Journal of Childhood, Education & Society Volume 1, Issue 2, 2020, pp. 141-166 ISSN: 2717-638X DOI: 10.37291/2717638X.20201242 Research Article ©2020 Journal of Childhood, Education & Society. This is an open access article under the CC BY- NC- ND license. Effects of a parent training using telehealth: Equity and access to early intervention for rural families Deborah L. Rooks-Ellis1, Sarah K. Howorth2, Susane Boulette3, Megan Kunze4, Ella Sulinski5 Abstract: 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. Article History Received: 05 May 2020 Accepted: 09 July 2020 Keywords Early intervention; Autism; Parent training; Telehealth; Rural; Family-practices Introduction Autism spectrum disorder (ASD) is an early emerging neurodevelopmental disorder defined by delays in social-communication (i.e., social-emotional reciprocity, nonverbal communication, and social relationships) and the presence of restricted and repetitive behaviors, interests, or activities, (i.e., stereotyped or repetitive motor movements, use of objects, or speech; inflexibility; restricted interests or focus; or hyper- or hypo-reactivity to sensory input) (American Psychiatric Association [APA], 2013). The prevalence of ASD has steadily risen to the current rate of 1 in 54 children in the U.S. (Maenner et al., 2020). In the past decade, the age for a reliable diagnosis of ASD has decreased to as early as 14-months with the recommended age for early diagnosis at 18-months (Hyman, Levy, & Myers, 2020; Pierce et al., 2019). Early diagnosis has led to an increased demand for developmental and behavioral early intervention. The supply of services has not kept up with this demand, forcing families to wait for these intervention services (Hyman et al., 2020; Smith-Young, Chafe, & Audas, 2020). Early Intervention for ASD Population The benefits of early intervention are long established in research (Chawarska, Macari, Volkmar, Kim, & Shic, 2014; Estes et al., 2014; Hyman et al., 2020). Interventions initiated before age three have a greater and more positive impact on development than interventions that began after age five (Kasari, _____________ 1 University of Maine, School of Learning and Teaching, Orono, ME, USA, e-mail deborah.l.rooks@maine.edu, ORCID: https://orcid.org/0000-0002-4317-1593 2 University of Maine, School of Learning and Teaching,, Orono, ME, USA, e-mail: sarah.howorth@maine.edu, ORCID: https://orcid.org/0000-0002-4292-301X 3 Maine Department of Education, Maine Child Development Services, Augusta, ME, USA, e-mail: sue.boulette@gmail.com, ORCID: https://orcid.org/0000-0003-4566-7995 4 University of Oregon, Department of Special Education and Clinical Sciences, Eugene, OR, USA, e-mail: mkunze@uoregon.edu, ORCID: https://orcid.org/0000-0002-4449-2719 5 University of Maine, School of Social Work, Orono, ME, USA, e-mail: ella.sulinski@maine.edu, ORCID: https://orcid.org/0000-0002-1830-5609 https://doi.org/10.37291/2717638X.20201242 https://creativecommons.org/licenses/by-nc-nd/4.0/ mailto:deborah.l.rooks@maine.edu https://orcid.org/0000-0002-4317-1593 mailto:sarah.howorth@maine.edu https://orcid.org/0000-0002-4292-301X mailto:sue.boulette@gmail.com https://orcid.org/0000-0003-4566-7995 mailto:mkunze@uoregon.edu https://orcid.org/0000-0002-4449-2719 mailto:ella.sulinski@maine.edu https://orcid.org/0000-0002-1830-5609 Deborah L. ROOKS-ELLIS et al. 142 Gulsrud, Freeman, Paparella, & Hellemann, 2012; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010). Specifically, children with autism who receive early, intensive interventions demonstrate improvements in social-communication and adaptive skills with decreased engagement in restricted and repetitive behaviors; often demonstrating improvements in adaptive functioning throughout childhood and later in life (Lin & Koegel, 2018; Reichow, Hume, Barton, & Boyd, 2018; Shire, Gulsrud, & Kasari, 2016). The positive outcomes associated with early intervention have been attributed to systematically implemented evidence-based interventions (Wong et al., 2015). Evaluation of intervention effectiveness as measured by fidelity (Caron, Bérubé, & Paquet, 2017), and assessment of these interventions for usability and acceptability (e.g., measurement of social validity, generalization to other caregivers, and maintenance over time), as well as flexibility (e.g., planning for uniqueness of individualized behavior targets), continue to raise the bar; ideally resulting in established, high-quality intervention packages to better target ASD symptomatology and serve young children and families (Matson & Goldin, 2014; Matson & Konst, 2013; Matson & Rieske, 2014; Rivard et al., 2017; Zwaigenbaum et al., 2015). Parent-Mediated Early Intervention Parent-mediated interventions are defined as “technique-focused interventions where the parent is the agent of change and the child is the direct beneficiary of treatment” (Bearss, Burrell, Stewart, & Scahill, 2015; Bearss et al., 2018). Parent-mediated interventions can positively impact child outcomes, which speaks to the importance of individualized, evidence-based early intervention by parents as mediators and adequate interventionist coaching (Beaudoin, Sébire, & Couture, 2019; Fettig & Ostrosky, 2011). Recent studies have suggested that when parents are actively engaged in the treatment process and are coached to incorporate specific behavioral and developmental strategies into daily routines and family activities, then positive outcomes are achieved for young children with ASD (McIntyre & Zemantic, 2017). Likewise, researchers have demonstrated parent involvement helps to facilitate generalization across environments, thereby providing the “real life” intensity of services necessary for significant changes in many toddlers with ASD (Brian, Smith, Zwaigenbaum, & Bryson, 2017; McIntyre & Zemantic, 2017; Wallace & Rogers, 2010). Telehealth (i.e., two-way computer-based videoconferencing) research when used with families of children with ASD is increasing. For example, functional communication training (Wacker et al., 2013, Wainer & Ingersoll, 2015), pivotal response training (Nefdt, Koegel, Singer, & Gerber, 2010), and behavioral consultation (Simacek, Dimian, & McComas, 2017) have been successfully delivered using telehealth with this population. This transference of intervention skills through coaching of parents via telehealth has become more prominent (Ashburner, Vickerstaff, Beetge, & Copley, 2016). In fact, telehealth has shown to be a successful means of training educators and caregivers in both school and early intervention settings to conduct functional assessments, create individualized behavior plans and innovative classroom management techniques (Neely, Rispoli, Gerow, & Hong, 2016). Similarly, it has been demonstrated that fidelity of parent-mediated intervention has been at higher levels when compared to similar interventions delivered face to face (McDuffie et al., 2016). More recently, telehealth has been used to train parents of young children with autism to implement early intervention strategies in their home using the parent- implemented Early Start Denver Model (P-ESDM), which employs the science of applied behavior analysis and developmental, relationship-based intervention (Rogers, Dawson, & Vismara, 2012; Vismara et al., 2018). Parents reported positivity toward the use of technology and telehealth as a means to learn parent- led intervention skills, and findings demonstrated emerging support for P-ESDM (Rogers, et al., 2012; Vismara et al., 2018). Access for Families in Rural Areas 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 (Mello, Goldman, Urbano, & Hodapp, 2016). Access to trained providers is also identified as a barrier for rural families as they are often made to wait their turn for services or face additional costs to travel long distances to obtain necessary services widening the equity gap due Effects of a parent training using telehealth: Equity and access to early intervention… 143 to geographical location (Martinez et al., 2018). 