidelity (.99), child imitation rates (.94), coordinated joint engagement (.89), child affect
(.94) and parent affect (.91).
Missing Data
Observational data was missing for Dyad 1 (session 1; parent fidelity, child imitation,
joint engagement) and Dyad 2 (session 7; joint engagement) because of problems with session
audio/video. The one-month follow-up data collection probe was not collected for Dyad 5
because this time point overlapped with the birth of a child.
Data Analysis
Paired sample t-tests were conducted to test for significant differences in participant
scores on the RIT knowledge quiz, PSOC, and FIQ. Given the predicted direction of effect, onetailed tests were used. Visual inspection of session data was used to examine changes in parent
fidelity ratings, rates of child spontaneous imitation, and social engagement ratings from baseline
to treatment, and at follow-up for each participant (Gliner, Morgan, & Harmon, 2000).

21

Multilevel modeling was use to examine the effect of study phase on behavioral outcomes,
aggregated across participants (Van den Noortgate & Onghena, 2008). The random component
of these models included an autoregressive lag 1 model to account for temporal
nonindependence. For these analyses, missing data due to recording equipment failure (<1% of
sessions) were imputed by averaging the data point immediately preceding and immediately
following the missing data point.
The relationship between the parents’ use of the intervention techniques and their
children’s rate of spontaneous imitation and joint engagement was also examined using
multilevel modeling. Multilevel modeling can help identify the active treatment component(s)
of an intervention package, by examining which, if any, of its individual components are related
to outcomes, after controlling for both within and between participant variance on the outcome.
For the first set of analyses, overall parent fidelity was entered as a predictor to examine the
relationship between overall parent fidelity and child behavior. For the second set of analyses,
parent scores on Contingent Imitation, Linguistic Mapping, and the Prompting Sequence were
entered simultaneously to determine which fidelity dimensions were unique predictors of child
behavior when controlling for the other dimensions.

22

RESULTS
Program Engagement
The amount of time between initial access to the Online RIT website and completion of
the final instructional component ranged from 21 to 73 days (M = 35). During this time, parents
logged in to the program between 4 and 11 times (M = 8). The most common time of access was
Lunch (10:00 A.M. – 1:59 P.M.; 11 log-ins), followed by Dinner (6:00 P.M. – 9:59 P.M.; 10 logins), Night (10:00 P.M. – 1:59 A.M.; 10 log-ins), Afternoon (2:00 P.M. – 5:59 P.M.; 8 log-ins),
and then Morning (6:00 A.M. – 9:59 A.M.; 4 log-ins).
Of the 40 total instructional components included in the website, parents completed
between 12 and 40 components (M = 33). They spent an average of 52.5 minutes (range = 34 –
77) viewing all the slideshows, and an average of 7 minutes (range = 4 – 11) and 14.9 minutes
(range = 1 – 24.5) on the self-check and exercise questions, respectively. On average, parents
spent 12 minutes (range = 0 – 18) working on the homework plan and 13.6 minutes (range = 0 –
25) on the reflection questions.
Parent Knowledge of RIT
A one-tailed paired t-test indicated that participant scores on the RIT knowledge quiz
improved significantly from the start (M = 11.60, SD = 3.78) to the completion (M = 15.20, SD =
3.11) of the self-directed portion of telehealth program, t(4) = 2.25, p < .05.
Fidelity of Implementation of RIT
During baseline, all parents occasionally used some RIT techniques (see Figures 2 and
3). However, no parent met overall fidelity of implementation (rating ≥ 4) during any of the
baseline sessions (Figure 2).

23

After completing the self-directed portion of the telehealth program, four of the five
parents (1, 3, 4, and 5) demonstrated clear increases in overall fidelity, with parents 1 and 5
achieving overall fidelity of implementation (rating ≥ 4). Parent 2 continued to show low to
moderate levels of overall fidelity.
During the coaching phase, Parent 1 and Parent 2 demonstrated increases in overall
fidelity. Parent 2 achieved overall fidelity of implementation, and parents 1 and 5 maintained
overall fidelity of implementation. Parent 3 did not demonstrate a clear increase in overall
fidelity until the final coaching probe; however at this point overall fidelity of implementation
was achieved. Parent 4 maintained moderate levels of overall fidelity, but did not achieve
fidelity of implementation.
Four of the five parents (parents 1, 2, 3 and 5) achieved overall fidelity of implementation
at some point during either the self-directed and/or the coaching phase. Once parents achieved
fidelity of implementation, most maintained high levels of overall fidelity at the one- and/or
three-month follow up time points. While Parent 4 did not achieve overall fidelity of
implementation, overall fidelity ratings at one- and three-month follow up probes continued to be
higher than baseline ratings.

