This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
Parent training programs for families living outside of urban areas can be used to improve the social behavior and communication skills in children with autism spectrum disorder (ASD). However, no review has been conducted to investigate these programs.
The aim of this study was to (1) systematically review the existing evidence presented by studies on parent-mediated intervention training, delivered remotely for parents having children with ASD and living outside of urban areas; (2) provide an overview of current parent training interventions used with this population; (3) and provide an overview of the method of delivery of the parent training interventions used with this population.
Guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement, we conducted a comprehensive review across 5 electronic databases (CINAHL, Embase, ERIC, PsycINFO, and Pubmed) on July 4, 2016, searching for studies investigating parent-mediated intervention training for families living outside of urban centers who have a child diagnosed with ASD. Two independent researchers reviewed the articles for inclusion, and assessment of methodological quality was based on the Kmet appraisal checklist.
Seven studies met the eligibility criteria, including 2 prepost cohort studies, 3 multiple baseline studies, and 2 randomized controlled trials (RCTs). Interventions included mostly self-guided websites: with and without therapist assistance (n=6), with training videos, written training manuals, and videoconferencing. Post intervention, studies reported significant improvements (
There is preliminary evidence that parent-mediated intervention training delivered remotely may improve parent knowledge, increase parent intervention fidelity, and improve the social behavior and communication skills for children with ASD. A low number of RCTs, difficulty in defining the locality of the population, and a paucity of standardized measures limit the generalization of the findings to the target population. Future studies should investigate the appropriateness and feasibility of the interventions, include RCTs to control for bias, and utilize standard outcome measures.
Autism spectrum disorders (ASD) are characterized by deficits in social communication and social behavior, including problems interpreting nonverbal gestures, difficulty developing age-appropriate friendships, adherence to rigid routines, and adapting to environmental change [
The increasing prevalence of ASD exerts major demands on early intervention services and education institutions resulting in calls for innovative service delivery models and methods [
Effective early intervention requires skilled health and education professionals and places an increased financial and time burden on families to access services [
The rise of technological advances in information communication technology (ICT) has paved the way for alternative modes of delivery for health interventions. Evidence suggests that services provided by health professionals using ICT have high efficacy in areas of health, such as delivering behavioral treatment for people with anxiety and depression [
Systematic literature reviews support the use of parent-mediated interventions in children with ASD [
Evidence suggests that the characteristics of families having a child with ASD and living outside of urban areas are unique; however, categorizing and comparing populations across countries is challenging because of differing definitions and classifications systems. For example, in Canada, all territories outside of an urban area are considered to be rural. Rural areas include those “...having a population of at least 1000 and a density of 400 or more people per square kilometer...” [
The purpose of this systematic review was to review the existing evidence for parent-mediated intervention training delivered remotely for parents having a child with ASD and living outside of urban areas. In doing so, this review will (1) provide an overview of the studies involving the use of parent-mediated intervention training delivered remotely to parents who have a child with ASD, (2) provide an overview of current parent training programs used with this population, and (3) provide an overview of the method of delivery of parent training interventions used with this population.
The systematic review was registered with PROSPERO (registration number CRD42015027300). The preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement guided the methodology and reporting of this systematic review. The statement provides the structure and transparency considered necessary for reporting systematic reviews in areas of health care.
Participants needed to be parents or caregivers of children diagnosed with ASD. With the recent update to the diagnostic and statistical manual of mental disorders (DSM-V), inclusion criteria were expanded to include participants whose children had a diagnosis of autism, Asperger’s syndrome, or pervasive developmental disorder not otherwise specified under criteria of the previous DSM-IV [
Articles were included if the intervention involved training the parents or caregivers in intervention skills to improve the social behavior and communications skills for their child with ASD using telehealth (remote delivery) methods. Face-to-face training, which required parents to travel to a center for training were excluded. Studies were excluded if training was provided solely to therapy professionals or teachers. Telehealth interventions delivered directly and solely by clinicians were excluded from the review, as one study explicitly addressing this issue already exists [
To identify eligible studies, the authors conducted a comprehensive systematic search across 5 electronic databases on July 4, 2016. Databases searched included (1) Cumulative Index to Nursing and Allied Health Literature (CINAHL), (2) Embase, (3) Education Resources Information Center (ERIC), (4) PsycINFO, and (5) Pubmed.
Search terms.