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. Telehealth integrates principles of adult learning within the multimedia environment to increase parents’ understanding, retention, and use of early intervention (Baggett et al., 2010). Increasing the availability of evidence-based interventions through telehealth may be a valid solution to closing the gap between service demand and availability in rural and underserved areas. Current Study The current study investigated the effects of the P-ESDM as implemented by an early interventionist present within the state’s existing Individuals with Disabilities Education Act (IDEA, 2004) Part C early intervention program. The study examined the feasibility of parent implementation of P-ESDM via telehealth to allow for statewide implementation of P-ESDM across a rural northeastern state to improve outcomes for young children with ASD and their families. Additionally, researchers sought to understand the pre to post change in child’s ASD symptomatology and the usability of the telehealth presentation for families, specifically for families residing in rural and underserved areas. 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. Specifically, the research questions for this study were: Research Question 1: Is there a functional relationship between parents’ fidelity of implementation of P- ESDM intervention strategies and their participation in P-ESDM parent training via telehealth? Research Question 2: What changes in children’s ASD symptoms do parents report? And Research Question 3: How do parents residing in rural areas describe the usability and acceptability of P- ESDM via telehealth? Method Participants and Setting Family participants. Family participants were recruited through the state’s existing IDEA Part C early intervention program with a specific focus on recruiting families from rural and underserved areas. Families represented seven of the state’s nine IDEA Part C early intervention program sites. Inclusionary criteria for the parent-child dyads were as follows: (a) child was enrolled in the state’s early intervention program as defined by IDEA (b) child had high risk (i.e., M-CHAT scores, sibling with ASD, informed clinical opinion) or an existing diagnosis of ASD by a licensed psychologist or physician, (c) parents provided informed consent for at least one primary parent and child to participate in study activities, (d) participating parent was able to participate in all sessions, and (e) parent had access to technology to support Zoom® video conferencing (e.g., internet, smart phone, computer, laptop, tablet). A total of ten parent-child dyads participated in the study. Children ranged in age from 25 to 33 months at the start of the study, with a mean age of 29.3 months. None of the children were receiving services outside of the parent-implemented intervention during the course of this study. Parent participants were female (9/10, 90%) and male (1/10, 10%) and reported as Caucasian (8/10, 80%), Hispanic (1/10, 10%), and Native American (1/10, 10%), with 60% (6/10) having completed high school or some college, and 40% (4/10) having earned a college degree. Participants were employed part-to-full time (6/10, 60%), others reported not being employed outside of the home (3/6, 30%), and one parent chose not to respond (1/10, 10%). Six parents (60%) reported high internet usage (e.g., more than 5 hours/day) and four parents (40%) reported low internet usage (e.g., less than 5 hours/day). Income was reported as $50,000/year or higher by 60% (6/10) participants, with 40% (4/10) having earned less than $50,000/year. Using the U.S. Census Bureau’s measure of population size and density to define rural, 100% of participating families lived in rural settings. Deborah L. ROOKS-ELLIS et al. 144 Setting. Assessment and intervention activities were conducted in family participants’ homes in person during baseline, and via internet-based telehealth during intervention. Family demographic information is included in Table 1. Table 1. Child and family characteristics Baseline characteristics N=10 Child’s age at enrollment (months) M=29.3 (SD=2.36) Child’s gender Male 6 Female 4 Child’s ethnicity Hispanic 1 American Indian or Alaska Native 1 Caucasian 8 Parent’s gender Male 1 Female 9 Parent’s age 25-34 6 35-44 3 55+ 1 Geographic setting Rural 10 Family income Less than $50,000 4 More than $50,000 6 Parent’s education High school 1 Some college 5 College degree 3 Graduate degree 1 Parent’s employment Not employed outside of the home 3 Part- or full-time employment 6 Parent’s internet use Low internet use 4 High internet use 6 Experimental Design Research activities and training protocols were approved by the university’s institutional review board (IRB). This study used a concurrent multiple baseline across participants design to evaluate the effects of a parent-implemented intervention for toddlers with ASD in terms of three dependent variables: (a) fidelity of parents’ implementation of intervention strategies, (b) pre to post change in children’s ASD symptomatology, and (c) parent description of the usability and acceptability of P-ESDM via telehealth. Each family served as its own control. To meet the quality indicators and standards of single-case experimental research, a minimum of three data points in the baseline phase were collected on parent fidelity and a decision to move to the next phase was based on the stability of the data (Horner et al., 2005; What Works Clearinghouse, 2020). Independent Variable (IV) P-ESDM intervention. In our rural northeastern state, parents and families of young children with autism are offered the Early Start Denver Model (Rogers & Dawson, 2010) as an option for IDEA Part C early intervention services. For this reason, the P-ESDM was chosen as the intervention for this study because it follows the same science of applied behavior analysis and developmental, relationship-based intervention of the ESDM. The family-centered approach of P-ESDM aligns with the state’s primary service provider model in which one member of the multidisciplinary team is selected to be the family’s primary contact for early intervention services. Likewise, our state faces persistent personnel shortages in early childhood intervention, often cited as a barrier to accessing high quality services for families living in rural Effects of a parent training using telehealth: Equity and access to early intervention… 145 and remote areas (Martinez et al., 2018). For this reason, telehealth was chosen as the means for implementation of P-ESDM. During the 12-weeks of P-ESDM intervention, parents were taught how to use the 10 topics of P- ESDM to target multiple skills within their child’s daily routines and activities to strengthen and support their child’s development. Examples of family routines and activities included reading a book together, eating breakfast, diaper changing, and family outings. P-ESDM topics included attention and motivation, sensory social routines, joint activity routines, nonverbal communication, imitation, joint attention, speech development, functional and symbolic play skills, and the teaching techniques of applied behavior analysis (see Table 2 for P-ESDM topics and strategies). Intervention sessions were scheduled at a time convenient for the family and conformed to the detailed parent training manual, curriculum, and parent fidelity of implementation measures (Rogers et al., 2012). Table 2. P-ESDM topics and strategies (Adapted from Rogers et al., 2012) Topic Goal Strategy Step into the spotlight: Capturing your child’s attention Increase child’s attention on parent for learning Identify and follow the child’s interests, reduce outside distractions that interfere with child’s ability to attend and participate in learning opportunities Find the smile: Fun with sensory social routines Increase child’s positive affect and social communication behaviors using songs, social games, and social exchanges Introduce and build a repertoire of sensory social routines to optimize child’s energy level for learning It takes two: Building back and forth interactions Increase opportunities for child learning within daily