24

Figure 2
Ratings of parents’ overall fidelity

SelfDirected

Coaching

Fidelity rating

Baseline

Session

25

Follow-Up

Figure 3
Parents’ average fidelity of individual RIT techniques across phase
Contingent Imitation
5
4
3
2
1
1

2

3

4

5

Fidelity rating

Linguistic Mapping
5
4
3
2
1
1

2

3

4

5

Prompting Sequence
5
4
3
2
1
1

2

3

4

5

A multilevel model examining parents’ overall fidelity ratings as a function of study
phase revealed significant differences, F(3,46) = 13.62, p < .001. Follow-up pairwise

26

comparisons using Tukey’s LSD indicated that the parents’ overall fidelity ratings were
significantly higher during the self-directed (M = 3.08, SE = .30), coaching (M = 3.53, SE = .28),
and follow-up (M = 3.50, SE = .33) phases than during baseline (M = 1.59, SE = .22).
Given that overall fidelity is an average of ratings across three fidelity dimensions,
multilevel models were run to examine parents’ fidelity on each dimension as a function of study
phase. Results revealed significant differences as a function of phase for Contingent Imitation,
F(3,44) = 17.07, p < .001, with follow-up pairwise comparisons indicating significantly higher
ratings during the self-directed (M = 3.63, SE = .35), coaching (M = 3.79, SE = .34), and followup (M = 2.93, SE = .39) phases than during baseline (M = 1.28, SE = .28). Results also indicated
significant differences as a function of phase for Linguistic Mapping, F(3,33) = 13.95, p < .001,
with follow-up pairwise comparisons indicating significantly higher ratings during the selfdirected (M = 3.90, SE = .33), coaching (M = 4.24, SE = .29), and follow-up (M = 3.88, SE = .36)
phases than during baseline (M = 2.16, SE = .22). Finally, a multilevel model revealed significant
differences as a function of phase for the Prompting Sequence, F(3,47) = 14.89, p < .001, with
follow up pairwise comparisons suggesting significantly higher fidelity ratings during the selfdirected (M = 3.00, SE = .33), coaching (M = 3.88, SE = .30) and follow-up (M = 3.40, SE = .35)
phases than during baseline (M = 1.49, SE = .24).
Child Imitation
During baseline, children 1, 2, 3, and 4 demonstrated low and stable rates of spontaneous
imitation (Figure 4). Child 5 demonstrated low rates of spontaneous imitation during initial
baseline probes, but showed an increasing trend in rate during the second half of the phase.

27

After the self-directed program, children 1, 2 and 3 showed increases in spontaneous
imitation rates. Child 5 maintained moderate rates of spontaneous imitation, while Child 4 did
not demonstrate any spontaneous imitation during this phase.
During the coaching phase, Child 1 and Child 2 demonstrated overall increases in
spontaneous imitation rates relative to the previous phase. Child 3 showed an increasing trend in
spontaneous imitation rates towards the end of the phase. Child 4 demonstrated an initial
increase in spontaneous imitation, but increases were not maintained for the duration of the
coaching phase. Finally, Child 5 maintained moderate rates of spontaneous imitation.
Most of the children demonstrated moderate to high levels of spontaneous imitation at the
one- and three-month follow up probes, with four out of the five children (children 1, 2, 3, and 4)
maintaining higher than baseline rates of spontaneous imitation during at least one of the followup time points.

28

Figure 4
Child spontaneous imitation rate
SelfDirected

Coaching Follow-Up

Rate per min

Baseline

Session
29

A multilevel model examining rate of spontaneous imitation as a function of study phase
revealed significant differences, F(3,34) = 4.39, p < .05 . Follow-up pairwise comparisons using
Tukey’s LSD indicated a significant increase in spontaneous imitation from baseline (M = .06,
SE = .04) to the coaching phase (M = .316, SE = .06); differences among the other phases were
not significant, p > .05.
Social Engagement
During baseline, children 2 and 3 demonstrated low levels of coordinated joint
engagement, while Child 1 demonstrated moderate to high levels of coordinated joint
engagement (Figure 5). Children 4 and 5 demonstrated highly variable levels of coordinated joint
engagement during the baseline phase.
After completing the self-directed portion of the program, children 2 and 3 showed
increases in coordinated joint engagement. Child 1 demonstrated a decrease in coordinated joint
engagement. Children 4 and 5 did not demonstrate mean level changes in coordinated joint
engagement during this phase; however, Child 5’s coordinated joint engagement became less
variable.
During the coaching phase, children 2 and 4 demonstrated increases in coordinated joint
engagement. Children 3 and 5 maintained moderate to low levels of coordinated joint
engagement. Child 1 demonstrated more stable moderate levels of coordinated joint engagement
during this phase.
With the exception of Child 2, most of the children demonstrated relatively high levels of
coordinated joint engagement during the follow-up probes.