Database and Search terms | Limitations | Number of abstracts |
ERIC: SU.EXACT(“Asperger syndrome”) or SU.EXACT(“pervasive developmental disorders”) or SU.EXACT(“autism”), and SU.EXACT(“rural population”) or SU.EXACT(“rural areas”) or SU.EXACT(“rural youth”) or SU.EXACT(“rural environment”) or SU.EXACT(“rural education”) or SU.EXACT(“teleconferencing”) or SU.EXACT(“telecourses”) or SU.EXACT(“videoconferencing”) or SU.EXACT(“telecommunications”) | English language | 29 |
Embase: autism or Asperger syndrome or “pervasive developmental disorder not otherwise specified,” and (rural health care or rural area or urban rural difference or rural population) or (teleconsultation or telediagnosis or telehealth or telemedicine or telemonitoring or teletherapy or videoconferencing or teleconference or health care delivery) | English language | 406 |
PsycINFO: autism or pervasive developmental disorders or Aspergers syndrome, and (exp rural environments or distance education) or (telemedicine or computer mediated communication or telecommunications media) | English language | 64 |
PubMed |
English language | 45 |
CINAHL: Autis* or Asperg* or ASD or (“pervasive,” “developmental,” and “disorder”) or PDD, and (rural* or remote* or regional* or telehealth or tele-health or telemedicine or tele-medicine or telerehab* or tele-rehab* or telediagnos* or tele-diagnos* or teletreat* or tele-treat or teletherap* or tele-therap* or telemonitoring or tele-monitoring or teleintervention or tele-intervention or teletreatment or tele-treatment or telepractice or tele-practice or videoconference* or video-conferenc* or teleconference* or tele-conference* or webbased OR web-based or internet-based or [“technology” and “mediated”] or technology-mediated) | English Language |
64 |
ERIC:As per CINAHL free text | As per CINAHL free text | 45 |
Embase |
As per CINAHL free text | 487 |
PsycINFO |
As per CINAHL free text | 131 |
PubMed |
As per CINAHL free text | 446 |
The categories of search terms used were (1) ASD (autism, autism spectrum disorder, pervasive development disorder not otherwise specified, and Asperger’s’ syndrome) and (2) residing outside of urban areas (rural health, regional health, remote health, telehealth, telemedicine, and videoconferencing) (see
The first author screened titles and abstracts of the entire pool of articles that met the inclusion criteria and removed duplicates. Following the removal of the duplicates, all abstracts were screened independently by 2 authors using the inclusion or exclusion criteria. Full-text articles were sourced for abstracts that met inclusion criteria, and articles that did not meet the inclusion or exclusion criteria were excluded. Agreement between authors was reached on 8 out of the 9 included articles. The remaining disagreement was resolved through discussion and consensus.
Methodological quality was assessed using the standard quality assessment criteria as described by Kmet et al [
Data were extracted using comprehensive data extraction forms and grouped under the following headings: (1) aims or objectives, (2) study design, (3) level of evidence, (4) participant characteristics (including geographical location and proximity to services), (5) intervention characteristics, (6) outcome measures, (7) discussion, (8) limitations, and (9) implications for future practice. Data extraction was undertaken by the first author. Data extracted was checked by a second author for accuracy. Only minor discrepancies occurred, and these were resolved through consensus. The level of evidence was determined using the hierarchy of evidence as outlined in the National Health and Medical Research Council (NHMRC) guidelines [
Participant characteristics were extracted and are represented in
The PRISMA diagram is presented in
The 7 studies included 1 quasi-experimental design by St. Peter et al [
The overall level of the evidence for the studies included in the systematic review was low. The studies by Hamad et al [
Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram.
Study Schema.
Study characteristics.