activities and routines Build joint activities and take turns with the child, use simple words, create new learning opportunities with additional materials, actions, and steps to the play, end the activity together and transition to the next activity Talking bodies: The importance of nonverbal communication Increase child’s nonverbal communication skills for promoting speech and language Add gestures, facial expressions, and simple language to family activities and routines. Identify communicative opportunities in which the child’s body language can be used to express feelings and interests Do what I do: Helping your child learn by imitating Increase child’s imitation of sounds, gestures, facial expressions, actions and words Imitate child’s play, sounds/ vocalizations, and movements and encourage imitation back from child inside toy play, songs, social games, and other daily activities Let’s get technical: How children learn Teach the basic strategies of applied behavior analysis for enhancing child learning Identify and use antecedent-behavior- consequence teaching principles for understanding child behavior and teaching new skills The joint attention triangle: Sharing interests with others Increase child’s interest to share objects and activities with others Give, show, and point to objects and pictures for sharing enjoyment It’s playtime Increase learning opportunities in parent–child toy play and support constructive, varied, and independent toy play. Use play to build and practice skills, including social skills, and to create new ways to play with toys independently and with others Let’s pretend Develop child’s pretend play that is spontaneous, creative, and flexible Use imitation to teach symbolic play actions to make scenes from life activities Moving into speech Increase child’s use and understanding of speech through active engagement with people, their facial expressions, and their gestures Develop vocal games to increase child’s sounds and build up child’s vocabulary with more opportunities for listening and responding to language During the first 90-minute videoconferencing P-ESDM session, parents shared which P-ESDM topics seemed more or less relevant to their learning needs and strategies of interest that they may have read about in the parent manual. Sessions 2-12 followed a similar format and began with a brief check in. Parents shared their experience and an example of using the P-ESDM topic inside an activity or routine with their Deborah L. ROOKS-ELLIS et al. 146 child. Next, the parent and the interventionist reflected about how the topic was used to support the child’s development and explored ways to expand or improve the activity to increase the child’s engagement and learning or to augment the child’s behavior. Then a new topic was introduced, and the interventionist coached the parent through several activities with the child. Parents used Bluetooth ear buds during this part of the session so as to not distract the child with the interventionist’s voice. Each session ended with the parent selecting activities and routines in which to use the new topic. After each session, parents were provided with an electronic handout of the goals and strategies taught during the session and the parent- selected activities to try with their child. Interventionist Training Sessions were delivered by a certified P-ESDM interventionist with a master’s degree and 20-years of experience in the field of early intervention. The interventionist was trained to implement P-ESDM by observing live and video-recorded intervention sessions, implementing intervention sessions, comparing self-completed fidelity checklists with trainer-completed fidelity checklists, and participating in reflection and problem-solving discussions. Before participating in the study, the interventionist achieved a fidelity rating of at least 85% or above on three video submissions as measured by the P-ESDM fidelity checklist. Dependent Variables (DVs) The study conducted observation coding and analyses. Primary outcome measures included parent and interventionist fidelity with a secondary outcome of pre-to post change in their child’s autism symptoms as a result of parent-implementation. Parent Fidelity of Implementation Intervention sessions were provided with and recorded using the Zoom® video conferencing system. Recordings were observed by the interventionist following each session to measure parent fidelity using the P-ESDM Parent Fidelity Rating System. This is a Likert-type rating scale with scores ranging from level 1 (e.g. poor or unacceptable) to level 5 (e.g. best possible example) across 13 adult behaviors related to (a) management of child attention, (b) quality of behavioral teaching, (c ) instructional techniques and application, (d) child affect and arousal, (e) management of unwanted behavior, (f) dyadic engagement, (g) child motivation for participating in the activity, (h) adult use of positive affect, (i) adult sensitivity and responsivity to child’s communicative cues, (j) multiple and varied communicative opportunities, (k) appropriateness of adult’s language for the child’s language level, (l) joint activity structure and elaboration, (m) transitions between activities, and (n) child engagement during unstructured times. Interventionist Fidelity of Implementation To evaluate the quality of implementation, the interventionist’s fidelity was examined using the P- ESDM Coaching Fidelity Rating System, a Likert-type rating scale with scores ranging from 1 (i.e., no competence) to level 5 (i.e., high competence) across the teaching behaviors. Fidelity was defined as no scores under 2 and a mean score of 80% or above on three consecutive coded sessions. The following activities were assessed (a) greeting and check-in, (b) warm up activity, (c) introduction of the topic, (d) coaching on the topic, (e) coaching activity 2, and (f) closing. Coaching fidelity of these behaviors were examined (g) collaborative, (h) reflective, (i) nonjudgmental, (j) conversational and reciprocal, (k) ethical conduct, (l) organization and management, and (m) managing conflict and implementation difficulties. Inter-rater agreement was defined as raters’ scores falling within 1 point on the Likert-type rating scale for each item. Reliability. Inter-observer agreement was established prior to fidelity scoring and maintained throughout the study. Two master’s level and certified ESDM therapists independently rated 100% of baseline session video recordings, 30% of randomly selected intervention video recordings, and 100% of maintenance and generalization video recordings. An agreement was defined as both raters’ scores being within 1-point on the Likert-type scale for each item. Inter-rater agreement was defined as raters’ scores Effects of a parent training using telehealth: Equity and access to early intervention… 147 falling within 1 point on the Likert-type rating scale for each item. The goal for achievement of fidelity was 80%. Inter-observer ratings in this study were 95% for parent fidelity and 94% for interventionist fidelity. See Table 3 for P-ESDM fidelity scoring instructions. Table 3. P-ESDM fidelity rating instructions (Adapted from Rogers et al., 2012) Instructions to Raters 1 If rating from a video recording, watch the recording in a confidential setting with minimal distractions. 2 Review the child’s objectives prior to coding. Keep them available to check as needed. 3 Read the language defining each behavior and anchor every score. 4 Take brief notes during the session you are observing in order to remember examples of behavior. 5 When rating, be aware of rater biases. 6 Observe each activity one time through without stopping. Make notes and replay as needed. 7 When a coaching problem has occurred, decide what the main difficulty is and code the item most closely related to the problem accordingly. 