30

Figure 5
Ratings of child coordinated joint engagement
SelfDirected

Coaching

Coordinated joint engagement rating

Baseline

Session

31

Follow-Up

A multilevel model examining coordinated joint engagement as a function of study phase
failed to demonstrate a significant effect, F(3,43) = .44, n.s.
Relationship between Parent Fidelity and Child Behavior
Multilevel modeling was also used to examine the association between child social
communicative behavior and parent fidelity ratings. A multilevel model examining the
relationship between parent overall fidelity and child spontaneous imitation failed to reveal a
significant relationship, F(1,33) = 2.28, n.s.; however, when the fidelity dimensions were entered
simultaneously in a model, both Contingent Imitation (F(1,50) = 6.33, p < .05) and the
Prompting Sequence (F(1,60) = 12.03, p < .05) explained unique variance in child spontaneous
imitation. A multilevel model examining the relationship between coordinated joint engagement
and overall parent fidelity revealed a significant effect, F(1,53) = 4.60, p < .05. When the fidelity
dimensions were entered in a model simultaneously, there were no significant effects of
Contingent Imitation (F(1,59) = .427, n.s.), Linguistic Mapping (F(1,57) = .97, n.s.), or the
Prompting Sequence (F(1,54) = 1.56, n.s.) on child coordinated joint engagement.
Affect
There were few consistent trends within or across phases in parent and child affect
(Figure 6). However, visual analysis of the single subject graphs suggest that parent and child
affect were strongly associated, such that changes in one of the individuals’ affect corresponded
with changes in the other’s affect. That is, within dyads and across probes, parent and child
affect increase and decrease at similar points.

32

Figure 6

Affect rating

Ratings of parent and child affect
SelfDirected Coaching Follow-Up
Baseline

Session

33

Parenting Sense of Competence & Parenting Stress
Although means appeared to change in the expected directions, there were no significant
differences between participant scores on the three Family Impact Questionnaire subscales
(Positive Feelings about Parenting, Negative Feelings about Parenting, Impact on Social Life)
from intake to completion of the hybrid telehealth program. Means on the Parenting Sense of
Competence Scale appeared to decrease from intake to program completion; however, these
changes were not significant either. See Table 3 for means and Table 4 for individual participant
scores.
Table 3
Mean Parenting Sense of Competence and Parenting Stress Scores
Measures

Intake

Parenting Sense of

Program Completion

M

SD

M

SD

T Score

3.47

.53

3.28

1.11

.61

1.71

.85

2.05

.79

1.60

1.00

.58

.83

.19

.91

.60

.54

.36

.30

.99

Competence Scale
Family Impact Questionnaire
Positive Feelings about
Parenting
Negative Feelings about
Parenting
Impact on Social Life

34

Table 4
Individual Participant Scores on the RIT Knowledge Quiz, Parenting Sense of Competence Scale, and Family Impact Questionnaire
RIT Knowledge
Quiz

PSOC

FIQ
Positive Feelings

Parent
1
Parent
2
Parent
3
Parent
4
Parent
5

Pre

Post

Intake

Intake

3.38

Program
Completion
3.81

9
(45%)
14
(70%)
8
(40%)
17
(85%)
10
(50%)

12
(60%)
14
(70%)
13
(65%)
18
(90%)
19
(95%)

4.00

Negative Feelings

Impact on Social
Life
Intake
Program
Completion
.33
.22

Intake

2.29

Program
Completion
2.57

.71

Program
Completion
.71

3.89

2.86

2.83

.29

.71

.56

.67

2.72

1.44

1.43

1.43

1.86

1.14

1.44

.22

3.67

4.22

1.29

2.43

1.14

.86

.67

.67

3.11

3.06

.71

1.00

1.00

.71

.00

.00

35

Treatment Acceptability
Parents responded favorably to the intervention and service delivery model on the
modified BIRS (Table 5) completed at the end of the coaching phase. They indicated that RIT
was highly acceptable (M = 5.69, Range = 6.00 – 4.00), effective (M = 4.93, Range = 6.00 –
1.00) and usable (M = 5.6, Range = 6.00 – 4.00), and that the self-directed portion of the
telehealth program was highly usable (M = 5.47, Range = 6.00 – 4.00). Parents provided
informative responses to the additional questions about the different aspects of the telehealth
service delivery model (Table 5). While they responded favorably to all parts of the self-directed
program, the video-based instructional components (e.g., video library, video-based exercises)
were rated especially highly. Furthermore, parents indicated that the remote coaching was a
favorable and helpful component of the program. In response to the open-ended question about
the benefits of the program, parents reported improvements in their children’s social
engagement, imitation skills, and play skills. In response to the open-ended questions about the
limitations of the program, parents noted challenges associated with the remote coaching
sessions including difficulty with accessing the video-conferencing program and difficulty
maintaining the child’s engagement in front of the video camera. They indicated that additional
information about teaching other kinds of imitation (e.g., specific techniques for teaching gesture
or vocal imitation), additional video examples in the video library, and additional coaching
sessions would have been helpful. One parent suggested making the videos of the parent-child
interactions available so that they could “see our progress and learn from our mistakes.”