Citation and methodology | Aim or objectives | Outcome measures | Results | Methodological quality |
Child outcome measures: not specified | ||||
Heitzman-Powell et al [ |
Evaluate the modified OASIS training intervention for use with parents from a distance. | Parent outcome measures: |
Implementations of ABA skills (41.23% mean increase) | Kmet rating: |
Parent knowledge assessment (Web-based) on ASDcand ABA principles and procedures | Knowledge assessments (39.15% mean increase) | |||
Parent satisfaction with training | High levels of importance and significance of Web-based tutorials (mean scale 1-5:4.62 and 4.71 respectively). High levels of importance and significance of telemedicine coaching sessions (mean scale 1-5:4.62 and 4.8 respectively) | |||
Cost savings (driving miles) |
Mean travel savings per family was 2,263 driving miles using telemedicine if compared with face-to-face coaching. |
|||
Child outcome measures: not specified | ||||
Ingersoll and Berger [ |
Compare parent engagement and effectiveness in self-directed and therapist-assisted versions of a novel telehealth-based parent-mediated intervention for young children with ASD | Parent outcome measures: |
Intervention completion was a significant predictor of postintervention knowledge ( |
Kmet rating: |
Videotape parent-child interaction for intervention fidelity using the ImPACT intervention fidelity checklist | Intervention completion ( |
Kmet rating: |
||
Parent sense of competence scale | Statistically significant improvement ( |
|||
Parent sense of competence scale |
Statistically significant improvement ( |
|||
Family impact questionnaire |
Statistically significant improvement ( |
|||
Parent engagement using website analytics |
Therapist-assisted group statistical significantly performed better on parent engagement (number of logins and duration on site) and intervention completion when compared with self-directed groups ( |
|||
Intervention evaluation survey using 7-point Likert scale measuring treatment appropriateness, website usability, and overall intervention satisfaction. |
Participants rated intervention as highly acceptable (mean=6.07, SD=0.79), the website as highly usable (mean=6.36, SD=0.57). Overall satisfaction of intervention was high (mean=6.56, SD=0.71). No statistically significant difference in treatment appropriateness, website usability, and overall intervention satisfaction between groups. |
|||
49-item 7-point Likert scale quantitative survey administered post intervention examining intervention, appropriateness perceived child social communication gains, burden of the intervention on the family, and frequency of intervention use. |
Overall, parent rated intervention favorably with mean scores: |
|||
Qualitative interviews— semistructured investigated overall perception of intervention and content, perception of feasibility of intervention, experience of support during intervention, and intervention referral preferences. |
Qualitative themes: |
|||
Child outcome measures: |
Statistically significant ( |
|||
MacArthur communicative development inventories: words and gestures |
Statistically significant ( |
|||
Vineland adaptive behavior scales, 2ndedition | Statistically significant ( |
|||
St. Peter et al [ |
Compare parental adherence during written or asynchronous video teleconsultation designed to teach parents of children with ASD to implement discrete trial instruction. | Parent outcome measures: |
Adherence in the video group was significantly higher ( |
Kmet rating: |
Vismara et al [ |
To assess if a 12-week videoconferencing and DVD learning module (P-ESDMg) could improve parents’ acquisition of teaching procedures and result in changes in the child’s social communicative behavior [ |
Parent outcome measures: |
All parents reported satisfaction with support and ease of the telehealth learning intervention. |
Kmet rating: |
P-ESDM fidelity tool—5-point Likert rating tool of 13 parent behavior that define the child-centred, responsive interactive style used in PESDM | Significant increases over time from baseline to follow-up ( |
|||
MBRSh—A 5-point Likert rating scale measuring the parent’s style of interacting to or relating to their child. | Significant increases in parental behavior rating from baseline to follow-up in responsivity ( |
|||
Child outcome measures: |
Significant overall increases from baseline to follow-up in spontaneous functional verbal utterances ( |
|||
CBRSi[ |
Significant increase form baseline to follow-up in child attention ( |
|||
MacArthur communicative development inventories: words and gestures |
Significant increases from baseline to follow-up with vocabulary production |
|||
Vineland adaptive behavior scales, 2ndedition | Significant increase from baseline to follow-up on the adaptive behavior composite ( |
|||
Vismara et al [ |
Pilot study of a 12-week telehealth on the Web (videoconferencing and self-guided website) intervention (P-ESDM) and 3-month follow-up to assess: (1) parents’ perception of the intervention as a useful learning platform, (2) parents’ intervention skills and engagement style improvement, (3) website utility to support the intervention, and (4) improvements in the children’s verbal language and joint attention. | Parent outcome measures: |
All parents reported satisfaction with support and ease of the telehealth learning intervention. |
Kmet rating: |
P-ESDM fidelity tool—5-point Likert rating tool of 13 parent behavior that define the child-centred, responsive interactive style used in P-ESDM | Improvement in parent intervention fidelity. Baseline: 0/8 parents meeting criteria for fidelity in tool. Group mean 2.93 (SD 0.6), post intervention: 6/8 parent meeting criteria for fidelity in tool. Group mean 3.69 (SD.51), follow-up: 7/8 parents achieved at least one fidelity score. Group mean 4.15 (SD 0.51) | |||
Website use | Average number of logins 30 (SD 18, range 9-60); Average viewing time per day 18 min | |||
MBRS [ |
Improvement in parent engagement style. Baseline: low-moderate with MBRS total score mean=2.91, SD=0.68, post intervention: mean=3.50, SD=0.44, follow-up (3 months): moderate to high range with MBRS total score mean=3.87, SD=0.42 | |||
Child outcome measures: |
Increase in the range of vocalizations at all time points |
|||
MacArthur communicative development inventories: words and gestures |
Improvements in VPjand comprehension, Baseline: VP mean=111.87, SD=156.03, comprehension mean=224.37, SD=133.25, post intervention: VP mean=163.88, SD=156.03, comprehension mean=284.88, SD=141.53, follow-up: VP mean=213.88, SD=155.08, comprehension mean=314.88, SD= 94.16 |
|||
Wacker et al [ |
Conduct functional communication training using coaching from trained behavior analysts to parents via telehealth and compare it with completing the same training in-vivo within families’ homes. | Parent outcome measures: |
Parents rated training as acceptable (mean=6.47. Comparable with in-vivo training (mean=6.18) | Kmet rating: |
Costs: mileage and consultant costs | Costs through telehealth were considerably lower that for in-home behavior therapy | |||
Child outcome measures: |
Reduction in child-targeted problem behavior when parents coached via telehealth (mean reduction=93.5%). Comparable with in-vivo training (mean reduction=94.1%). |
aNHMRC: National Health and Medical Research Council. Designation of levels of evidence: I—Evidence obtained from a systematic review of all relevant randomized controlled trials, II— evidence obtained from at least one properly designed randomized controlled trial, III-1
bABA: applied behavior analysis.