8 If you are caught between two codes, then give the higher code. 9 One is considered to have achieved fidelity to the model if they have no scores under 2 and a mean score of 80% or above on three consecutively coded sessions. Autism Impact Measure Severity of children’s ASD symptoms was measured using the Autism Impact Measure, a 41-item parent-report measure of core autism symptoms (see Table 7 for AIM items). Developed using a large sample of 440 children and adolescents with ASD, test-retest reliability ranged from .65 to .85 for the frequency subdomains and .53 to .78 for the impact subdomains (Kanne et al., 2014). Given these sound psychometric properties, the Autism Impact Measure was selected for the ability to track short-term improvement across clinically relevant ASD symptom domains. Items were rated on the following corresponding 5-point scales for frequency of symptom occurrence (1=never, 5=always) and symptom- related impact on daily functioning (1=not at all, 5=severe). Positively phrased frequency items 28-41 were reverse scored to ensure that all items reflected frequency of problematic behavior for analysis (Kanne et al., 2014, p. 173). Social validity: Telehealth usability and acceptability questionnaire. Parents completed a program developed electronic questionnaire following the intervention phase to characterize the intervention’s utility, acceptability and feasibility. Parents responded to 17 Likert-type 6-point scale questions about the usability and acceptability of the telehealth format, 18 Likert-type 6-point scale questions about their level of satisfaction with the interventionist’s coaching, and three open-ended questions about the coaching process. Example Likert-type scale items (with response anchors of strongly agree, somewhat agree, somewhat disagree, and strongly disagree) included “I felt supported by the telehealth intervention and therapist coaching in spite of distance.”; “Telehealth saves me time traveling for services.”; “The discussion and problem solving with the coach were helpful for reaching goals.”, “I think the visits provided by telehealth are the same as in-person visits.”, and “I was able to use the telehealth intervention to increase my child’s participation in activities and play.” Open-ended questions included “What did you like best about the telehealth parent coaching?” and “What did you like least?” Procedure Project staff met with interested families, explained the project, and obtained informed consent from the parents. A routines-based interview (McWilliam, 2010) was completed to gather information about the family’s priorities and concerns and information about their typical routines and activities. Baseline Phase Baseline sessions were conducted in-person. The camera setting of an iPad was used to video-record a minimum of three 10-minute play sessions between the child and parent. The iPad was set up on a table or shelf to minimize distractions. Parents were asked to interact with their child as they typically would during everyday activities, with no attempt to influence parents’ behaviors. Examples of parent-child activities observed included playing with preferred toys, building with blocks, eating a snack among others. Parent fidelity of implementation of intervention strategies was measured using the P-ESDM Deborah L. ROOKS-ELLIS et al. 148 Parent Fidelity Rating System (Rogers et al., 2012) by the interventionist, and no parent coaching occurred during baseline sessions. Parents were provided a copy of the parent manual, Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn (Rogers et al., 2012). Additionally, the interventionist and parent worked together to set up and test-run the technology that would be used for the intervention sessions (e.g., ear buds for coaching, video-conferencing system on smart phone, tablet, or computer). Parents were provided training as needed to operate the Bluetooth ear buds and the Zoom® video conferencing system. P-ESDM Intervention Phase Each 90-minute intervention session followed the format of the manualized P-ESDM intervention. Sessions were video recorded using the Zoom® video conferencing system. Parent fidelity was measured during the warm-up activity for previously taught strategies and during the coaching activity for new strategies. Parents were encouraged to use the strategies in their everyday activities with their child; however, there were no specific requirements given to parents about the frequency and duration that parents should use to implement the intervention strategies. Parents completed the telehealth usability and acceptability questionnaire following the intervention phase. Maintenance Phase The interventionist observed the family interacting with their child as they typically would during activities and play two weeks after intervention sessions were completed as a maintenance measure of the parent’s fidelity of intervention strategies. Parent fidelity of implementation of intervention strategies was measured using the P-ESDM Parent Fidelity Rating System by the interventionist, but no parent coaching occurred during these sessions. This 90-minute telehealth session was video recorded. Generalization Phase Two weeks following the maintenance session, parents were invited to submit a 10-20- minute video recording to measure generalization of parent fidelity of implementation of intervention strategies. Parent fidelity of implementation of intervention strategies was measured using the P-ESDM Parent Fidelity Rating System by the interventionist, but no parent coaching occurred during these sessions. Data Analysis The functional relationship between the P-ESDM via telehealth intervention and dependent variable of parent fidelity of intervention strategies was analyzed through visual inspection and descriptive statistics of graphed data. The level, trend, variability of data across phases, and single case measures of effect for each participant provided the context for the analysis (Kratochwill et al., 2010). Data on dependent measures was analyzed using nonoverlap of all pairs (NAP), TAU-U, and percent non overlapping data (PND). NAP is a nonparametric measure of effect for measuring nonoverlap or between two phases. It does not include adjustment for data trends in baseline (Scruggs & Mastropieri, 1998). TAU-U is a nonparametric measure to measure data overlap between phases. It allows for analysis adjustment for baseline trends and is a measure that can distinguish how much of the nonoverlap was an improvement over baseline. It is a way to determine whether or not improvement was due to the intervention versus chance (Parker, Vannest, & Davis, 2011). The PND was calculated using the following formula: the number of intervention data points that surpassed the highest baseline data point divided by the total number of intervention data points, then multiplied by 100 (Scruggs, Mastropieri, & Casto, 1987). Scruggs and Mastropieri (2001) suggested interpretational guidelines of PND when used to evaluate the effectiveness of the intervention. Using their guidelines, authors evaluated PND greater than 90% as a highly effective intervention, PND greater than 70% and less than 90% as an effective intervention, PND greater than 50% and less than 70% as questionable effectiveness, and PND less that 50% was considered unreliable effectiveness for interventions. Statistical analyses of the pre-post Autism Impact Measure responses were performed using SPSS Statistics version 25. Positively phrased frequency items were reverse scored, so that “all items reflected Effects of a parent training using telehealth: Equity and access to early intervention… 149 frequency of problematic behavior” (Kanne et al., 2014, p. 173). In addition to descriptive statistics, the Wilcoxon Signed-rank test was conducted. The Wilcoxon is a non-parametric statistical hypothesis test used to compare two repeated measurements on a single sample to determine if mean ranks differ. This non-parametric test was chosen because 1) the pre-post responses were measured at the ordinal level using Likert scale questions, 2) the responses consisted of related pairs, and 3) given the sample size, the population was not assumed to be a normal distribution. Results Parent Fidelity Parents’ fidelity of implementation of P-ESDM are reported in Figure 1 (see Appendix