36

Table 5
Treatment Acceptability
Mean

Range

5.69
4.93
5.6
5.47

6.00 – 4.00
6.00 – 1.00
6.00 – 4.00
6.00 – 4.00

5.2

6.00 – 3.00

5.4
5.0

6.00 – 5.00
6.00 – 3.00

5.6

6.00 – 5.00

5.0
4.6

6.00 – 4.00
6.00 – 3.00

5.6
4.8

6.00 – 5.00
6.00 – 3.00

5

6.00 – 4.00

6.00

6.00 – 6.00

6.00

6.00 – 6.00

6.00

6.00 – 6.00

4.2

6.00 – 2.00

6.00
6.00
6.00
5.6

6.00 – 6.00
6.00 – 6.00
6.00 – 6.00
6.00 – 4.00

5.6

6.00 – 4.00

Modified BIRS
Intervention Acceptability
Intervention Effectiveness
Intervention Usability
Telehealth Program Usability
Additional Items
Online RIT Website (Self-Directed Portion)
The slideshows were helpful for learning about the RIT
intervention.
The manual was helpful for learning about the RIT intervention.
The self-check questions were helpful for learning the RIT
intervention.
The video-based exercises were helpful for learning the RIT
intervention.
The homework was helpful for learning the RIT intervention.
The reflection questions were helpful for learning the RIT
intervention.
The video library was helpful for learning the RIT intervention.
The amount of information provided in the Online RIT website
was sufficient for me to learn the intervention techniques.
The amount of information provided in the Online RIT website
was sufficient for me to feel comfortable and competent when
using the intervention techniques.
Remote Coaching
The coaching sessions with my child were helpful for learning
the RIT intervention.
The discussion and problem solving with the coach was helpful
for learning the RIT intervention.
The written feedback provided by the coach was helpful for
learning the RIT intervention.
I would have liked more formal feedback (e.g., the use of a
rating form) on how well I was using the RIT techniques.
The coach was interested in me.
The coach understood me.
The coach understood my child.
The amount of coaching I received was sufficient to learn the
intervention strategies.
The amount of coaching I received was sufficient to feel
comfortable and competent with using the intervention
strategies.

37

Parents completed an additional feedback questionnaire at the 3-month follow-up and
indicated that the one- and three-month follow-up sessions were beneficial for supporting
continued use of the RIT techniques, as well as for other reasons (e.g., checking in about other
behaviors, receiving social support, getting recommendations about additional intervention
services). Four out of the five parents reported that they use RIT intervention techniques 5 or
more times per week (the fifth parent indicated that she used the techniques once or twice per
week). When asked about barriers associated with continued use of the intervention strategies,
one parent noted personal time constraints, while another noted challenges with picking toys and
activities that keep her child engaged long enough to use the strategies. Suggestions for helping
support parents’ continued use of the intervention techniques included additional coaching
sessions, sending “helpful tips” emails, and developing an expanded video library with children
at much higher and much lower developmental levels.
Parents reported accessing the Online RIT website between 0 and 3 times after
completing the coaching phase of the study. Specifically, they reported viewing the slideshows,
video library, homework/reflection questions, and resources section of the Online RIT website.
Reported barriers to the continued use of the Online RIT website included limited time,
incompatibility of the website with ipads and iphones, and poor internet connections which made
the slideshows and videos play more slowly. A suggestion for ensuring continued use of the
Online RIT website included offering monthly web-tutorials where a facilitator could talk about
specific techniques, show video clips and conduct a live Q&A session for parents joining in via
teleconferencing programs.

38

DISCUSSION
The discrepancy between the demand for and the availability of evidence-based
interventions for children with ASD necessitates the exploration of alternative service delivery
models. The current study sought to examine the use of a hybrid telehealth program to introduce
parents of children with ASD to an evidence-based imitation intervention.
The primary goal of this study was to assess the degree to which parents were able to
learn about and effectively implement RIT after engaging in the various components of the
hybrid telehealth program. Program use was associated with significant increases in parent
knowledge about RIT and naturalistic intervention, and all parents demonstrated meaningful
improvements in their abilities to correctly implement the intervention strategies in response to
the program. Two parents achieved fidelity of implementation after engaging in only the selfdirected portion of the program, while another two parents achieved fidelity of implementation
of RIT during the remote coaching phase of the intervention. Although one parent did not
achieve fidelity of implementation of RIT, she showed large improvements in her fidelity ratings
from baseline to the self-directed and coaching phases. It is important to note that her child was
already demonstrating relatively complex play skills at the start of the study. Thus, he appeared
to find some of the techniques (e.g., contingent imitation) a bit boring. Additionally, when she
would model an action for imitation, her son would often expand on the action, rather than
imitating it exactly. Her relatively lower levels of fidelity may have been due to the fit between
her child’s needs and the goals/procedures of the intervention, rather than to her ability to
implement the techniques as specified. Indeed, considering the fit between an individual’s and
family’s needs and a given intervention is critical for program adoption, implementation, and
sustainability (Rogers, 2003).