cASD: autism spectrum disorder.
dRCT: randomized controlled trials.
eTA: therapist-assisted group.
fSD: self-directed group.
gP-ESDM: parent model—early start Denver model.
hMBRS: maternal behavior rating scale.
iCBRS: child behavior rating scale.
jVP: vocabulary production.
For the purposes of this review, study participants were families having a child with ASD, living outside of urban areas, and having limited access to services as reported by the authors. The inherent difficulty of defining regional and remote localities between different countries made delineating study participants based on geography challenging. None of the studies provided quantitative detail about the participants’ proximity and access to services so the interpretation of the findings in relation to this information was impossible. Studies included a total of 197 parents aged between 24 and 69 years involved across the 7 studies. The highest education level achieved by the parents was specified in 5 out of 7 studies. Of the remaining two, one provided a range without specific data and the remaining study did not specify parental level of education. The study populations resided in either the United States, Canada, or Australia. Mothers represented a majority of the parents who received the education and delivered the intervention to the child. Vismara et al [
The aim of all of the studies was to improve social behavior and communication skills of children with ASD through increasing the knowledge of parents and caregivers by training them in intervention skills (parent-mediated). Outcome measures varied across all of the studies. All 7 studies used measures created by the researchers. Calculated effect sizes were only possible based on the published information in 3 studies included in the review and are reported in
Parental satisfaction and perceptions of appropriateness of the intervention were measured by Vismara et al [
Parents’ self-efficacy was evaluated in the study by Ingersoll et al [
Knowledge acquisition by parents was measured by Hamad et al [
Vismara et al [
Improvements in social behavior were measured in 2 studies using the Vineland adaptive behavior scales (2nd edition)[
Participant characteristics.
Study | No. of participants | Geographical location | Demographics: parent | Demographics: child |
Hamad et al [ |
51 | “Geographically disparate” in the United States | Gender: male n=4, female n=47 |
Gender: not specified |
Heitzman-Powell et al [ |
7 | Remote areas in the United States | Gender: not specified |
Gender: not specified |
Ingersoll and Berger [ |
27 | 70% (19/27) of participants resided in “rural or medically underserved areas” | Gender: male n=1, female n=26 |
Gender: male n=19, female n=8 |
St. Peter et al [ |
32 | Rural Appalachian counties in West Virginia, Kentucky, Maryland, Virginia, or Pennsylvania, United States | Gender: male n=11, female n=21 |
Not specified |
Vismara et al [ |
8 | “Very little access to early intervention services” in California, North Carolina, Arkansas, Texas, and Pennsylvania, United States. |
Gender: male n=1, female n=7 |
Gender: male n=7, female n=1 |
Vismara et al [ |
8 | “Minimally available intervention services in their community” in the United States and Canada | Gender: male n=1, female n=7 |
Gender: not specified |
Wacker et al [ |
17 | Regional Iowa, United States |
Gender: male n=2, female n=16 |
Gender: male n=16, female n=1 |
Intervention characteristics.