A) and Tables 4 and 5. The intervention was delivered in one group of four families and two groups of three families. Group 1 included families identified as F1, F2, F3 and F4, group 2 included families identified as F5, F6, and F7, and group 3 included families identified as F8, F9, and F10. Data collected during the first three weeks indicated that the four families’ fidelity of implementation of the P-ESDM intervention strategies (F1, F2, F3, F4) ranged from 40% to 65% during baseline. Figure 1 shows a graphical display of these data. After a stable baseline, Family 1 showed minimal change and a moderate amount of variability in implementation fidelity data beginning in session three of the intervention. Maintenance data for Family 1 does indicate an increase in fidelity compared to baseline levels, however a functional relationship was not established due to the lack of immediacy of change. For family F1, the implementation of P-ESDM intervention resulted in a marked increased parent fidelity after the sixth intervention session (baseline M = 60%, intervention M = 68%). Single case design (SCD) measures of effect indicate that the intervention had a moderate effect: PND & NAP = 83%; TAU = 0.67, z = 1.73, p = .08. The trend for intervention data was stable. These gains were maintained at an even higher rate (maintenance = 82%) when measured two weeks after completion of the P-ESDM intervention. However, after a baseline with a decreasing trend, the fidelity of parent implementation of the P- ESDM intervention increased immediately and markedly for Family 2 after the introduction of the telehealth P-ESDM intervention. A functional relationship was established due to the immediacy of change. Family F2 had a decreasing trend during baseline fidelity collection (M = 43%) that increased when the P- ESDM intervention was introduced (M = 72%). Yet, SCD measures of effect indicate that the intervention demonstrated a large effect: PND & NAP = 100%; TAU = 1.0, z = 1.73, p = .009. Although intervention data was variable, this change in level was maintained, and then generalized at levels above those of baseline, demonstrating a therapeutic effect. These gains were maintained at an even higher rate (maintenance = 87%) when measured two weeks after completion of the P-ESDM intervention via telehealth. At generalization 8 weeks following the maintenance session, the parent fidelity for family F2 continued to be above the intervention mean (generalization = 80%). Likewise, family F3 had a stable, but decreasing trend during baseline fidelity collection (M=39%) that increased markedly, although not until the second session of the P-ESDM intervention (M=70%) limiting the interpretation of a functional relationship and the immediacy of effect of the treatment. Yet, SCD measures of effect indicate that the intervention demonstrated a large effect: PND = 92%, NAP = 96%, TAU = 1.0, z = 2.60, p = .009. Intervention data was relatively stable, and gains were maintained at a rate higher than baseline levels (maintenance = 83%) when measured two weeks after completion of the P- ESDM intervention. Family F4 had a decreasing trend during baseline fidelity collection (M = 74%) that increased only after the third intervention session (M = 78%) limiting the interpretation of a functional relationship and the immediacy of effect of the treatment. Similarly, SCD measures of effect indicate that the intervention demonstrated a questionable effect: PND = 41%, NAP = 63%, TAU = 0.33, z = .866, p = .39. However, when parent fidelity was collected at maintenance, there was an increased fidelity score (maintenance = 93%). At generalization eight weeks following the maintenance session, the parent fidelity for family F4 continued Deborah L. ROOKS-ELLIS et al. 150 to be above the intervention mean (generalization = 85%) but did overlap with much of the intervention data. The following three families’ data (F5, F6, and F7) across four weeks of baseline indicate similar results and their fidelity of implementation of the P-ESDM intervention strategies ranged from 48% to 63% during baseline. All three of these families also demonstrated an increase in P-ESDM fidelity of implementation. After a baseline with a decreasing trend for family F5, the implementation of P-ESDM intervention resulted in a marked increased parent fidelity, but only after the fourth intervention session (baseline M = 57%, intervention M = 67%) limiting the interpretation of a functional relationship and the immediacy of effect of the treatment. Yet, SCD measures of effect indicate that the intervention had a moderate effect, PND = 75%, NAP = 83%, TAU = 0.67, z = 1.73, p = .08 and intervention data indicate an increasing trend. These gains were maintained (maintenance M = 65%) when measured two weeks after completion of the P-ESDM intervention. Family F6 had a stable baseline (M = 63%) that increased immediately, then markedly after the fourth intervention session to a Mean of 81% demonstrating a weak effect based on visual analysis alone. Yet, SCD measures of effect indicate that the intervention had a large effect, PND & NAP = 100%; TAU=1.0, z = 2.60, p = .009, and intervention data were relatively stable. These gains were maintained at a higher rate of fidelity (maintenance = 97%) when measured two weeks after completion of the P-ESDM intervention. Family F7 had an increasing baseline, and the fidelity of implementation of P-ESDM increased during intervention sessions (baseline M = 48%, intervention M = 73%) limiting the interpretation of a functional relationship and the immediacy of effect of the treatment. Yet, SCD measures of effect indicate that the intervention had a large effect, PND & NAP = 100%, TAU = 0.91, z = 2.38, p = .0172). These gains were maintained at an even higher rate of fidelity (maintenance = 80%) when measured two weeks after completion of the P-ESDM coaching via telehealth intervention. At generalization eight weeks following the maintenance session, the parent fidelity for family F7 continued to be above the intervention mean (generalization = 82%). Baseline was conducted across five weeks for the final three families (F8, F9, and F10). The fidelity of implementation of the P-ESDM intervention strategies for these three families ranged from 50% to 55% during baseline. All three of these families demonstrated increased parent fidelity of implementation of P- ESDM after the introduction of the intervention. For family F8, after a variable baseline, the implementation of P-ESDM intervention resulted in a marked and immediate increased parent fidelity (baseline M = 55%, intervention M = 74%) with a relatively stable trend, indicating therapeutic effects. Yet, SCD measures of effect indicate that the intervention had the following effects: PND = 67% (questionable effect), NAP = 93% (large effect); TAU = 0.83, z = 1.17, p = .03 (large effect). Therapeutic gains were maintained at a higher rate of fidelity (maintenance = 83%) when measured two weeks after completion of the P-ESDM intervention. After a stable baseline (M = 50%), the data for family F9 increased immediately with a variable trend during intervention (M = 67%) indicating small therapeutic effects. Yet, SCD measures of effect indicate that the intervention had the following effect: PND = 83% (moderate effect), NAP= 93% (large effect); TAU = 0.88, z = 2.30, p = .02 (large effect). Therapeutic gains were maintained at a higher rate of fidelity (maintenance = 78%) when measured two weeks after completion of the P-ESDM intervention and at generalization 8 weeks following the maintenance session (generalization M = 92%). Lastly, family F10 had a stable baseline (M = 54%) that also increased, but not until the fourth session of intervention to a mean of 70% with moderate variability, limiting the interpretation of a functional relationship and the immediacy of effect of the treatment. Yet, SCD measures of effect indicate that the intervention had the following effect: PND = 83% (moderate effect), NAP = 96% (large effect); TAU = 0.92, z = 2.38, p = .017 (large effect). Gains in mean fidelity ratings