39

Taken together, these results contribute to the emerging body of literature suggesting
parents are able to implement social communication intervention techniques with fidelity after
engaging in a telehealth program (e.g., Nefdt et al., 2010; Vismara et al., in press; Wainer &
Ingersoll 2013a). Furthermore, these data are consistent with previous work indicating that a
self-directed program may be sufficient for some, but not all, parents to learn the intervention;
others may require additional support, in the form of remote coaching and feedback, in order to
implement the techniques with fidelity (Vismara et al., in press, Wainer & Ingersoll 2013a).
Importantly, parents demonstrated differences in program engagement that may have impacted
learning and implementation across the study phases. For example, the two parents who achieved
fidelity of implementation during the self-directed phase completed 90% or more of the Online
RIT website components, while the two parents who achieved fidelity of implementation during
the coaching phase completed less than 90% of the website components (Parent 2 = 88%, Parent
3 = 30%). Additional research is needed to understand the relationship between program
utilization and parent fidelity, with the ultimate goal of informing the development and structure
of self-directed telehealth programs to support parent engagement and learning.
The variability in parent engagement and learning observed in this and other studies
suggests that a hybrid telehealth program may lend itself well to a stepped-care service delivery
model. For example, parents whose children demonstrate imitation deficits could be triaged in to
a low resource-intensive self-directed program; if sufficient engagement or learning does not
occur, more intense support, such as remote coaching, could be provided as indicated. Scaling
hybrid telehealth programs to stepped-care delivery models could allow for a large number of
individuals to be served, while ensuring a mechanism to provide more intensive levels of support
and care when necessary (Steever, 2011). Indeed, there is an identified need for flexible parent

40

training programs and interventions that can be tailored to individual needs and treatment
response (Phaneuf & McIntyre, 2011). Future research should examine the feasibility and costeffectiveness of stepped-cared models of telehealth parent training in order to encourage the
dissemination and adoption of such programs on a larger scale.
Given that an ultimate goal of parent training is to support the development of child
skills, this study also examined the impact of parent participation on child behaviors such as
imitation and social engagement. Visual inspection of session data indicated that most of the
children demonstrated an increasing trend in spontaneous imitation skills concurrent with parent
participation in the program. Two of the children showed clear increases in spontaneous
imitation immediately after their parents’ completed the self-directed portion of the telehealth
program, and maintained improvements for the duration of the study. Another two demonstrated
increases in spontaneous imitation at various times while their parents were engaged in the
coaching phase of the program. Although the last child did not demonstrate improvements in his
spontaneous imitation rates, he showed moderate levels of spontaneous imitation across the
study phases, suggesting that his imitation skills were relatively well developed at intake and/or
that his mother entered the study with other effective strategies for teaching and eliciting
spontaneous imitation from her child.
Multilevel modeling supported the contention that the children increased their
spontaneous imitation rates as their parents’ participated in the telehealth program. Interestingly,
parents’ use of two of the RIT strategies, Contingent Imitation and the Prompting Sequence,
uniquely predicted spontaneous imitation rates. Thus, not all components included in RIT may
serve as “active ingredients” in promoting spontaneous imitation skills. Diffusion of innovation
theory suggests that the perceived complexity of an intervention can strongly influence

41

innovation adoption, implementation and maintenance (Dingfelder & Mandell, 2011; Rogers,
2003). Additionally, the complexity of interventions may influence response acquisition and
impede behavioral change in parent training programs specifically (Allen & Warzak, 2000).
Thus, considering ways to decrease the perceived complexity of interventions, perhaps by
limiting the number of techniques introduced to only those “active” components, may be an
important step in supporting parents’ implementation of interventions during, as well as after,
participating in telehealth programs. Additionally, results from the current research offer further
evidence for the suggestion that interventions that promote both parent responsiveness and the
use of effective prompting may be particularly beneficial for supporting the development of early
social communication skills in children with ASD (e.g., Ingersoll, 2010; Ingersoll & Wainer, in
press; Stahmer, Schreibman, & Cunningham, 2011).
Previous research has indicated that the use of RIT techniques is effective for increasing
coordinated joint engagement (Ingersoll & Schreibman, 2006; Lewy & Dawson, 1992). Yet, in
the current study, clear increases in coordinated joint engagement concurrent with parent
participation in the program were observed for only one child. In earlier studies examining the
relationship between RIT and joint engagement, the intervention was implemented at greater
levels of intensity (e.g., 40-60 minutes per session, three sessions per week for 10 weeks) than
was likely the case in the current study. As such, it is possible that the lack of consistent gains in
social engagement observed in the current study were due to issues of intervention dose and
intensity. Additionally, previous studies of RIT utilized trained therapists who were instructed to
act in a contrived way (e.g., model an action for imitation once per minute, but do not make any
other social initiations) during baseline or comparison sessions in order to standardize the
interactions. However, during baseline sessions in the current study, parents were instructed to

42

interact with their child as usual. Moderate to high levels of coordinated joint engagement
observed during baseline sessions suggest that parents were already using other effective
strategies to elicit engagement from their children during usual play interactions. Thus, it is
possible that obvious changes in coordinated joint attention were not observed because of
parents’ strong ability to elicit their child’s attention prior to learning the RIT intervention
techniques. Nonetheless, results from multilevel modeling revealed that parents’ overall fidelity
of RIT was related to the children’s coordinated joint engagement, suggesting that the correct
implementation of the RIT intervention, as a whole, may have some effect on child joint
engagement. Furthermore, in the qualitative feedback, all parents mentioned that RIT helped
improve their children’s social engagement. Although these data suggest a relationship between
RIT and social engagement, additional research in needed to understand the specifics of this
association.
Given that the adoption and implementation of a program is dependent on users’
perceptions of the acceptability of the intervention (Rogers, 2003) the final goal of the study was
to assess the social validity of this hybrid telehealth service delivery model in serving parents of
children with ASD. With respect to the self-directed Online RIT website, parents rated the videobased instructional components most favorably. This finding is not surprising given that previous
research suggests that video is a powerful online teaching tool (Anaraki, 2004); it allows for
visual and auditory learning and demonstrates learning objectives in context, and has been found
to be associated with an enhanced learning experience (Wetzel, Radtke, & Stern, 1994) and
better learning outcomes (e.g., Romanov & Nevgi, 2007). Parents also rated the coaching
sessions as particularly useful and acceptable. Previous research suggests that collaboration and
dialogue are important in the learning process (Bonk & Cunningham, 1998), and that too little

43

interaction may serve as a source of dissatisfaction with online learning (Casebeer et al., 2004).
Additionally, components of the parent coaching sessions, including opportunities for practice
and feedback, have been identified as particularly important for producing positive intervention
outcomes (Kaminski, Valle, Filene, & Boyle, 2008). Thus, although coaching may not be
necessary for some parents to learn evidence-based interventions, it may be a desirable element
of telehealth programs and could influence other factors such as parent engagement and
sustainability of the intervention. While additional research in this area is needed, it is clear that
program developers must consider a balance between ensuring social validity, positive program
outcomes, and maximum dissemination and impact.
The primary limitations to the current study include a small sample size and a lack of
comparison data. Future research using randomized clinical trials is necessary to establish the
effectiveness of this service delivery model; in particular, use of non-inferiority methodology
will be especially useful in elucidating how this service delivery model compares to traditional
in-person service delivery models including individual and group parent training formats (Gros
et al., 2013). Randomized clinical trial research is also required to establish the effectiveness of
RIT as implemented by parents, especially when compared to other parent- and therapistimplemented social communication interventions. Additionally, information about parents’
fidelity of enactment of the intervention is lacking. It is likely that the amount, duration, and
context of parent practice of the intervention techniques would influence both parent and child
behavioral outcomes (Wainer & Ingersoll, 2013b). Although it is difficult to collect this kind of
information, technology-based applications, such as “practice” calendars or automatic email
practice reminders, could be integrated into telehealth programs to understand and support
ongoing parent use of the intervention strategies. Furthermore, it is likely that factors such as

44

computer and internet literacy, as well as ease of access to computer and internet technology,
could strongly influence participant engagement and program outcomes. In support of this
contention, the one family in the current study who experienced problems with internet
connectivity at home, also reported limited familiarity with technology, took the longest amount
of time to complete the self-directed portion of the program, and felt discouraged and
demotivated in the face of the technological problems that arose. Interestingly, this family, and
others, reported feeling comfortable with other forms of technology including smartphones and
tablets. Examining the use of these delivery platforms and their effects on program engagement
and outcomes will be in important next step in expanding the accessibility, reach, and impact of
telehealth programs (Vismara et al., in press).
Summary
This study provides initial evidence for the effectiveness of a hybrid telehealth program
for disseminating training in evidence-based intervention to parents of young children with ASD.
Hybrid telehealth programs, particularly those provided via a model of stepped care, may serve a
significant role in increasing access to evidence-based interventions for those on lengthy waitlists
or living in areas with limited services. As empirical evaluations of this, and other, telehealth
programs become more common, research questions beyond the acceptability and general
effectiveness of the program, including the cost-effectiveness, reach, referral processes and
characteristics of program completers and non-completers must be explored to determine how
telehealth programs can fit within the larger context of ASD intervention services.