were maintained at a higher rate of fidelity (maintenance M = 85%) when measured two weeks after completion of the P-ESDM intervention, and at generalization 8 weeks later the parent fidelity for family F10 continued to be above the intervention mean Effects of a parent training using telehealth: Equity and access to early intervention… 151 (generalization M = 90%). Table 4 displays the single case design measure of effect for parent fidelity and mean coaching fidelity. Table 5 displays the mean baseline versus intervention parent fidelity. Table 4. Parent fidelity single case design measure of effect and coaching fidelity Family Baseline to Intervention PND Baseline to Intervention NAP TAU-U Baseline to Intervention Mean Coaching Fidelity F1 83% Moderate Effect 83% Moderate Effect 0.67 z =1.73 p =.08 92% F2 100% Large Effect 100% Large Effect 1.0 z = 1.73 *p =.009 90% F3 92% Large Effect 96% Large Effect 1.0 z = 2.60 *p =.009 90% F4 41% Questionable Effect 63% Questionable Effect .33 z =.866 p =.39 92% F5 75% Moderate Effect 83% Moderate Effect .67 z = 1.73 p =.08 88% F6 100% Large Effect 100% Large Effect 1.0 z = 2.60 *p=.009 91% F7 100% Large Effect 100% Large Effect .91 z = 2.38 *p=.017 93% F8 67% Questionable Effect 93% Large Effect 0.83 z = 1.17 *p =.03 93% F9 83% Moderate Effect 93% Large Effect 0.88 z = 2.30 *p= .02 91% F10 83% Moderate Effect 96% Large Effect 0.92 z = 2.38 *p=.017 90% Table 5. Mean baseline as compared to intervention parent fidelity Family Mean Baseline Fidelity Mean Intervention Fidelity Maintenance Fidelity Generalization Fidelity F1 60% 68% 82% NA F2 43% 72% 87% 80% F3 39% 70% 83% NA F4 74% 78% 93% 85% F5 57% 67% 65% NA F6 63% 81% 97% NA F7 48% 73% 80% 82% F8 55% 74% 83% NA F9 50% 67% 78% 92% F10 54% 70% 85% 90% AVERAGE 54% 72% 83.30% 85.80% Telehealth Usability and Acceptability Parents rated the 17 items on the program developed Telehealth Usability and Acceptability Questionnaire with strongly agree, agree and somewhat agree. Parents felt well supported by the telehealth intervention and coaching process with 88.89% (8/9) strongly agreeing and 11.11% (1/9) agreeing with the statement. Parents selected strongly agree with 100% (9/9) being satisfied with the telehealth intervention. Parents felt the intervention increased their child’s participation in activities and play with 100% (9/9) reporting as strongly agree. Additionally, parents reported that the intervention was effective in helping the parent create solutions for their child with 88.89% (8/9) strongly agreeing and 11.11% (1/9) agreeing Deborah L. ROOKS-ELLIS et al. 152 with the statement. Overall, parents reported they would use the telehealth services again with 77.78% (7/9) strongly agreeing and 22.22% (2/9) agreeing with this statement. Parents responded to three open-ended questions. One parent summed up their experience with the P-ESDM intervention via telehealth intervention by responding, “It helped me gain so much insight and knowledge about how to effectively play and interact with my child. I loved the book that was provided to me and found it an extremely helpful resource.”. Another parent indicated the intervention’s impact by responding, I felt I was learning and using skills that were making a difference in my life as a ...parent giving me confidence that I could give our little one a real chance to be happy and healthy and to have the best shot at a full and rewarding life. Being the person doing the work, studying and applying the knowledge makes this a life changer not just a program that is carried out by someone else and ends and is forgotten. Any child and parent willing to commit to this program would have long term benefits. It’s a life solution not just a short-term intervention. Families reported that the intervention conducted in their homes was convenient, and commented positively on the interventionist’s insight, input, support and suggestions provided during videoconferencing, “The guidance (of the interventionist) helped me expand my tools to help me help my child.”. Autism Impact Measure Pre-to-post change in autism symptomatology for child participants was examined. A Wilcoxon Signed-rank test revealed a statistically significant reduction in frequency of reported problematic behaviors after participating in the P-ESDM intervention, z = 2.35, p = .019, with a large effect size (r = .53). The median frequency score decreased from pre-intervention (Mdn = 91.0, SD = 20.30) to post-intervention (Mdn = 75.5, SD = 11.44), indicating a positive change. Additionally, the Wilcoxon Signed-rank test revealed a statistically significant reduction of the impact of problematic behaviors on everyday activities after participating in the P-ESDM intervention, z = 2.55, p = .011, with a large effect size (r = .57). The median impact score decreased from pre-intervention (Mdn = 67.0, SD = 21.51) to post-intervention (Mdn = 54.4, SD = 12.09). To further answer the research questions, the difference between means was examined for each item. We report on statistically significant items below. Because of the small sample, we use Hedges’ g to report the effect size. See Table 6 for statistically significant items and Appendix B for items, means, standard deviations, difference between means and p values. Table 6. Statistically significant items and difference between means of the autism impact measure Item# Item Pre-Intervention Post-Intervention M SD M SD M difference p g Frequency Items 5 Used someone else's hand to point, touch or perform a task 2.60 1.65 1.70 .823 0.90 *.041 .69 14 Experienced problems in communicating with others 4.30 .949 2.80 .789 1.50 *.004 1.72 22 Resisted changes in routines 2.50 1.58 1.40 .966 1.10 *.014 .84 26 Experienced problems in social interactions 3.10 1.37 2.50 1.18 .60 *.034 .47 ^30 Shared his enjoyment or excitement with others 1.60 1.07 2.50 1.43 .90 *.034 .71 ^33 Used a social smile to greet people or respond to them 1.60 1.07 2.70 1.57 1.10 *.026 .82 ^34 Used gestures to communicate 2.30 1.16 3.80 1.23 1.50 *.006 1.25 ^36 Seemed interested in other children his age 2.33 1.58 3.20 1.75 .87 *.008 .52 Impact Items 7 Had certain rituals or routines that have to be followed 2.00 1.41 1.40 .843 .60 *.034 .52 18 Experienced problems in communicating with others 4.00 1.25 2.70 .823 2.30 *.010 1.23 22 Resisted changes in routines 2.40 1.43 1.50 1.08 .900 *.024 .71 ^41 Made eye contact with others 1.60 .966 2.70 1.25 1.10 *.026 .98 Effects of a parent training using telehealth: Equity and access to early intervention… 153 ^ denotes reverse scored items Social reciprocity. A statistically significant difference between means was found for several items in the social reciprocity domain. Following the intervention, parents reported their child shared enjoyment or excitement with others (pre- M = 1.60, SD = 1.07; post- M = 2.50, SD = 1.43, p=.034), used a social smile to greet or respond to people (pre- M =1.60, SD = 1.07; post- M = 2.70, SD = 1.57, p = .026), used gestures to communicate (pre- M = 2.30, SD = 1.16; post- M = 3.80, SD = 1.23, p = .006), and seemed interested in other children of a similar age (pre- M = 2.33, SD =1.58; post- M = 3.20, SD = 1.75, p = .008). Children also had problems with social interactions less frequently (pre- M = 3.10, SD = 1.37; post- M = 2.50, SD = 1.18, p = .034). Communication and language. A statistically significant difference between means was found for two language and communication items, indicating positive change in children’s communication behaviors. Parents reported their child used someone else’s hand to point, touch or perform a task less frequently following the intervention (pre- M = 2.60, SD = 1.65; post- M = 1.70, SD = .823, p = .041). Children experienced problems in communicating with others less frequently (pre- M = 4.30, SD = .949; post- M = 2.80, SD = .789, p = .004) and with less impact on their daily functioning (pre- M = 4.00, SD = 1.25; post- M = 2.70, SD = .823, p = .010). Repetitive behaviors and restricted interests. Parents reported their child was less resistant to change in routines (pre- M = 2.50, SD = 1.58; post- M = 1.40, SD = .966, p = .014) and that change in routines had less impact on their child’s daily functioning (pre- M = 2.40, SD = 1.43; post- M = 1.50, SD = .900, p = .024). In addition, a child’s certain rituals or routines were reported to have less impact on their child’s daily functioning (pre- M = 2.00, SD = 1.41; post- M = 1.40, SD = .843, p = .034). Conclusion and Discussion The current study investigated the effects of the P-ESDM as implemented by an early interventionist present within the state’s existing IDEA Part C early intervention program. Telehealth technology was used to coach parents to conduct the intervention procedures, and all families demonstrated an increased level of implementation fidelity of the P-ESDM intervention as compared to baseline levels. The study demonstrated that positive outcomes for very young children with ASD can be achieved when parents are trained to use this naturalistic developmental behavioral intervention within and across family routines and activities. The results are among the first to demonstrate the feasibility of statewide implementation of P-ESDM in natural environments within the framework of a state’s early intervention program. The results of the current study are promising. First, the results extend support for parent-mediated early intervention for toddlers with autism. Next, the results align with previous research about P-ESDM and highlight that this low dosage intervention may be adequate to sustain intervention effects. Next, a functional relationship existed between parent fidelity of P-ESDM intervention strategies and parent participation in P-ESDM training, expanding the literature on the use of telehealth to deliver early intervention services for families, specifically in rural and underserved areas. Parent-mediated early intervention Parent-mediated interventions develop a parent’s capacity to implement evidence-based strategies with their child. In fact, these interventions are based on the assumption that parents will implement the target strategies within their daily routines and activities with their child; thereby increasing the opportunities provided to the child to interact and engage with peers, others, and the environment (Siller & Morgan, 2018). In the current study, parents reported statistically significant positive change in their child’s autism symptoms, specifically in the domains of communication, social reciprocity and repetitive behaviors and restricted interests. These results are in agreement with the hypothesis that early intervention for toddlers at risk or diagnosed with ASD may “remit or reduce the expression of symptoms” (Webb, Jones, Kelly & Dawson, 2014). This is promising given that even moderate and non-significant gain in ASD symptom severity post-intervention have resulted in a significant reduction of symptom severity Deborah L. ROOKS-ELLIS et al. 154 one year (Green et al., 2017) and two years (Estes et al., 2014) following the conclusion of the intervention. Increased Fidelity of P-EDSM Maintenance is often noted to be lacking in studies of parent-mediated interventions, limiting the ability to determine sustained implementation or potential outcomes (Fettig, Barton, Carter, & Eisenhower, 2016; Roberts & Kaiser, 2011). In this study, parent fidelity of implementation was shown to increase during the generalization and maintenance phases; a possible assurance that parents’ sustained implementation may likely impact the child’s developmental trajectory and targeted communication and social behaviors over time. This “real life” intensity of services is necessary for significant change in toddlers with ASD, and these results are congruent with other researchers who have demonstrated that parent involvement helps to facilitate generalization across environments (Brian et al., 2017; McIntyre & Zemantic, 2017; Wallace & Rogers, 2010). Telehealth A functional relationship between the P-ESDM via telehealth intervention and parent fidelity of intervention strategies was demonstrated. This result is consistent with literature that telehealth can be used as a mechanism to deliver naturalistic developmental behavioral interventions and achieve positive child outcomes (McIntyre & Zemantic, 2017; Wainer & Ingersoll, 2015). In rural areas, equity and access to early intervention and parent coaching services can be a challenge (Olsen, Fiechtl, & Rule, 2012). The results of this study are encouraging in that they show that parents can be coached to implement evidence-based practices at a high level of fidelity using telehealth. Providing intervention using telehealth as a service delivery model may alleviate higher costs of services associated with travel time, distance between families, and provider shortages (Little, Wallisch, Pope, & Dunn, 2018; Olsen et al., 2012). Findings from this study suggest the use of telehealth coaching may be an equitable response to a family's limited access to professional support due to rural location. Likewise, social validity is imperative when determining the feasibility and utility of the parent training. Parents in this study expressed high satisfaction with the telehealth delivery of the P-ESDM and the intervention procedures. Limitations The study had several limitations. First, cellular and broadband access were a challenge in very rural areas. This did not prevent family participation, but two parents did note that an intermittent connection interfered with the video stream and the ability to clearly hear and see the interventionist. Next, the fidelity of implementation measure was coded by two providers who were trained and certified to implement ESDM procedures; however, this was not a blind review, which could have hindered the validity of their coding. Although we report large effect sizes, the analysis to examine pre to post change in autism symptomatology was limited to a non-parametric test, and we did not control for other outcomes such as age or gender. Likewise, the sample was not highly diversified, limiting generalization of the results to the participants of the study. It is also important to note that the AIM is a parent report measure, and as such is subject to potential informant bias. Applied research is difficult to control for all potential confounding variables. Generally, all families in this study did demonstrate an increased level of fidelity in implementing the P-ESDM intervention compared to baseline levels. However, due to increasing and decreasing trends in the baseline data of many families, and the lack of immediate effect of the intervention, more research is needed to determine the functional relationship of the delivery of parent coaching via telehealth on the increase in parent fidelity to rule out maturity and test-retest effects. Future Research Increasing the availability of evidence-based interventions through telehealth may be a valid solution to closing the gap between service demand and availability in rural and underserved areas. Other Effects of a parent training using telehealth: Equity and access to early intervention… 155 studies have demonstrated effective results with telehealth as a service delivery model for behavioral consultation services as compared with on-site coaching (Suess, Wacker, Schwartz, Lustig, & Detrick, 2016; Wacker et al., 2013). More research examining the comparative effectiveness of P-ESDM versus other models is needed. In this study, parent fidelity increased during maintenance and generalization, and positive long- term effects of parent-mediated interventions have been reported to be sustained up to 6 years following the end of the intervention (Green et al., 2017; Pickles et al., 2016). Continued research is needed to examine long-term effects of parent fidelity to support increased improvement of autism symptoms and the developmental trajectories for toddlers with autism. Intervention that builds parent capacity and supports children’s development and learning through the use of evidence-based practices in everyday activities can lead to positive parent and child outcomes. In the current study, the interventionist was nationally certified to implement P-ESDM. 