45

APPENDICES

46

Appendix A
Online RIT Fidelity Form
Figure 1A
Online RIT Fidelity Form

RIT COMPONENT
CONTINGENT
IMITATION
Imitate child’s
appropriate toy
play, gestures,
and vocalizations.
LINGUISTIC
MAPPING
Use simplified,
repetitive
language around
child’s attentional
focus.
MODEL
Model actions
around child’s
focus of interest

LOW FIDELITY
1
Does not imitate
the child’s
gestures,
vocalizations,
and toy play.

HIGH FIDELITY
5
Imitates almost all of
the child’s gestures,
vocalizations, and toy
play throughout the
session when the
child is appropriately
engaged.

2
Imitates a few of the
child’s gestures,
vocalizations, and
toy play, but misses
the majority of
opportunities.

3
Imitates the child’s
gestures,
vocalizations, and
toy play about 50%
of the time, but
misses many
opportunities.

4
Imitates more than 50%
of the child’s gestures,
vocalizations, and toy
play when the child is
appropriately engaged,
but misses
opportunities.

Does not use
simplified
language around
the child’s
attentional
focus, language
is too complex,
or does not use
any language.

Uses simplified
language around the
child’s attentional
focus for some of
the session, but
misses the majority
of opportunities or
majority of language
is too complex.

Uses simplified
language around the
child’s attentional
focus up to 50% of
the time, but misses
many opportunities
or much of the
language is too
complex.

Uses simplified
language around the
child’s attentional
focus for more than
50% of the session, but
misses opportunities or
some language is not
appropriate for child’s
level of language.

Uses simplified
language around the
child’s attentional
focus throughout the
session. Most of the
language is
appropriate for child’s
language level.

Models actions
that are
inappropriate
for child’s
level/interest or
does not recruit
child’s
attention.

Models some
actions that are
appropriate for
child’s level/interest
but also many that
are not, or often fails
to recruit the child’s
attention.

Models some actions
that are appropriate
for child’s
level/interest and
recruits child’s
attention some of the
time.

Models actions that are
appropriate for child’s
level/interest more than
50% of the time and
recruits child’s
attention the majority
of the time.

Models actions that
are very appropriate
for child’s
level/interest and
recruits child’s
attention.

47

Figure 1A (con’t).
PACING
Model an action
every 1 to 2
minutes on
average.
Adjusts rate
when necessary
to keep child
engaged.

PROMPT
Physically
prompt child to
imitate after 3
presentations of
action.

PRAISE
Animatedly
praise child’s
spontaneous or
prompted
imitation.

Does not model
any actions for
imitation. Pacing
significantly
disrupts child’s
engagement or
learning.

Does not
physically prompt
child to imitate
action after
presenting the
action 3 times. Or
physically
prompts the child
to imitate all
actions before 3
models.
Does not praise
child’s
spontaneous or
prompted
imitation or
consistently
praises incorrect
responses.

Models actions at a
significantly lower
or higher rate
throughout session
(1-2 models).
Pacing somewhat
disrupts child’s
engagement or
learning.
Prompts child to
complete action
after third trial a
minority of the
time. Prompting
often does not result
in imitation, or
often physically
prompts before 3rd
model.

Models actions at a
somewhat lower or
higher rate
throughout session
(3 or 12 models).
Pacing does not
significantly disrupt
child’s engagement
or learning.
Prompts child to
complete action after
third trial up to 50%
of the time, but
misses many
opportunities,
prompting does not
result in imitation or
prompts before 3rd
model.

Models at an
appropriate rate for
some, but not all of the
session (4 or 11
models). Pacing does
not significantly
disrupt child’s
engagement or
learning.
Prompts child to
complete action after
third trial the majority
of the time, but misses
opportunities or
prompting occasionally
does not result in
imitation, or prompts
before 3rd model.

Models actions at an
appropriate rate
throughout session (510 models). Pacing is
appropriate for
keeping child engaged
and learning.

Praises a minority
of the child’s
spontaneous and
prompted
imitations, but
misses the majority
of opportunities or
praises multiple
responses.

Praises some of the
child’s spontaneous
and prompted
imitations, but
misses many
opportunities or
praises incorrect
responses.

Praises the majority of
the child’s spontaneous
and prompted
imitation, but misses
some opportunities or
praise is provide for an
incorrect response.

Praises all of the
child’s spontaneous
and prompted
imitation throughout
the session. Praise is
withheld for incorrect
responding.

48

Consistently prompts
child to complete
action after third trial
if child has not
spontaneously
imitated. Follows
through such that the
trial ends in imitation.