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Parent Fidelity of Implementation of P-ESDM Baseline Intervention Maintenance Generalization 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 Family 1 (F1) Family 2 (F2) Sessions Pa re nt F id el it y of E SD M In te rv en ti on Im pl em en ta ti on Deborah L. ROOKS-ELLIS et al. 160 Baseline Intervention Maintenance Generalization 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Family 3 (F3) Family 4 (F4) Sessions Pa re nt F id el it y of E SD M In te rv en ti on Im pl em en ta ti on Effects of a parent training using telehealth: Equity and access to early intervention… 161 Baseline Intervention Maintenance 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Family 6 (F6) Family 5 (F5) Sessions Pa re nt F id el it y of E SD M In te rv en ti on Im pl em en ta ti on Deborah L. ROOKS-ELLIS et al. 162 Baseline Intervention Maintenance Generalization 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Family 8 (F8) Family 7 (F7) Sessions Pa re nt F id el it y of E SD M In te rv en ti on Im pl em en ta ti on Effects of a parent training using telehealth: Equity and access to early intervention… 163 Baseline Intervention Maintenance Generalization 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Family 10 (F10) Family 9 (F9) Sessions Pa re nt F id el it y of E SD M In te rv en ti on Im pl em en ta ti on Deborah L. ROOKS-ELLIS et al. 164 Appendix B Items and Difference Between Means of the Autism Impact Measure Item # Item Pre-Intervention Post-Intervention M SD M SD M difference p Frequency Items 1 Shown fascination with parts of objects rather than the whole toy 3.10 1.10 3.20 1.40 0.10 .276 2 Been fascinated with looking at, feeling, touching, and licking certain objects 3.10 1.66 2.70 1.57 0.40 .194 3 Lined things up 2.00 1.70 2.60 1.65 0.60 .273 4 Responded oddly or inappropriately to others 2.00 1.33 1.70 1.06 0.30 .453 5 Used someone else's hand to point, touch or perform a task 2.60 1.65 1.70 .823 0.90 *.041 6 Had speech problems or been hard to understand 4.00 1.41 2.75 1.26 1.25 .083 7 Had certain rituals or routines that have to be followed 2.20 1.48 1.70 1.06 0.50 .160 8 Used odd or unusual pitch, volume or tone when talking 1.70 1.16 2.10 1.37 0.40 .496 9 Withdrawn from playing with children of the same age 2.60 1.67 2.67 1.51 0.07 .854 10 Repeated actions over and over 2.40 1.26 2.10 1.29 .30 .317 11 Had a strong interest in collecting things 1.80 1.46 1.10 .316 0.70 .102 12 Shown repetitive hand or finger movements 2.90 1.37 2.00 1.33 0.90 .121 13 Shown strong attachments to unusual toys or objects 1.00 .000 1.10 .316 0.10 .317 14 Experienced problems with repetitive behaviors or restricted interests 1.80 1.14 1.60 1.07 0.20 .414 15 Avoided certain sounds, textures or smells to an unusual extent 2.00 1.49 2.10 1.60 0.10 .891 16 Appeared aloof, distant or detached 2.60 1.07 1.90 .876 .70 .068 17 Had repetitive movements with his/her whole body 2.50 1.58 1.60 .843 .90 .059 18 Experienced problems in communicating with others (verbally and/or nonverbally) 4.30 .949 2.80 .789 1.50 *.004 19 Approached others in odd or in an inappropriate way 1.60 1.07 1.30 .675 0.30 .257 20 Shown a preoccupation with one subject or area of interest 1.60 1.07 1.30 .675 0.30 .450 21 Had difficulty showing or accepting affection 1.40 .699 1.20 .422 0.20 .414 22 Resisted changes in routines 2.50 1.58 1.40 .966 1.10 *.014 23 Had problems with pronouns 3.66 2.31 3.00 1.63 .66 1.00 24 Used repetitive or odd phrases 1.50 1.22 1.56 1.13 .06 1.00 25 Echoed words or phrases 1.86 1.36 2.10 1.66 .24 .705 26 Experienced problems in social interactions 3.10 1.37 2.50 1.18 .60 *.034 27 Used a private or made up language 2.40 1.90 1.80 1.03 .60 .180 ^28 Played with same age friends 2.33 1.51 2.60 1.67 .27 1.00 ^29 Held back and forth conversations 3.00 .817 3.67 .577 .67 .157 ^30 Shared his enjoyment or excitement with others 1.60 1.07 2.50 1.43 .90 *.034 ^31 Played cooperatively with groups of children 2.80 2.05 3.75 1.50 .95 1.80 ^32 Responded positively to other children's approaches 2.11 1.69 2.20 1.56 .09 .480 Effects of a parent training using telehealth: Equity and access to early intervention… 165 ^33 Used a social smile to greet people or respond to them 1.60 1.07 2.70 1.57 1.10 *.026 ^34 Used gestures to communicate 2.30 1.16 3.80 1.23 1.50 *.006 ^35 Comforted others when they were upset 3.60 1.43 4.67 .707 1.07 .058 ^36 Seemed interested in other children his age 2.33 1.58 3.20 1.75 .87 *.008 ^37 Played using his imagination 2.80 1.55 3.20 1.48 .40 .391 ^38 Used social chit chat 3.50 1.73 5.00 .000 1.50 .317 ^39 Used a number of different facial expressions 2.10 1.45 3.00 1.49 .90 .084 ^40 Brought things to others just to share his interest 2.70 1.70 3.40 1.26 .70 .229 ^41 Made eye contact with others 2.00 .942 2.50 1.08 .50 .276 Impact Items 1 Fascination with parts of objects rather than the whole toy 2.10 .876 1.90 .994 .20 .516 2 Fascination with looking at, feeling, touching, and licking objects 2.40 1.35 1.60 .843 .08 .071 3 Lined things up 1.40 .966 1.20 .421 .20 .317 4 Responded oddly to others 1.80 1.48 1.50 1.08 .30 .461 5 Used someone else's hand to point, touch or perform a task 1.80 1.03 1.40 .843 .40 .157 6 Had speech problems or been hard to understand 3.50 1.73 2.75 1.26 .75 .317 7 Had certain rituals or routines that have to be followed 2.00 1.41 1.40 .843 .60 *.034 8 Used odd or unusual pitch, volume or tone when talking 1.80 1.32 1.40 .699 .40 .357 9 Withdrawn from playing with children of the same age 2.40 1.95 2.50 1.76 .10 .317 10 Repeated actions over and over 2.10 .994 1.50 .850 .60 .063 11 Had a strong interest in collecting things 1.50 1.08 1.00 .000 .50 .180 12 Shown repetitive hand or finger movements 1.30 .949 1.00 .000 .30 .317 13 Shown strong attachments to unusual toys or objects 1.00 .000 1.10 .316 .10 .317 14 Experienced problems with repetitive or restricted behaviors 1.60 .843 1.40 .699 .20 .157 15 Avoided certain sounds, textures or smells 1.80 1.32 2.00 1.63 .20 .655 16 Appeared aloof, distant or detached 2.30 1.16 1.60 .843 .70 .066 17 Had repetitive movements with his whole body 1.70 1.06 1.10 .316 .60 .109 18 Experienced problems in communicating with others 4.00 1.25 2.70 .823 2.30 *.010 19 Approached others in odd or in an inappropriate way 1.60 1.07 1.20 .632 .40 .102 20 Shown a preoccupation with one subject or area of interest 1.40 .699 1.20 .421 .20 .414 21 Had difficulty showing or accepting affection 1.2 .422 1.00 .000 .20 .157 22 Resisted changes in routines 2.40 1.43 1.50 1.08 .90 *.024 23 Had problems with pronouns 1.33 .577 1.75 1.50 .42 .317 24 Used repetitive or odd phrases 1.00 .000 1.22 .441 .22 .317 25 Echoed words or phrases 1.25 .463 1.20 .632 .05 1.0 26 Experienced problems in social interactions 2.70 1.49 2.60 1.07 .10 .792 27 Used a private or made up language 1.70 1.16 1.11 .333 .59 .276 Deborah L. ROOKS-ELLIS et al. 166 ^28 Played with same age friends 1.28 .756 2.00 1.73 .72 .655 ^29 Held back and forth conversations 1.50 1.00 2.00 1.00 .50 .317 ^30 Shared his enjoyment or excitement with others 1.44 .881 1.50 1.08 .06 .655 ^31 Played cooperatively with groups of children 2.20 1.79 2.75 2.06 .55 1.0 ^32 Responded positively to other children's approaches 1.70 1.49 2.40 1.71 .70 .109 ^33 Used a social smile to greet people or respond to them 1.00 .000 1.70 1.34 .70 .109 ^34 Used gestures to communicate 2.00 1.33 3.20 1.81 1.20 .092 ^35 Comforted others when they were upset 1.00 .000 1.20 .422 .20 .157 ^36 Seemed interested in other children his age 1.90 1.20 2.11 1.54 .21 .461 ^37 Played using his imagination 1.10 .316 1.80 1.40 .70 .141 ^38 Used social chit chat 1.00 .000 2.33 1.53 1.33 .180 ^39 Used a number of different facial expressions 1.10 .316 2.00 1.15 .90 .059 ^40 Brought things to others just to share his interest 1.80 1.32 1.50 .850 .30 .496 ^41 Made eye contact with others 1.60 .966 2.70 1.25 1.10 *.026 ^ denotes reverse scored items Effects of a parent training using telehealth: Equity and access to early intervention for rural families