Appendix B
Online RIT Imitation Scoring Form
Figure 1B
Online RIT child imitation scoring form

CHILD:
DATE:
SESSION:
Toy

SCORER:
Primary

Action

Verbal Marker

1
2
3
4
5
6
7
8
9
10

Object Imitation
S
S
S
S
S
S
S
S
S
S

S = Spont.
P = Prompted

Rely

P
P
P
P
P
P
P
P
P
P

None
None
None
None
None
None
None
None
None
None

# of S
# of Minutes
Rate Per Minute

49

Gesture Imitation
S
S
S
S
S
S
S
S
S
S

P
P
P
P
P
P
P
P
P
P

None
None
None
None
None
None
None
None
None
None

Prompt Level

Vocal
Imitation

VP PP FP
VP PP FP
VP PP FP
VP PP FP
VP PP FP
VP PP FP
VP PP FP
VP PP FP
VP PP FP
VP PP FP
VP = Verbal Prompt
PP = Partial Physical Prompt
FP = Full Physical Prompt

Appendix C
Social Engagement and Affect Rating Scales
Figure 1C
Coordinated joint engagement rating scale

1
No episodes of the
coordinated joint
engagement state

2

CHILD’S COORDINATED JOINT ENGAGEMENT
3
4
5
Spends about a third of the scene in
coordinated joint engagement that is of
moderate quality, or briefly in
coordinated joint engagement in a
highly striking manner.

50

6

7

Frequently in rich and
varied episodes of
coordinated joint
engagement.

Figure 2C
Child affect rating scale

1

2

Affect is either
disruptive, highly
inappropriate, or very flat
and constricted

3

CHILD AFFECT
4

5

Affect appears mellow or content as
opposed to flat; affect does not impede
communication, but neither does it
enhance it

51

6

7

Affect is smoothly
modulated, appropriate,
and serves to enhance
other modes of
communication

Figure 3C
Parent affect rating scale.

1

2

Tense, disruptive, or
affectively flat, to the
point of being
expressionless and
subsequently very hard
to read

3

PARENT AFFECT
4

5

Mellow or content as opposed to flat;
affect does not impede
communication, but neither does
enhance it

52

6

7

Smoothly modulated,
appropriate, and serves
to enhance of modes of
communication

Appendix D
Modified Behavioral Intervention Rating Scale
Figure 1D
Modified Behavioral Intervention Rating Scale
Please evaluate the format of Online RIT by checking the number that best describes your agreement or disagreement with each statement. Please
check only one number for each item.
Strongly
Agree
Disagree (2) (3) (4) (5)
(6)
(1)
This is an acceptable intervention for my child's social imitation skills.
Most parents would find this intervention appropriate for teaching social imitation skills.
The intervention was effective in teaching my child social imitation skills
I would suggest the use of this intervention to other parents.
Most parents would find this intervention suitable for teaching social imitation skills.
I use this intervention at home.
The intervention did not result in negative side effects for my child.
The intervention would be an appropriate intervention for a variety of children.
The intervention is consistent with other interventions I have used with my child.
I like the procedures used in the intervention.
The intervention was a good way to teach social imitation skills to my child.
Overall, the intervention was beneficial for my child.
The intervention quickly improved my child's social imitation skills.
The intervention will produce lasting improvement in my child's social imitation skills.
My child's social imitation skills will remain at an improved level after the intervention is
discontinued.
Using the intervention not only improved my child's social imitation skills at home, but
also in other settings (e.g., classroom, community).
Other behaviors related to social imitation were also improved by the intervention.
The goals of the intervention are important to my child's functioning at home.
The goals of the intervention are regarded as important outcomes by most parents.
53

Figure 1D (con’t.)
I use the intervention with my child regularly.
It was easy to find information on the Online RIT website.
I used the website to complete the self-directed portion of the Online RIT program.
I understood the audio and text information that was presented.
The slideshows were helpful for learning the RIT intervention.
The manual was helpful for learning the RIT intervention.
The self-check questions were helpful for learning the RIT intervention.
The video-based exercises were helpful for learning the RIT intervention.
The homework was helpful for learning the RIT intervention.
The reflection questions were helpful for learning the RIT intervention.
The video library was helpful for learning the RIT intervention.
The amount of information provided on the Online RIT website was sufficient for me to
learn the intervention techniques.
The amount of information provided on the Online RIT website was sufficient for me to
feel comfortable and competent using the intervention techniques.
The coaching sessions with my child were helpful for learning the RIT intervention.
The discussion and problem solving with the coach were helpful for learning the RIT
intervention.
The written feedback provided by the coach was helpful for learning the RIT intervention
I would have like more formal feedback (e.g., use of a rating form) on how well I was
using the different RIT techniques.
The coach was interested in me.
The coach understood me.
The coach understood my child.
The amount of coaching I received was sufficient for me to learn the intervention
strategies.
The amount of coaching I received was sufficient for me to feel comfortable and competent
using the intervention strategies.
I would recommend this program to other parents of young children with social imitation
difficulties.

54

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55

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