Study | Intervention description and dosage | Method of delivery to parent | Skills or aims of intervention |
Hamad et al [ |
Web-based training intervention in behavioral interventions |
On the Web using Blackboard Vista 4 platform |
• Positive reinforcement: selection and use of reinforcement. |
Heitzman-Powell et al [ |
OASIS training intervention Research-to-practice |
Training program combines Web-based instructional modules and participation in distance coaching sessions. | • Introduction to ASDaand behavioral treatment; |
Ingersoll and Berger [ |
Project ImPACT on the Web—Website-based training for a naturalistic, developmental-behavioral, parent-meditated intervention for children with ASD |
Access to training material was on the Web via personal computer. |
• Promote child social communication within the context of play and daily routines |
St. Peter et al [ |
Implementation discrete-trial instructions using a video training materials |
Written training materials (control) or video training materials (experimental) containing similar content. | • Increase adherence to discrete-trial instruction procedures. |
Vismara et al [ |
Parent early start Denver model (P-EDSM) training |
Telehealth delivery using live, 2-way conferencing with a qualified therapist and the provision of a DVD including all intervention materials with the addition of video recorded examples of the therapist demonstrating skills. | • Increasing child’s attention and motivation |
Vismara et al [ |
Parent early start Denver model (P-EDSM) training |
Telehealth delivery using live, 2-way conferencing with a qualified therapist and a self-guided website. | • Increasing child’s attention and motivation |
Wacker et al [ |
Functional communication |
Telehealth using PC and video-monitors from behavior consultants | • Child taught to comply with task request and then to mand for a break to play |
aASD: autism spectrum disorder.
bABA: applied behavior analysis.
In summary, it appears that interventions targeting parents’ knowledge and including fidelity checks have statistically significant improvements with large effect sizes when reported. Additionally, large to small effect sizes were reported in the child’s improvement in social behavior and communication skills when reported within the studies.
All interventions were developed with consideration of the geographical isolation of participants, with the aim to ease administration of the intervention and increase feasibility of delivery. Parent training interventions investigated in the included articles are summarized in
All interventions were developed by the researchers and varied in dosage and method of delivery. This variation makes synthesis of the research challenging and limits the generalizability of these methods of intervention to the targeted population. Dosage for the interventions ranged from an intensive format of 5 h per day for 5 days, to once-a-week over a number of weeks. The most common dosage was once-a-week sessions, with sessions lasting 1-2 h; however, timeframes ranged from 6-12 weeks [
The methods of delivery for the parent-mediated interventions were equally as wide-ranging, with Hamad et al [
Identifying the superior delivery method of intervention for this population is limited by a lack of between-group comparisons within the included studies. Only the studies by Ingersoll and Berger [
Overall, these findings suggest that training delivered to parents who live outside of urban areas or with limited access to services can have some effect in improving the social behavior and communication skills in their child with ASD and a large effect on increasing their own knowledge and skills in of ASD interventions. Additionally, no specific content or dosage can be identified as being superior; however, more interactive methods of delivery, such as videos and regular therapist contact for training have been proven to (1) improve adherence, (2) increase completion rates, and (3) improve fidelity in parent-mediated interventions.
The St. Peter et al [
All 7 studies were subject to a high risk of bias due to a lack of blinding. Five of the studies in this review were at a higher risk of confounding bias due to the lack of controls. The small sample sizes of these articles increased the likelihood of type II errors with no article reporting a power calculation relative to the outcome measures.
Findings of this systematic review provide preliminary evidence that parent-mediated intervention training for families living in nonurban areas can assist in improving social behavior and communication skills of children with ASD. Weak study design, lack of standardized outcome measures, lack of measurement outcomes in children with ASD, small participant numbers, high risk of bias, and large variations in interventions limit the generalizability and conclusiveness of the findings to the target population. Despite the limitations, preliminary findings from this review suggest that parent-mediated intervention training delivered remotely could benefit both parents and children with ASD given the barriers they face in accessing traditional services.
The notion that parent-mediated interventions can fully address the gap of limited access to services and be an effective alternative intervention for children with ASD needs further investigation. A systematic review conducted by McConachie and Diggle [
In this review, effect sizes were larger for intervention outcomes that targeted parents’ knowledge and intervention fidelity skills, compared with intervention outcomes to improve social behavior and communication skills for their children. Only 2 studies included measures of social behavior and communication skills in the children with ASD despite all the interventions providing training for parents to deliver therapy to address these skills. This finding indicates that parents have the potential to improve their knowledge and intervention fidelity skills and be agents in the delivery of therapeutic interventions, thereby improving the social behavior and communication skills of their children with ASD.
The results of this review indicate that the use of telehealth, Web-based modules, and DVDs all seem to have some effect in educating parents about ASD and increasing the fidelity in the delivery of interventions. A lack of standardized measurements and RCTs limited the comparison of interventions within this review. Interventions that were delivered using videos were more effective and accepted by parents than written information. Additionally, weekly contact with a therapist to answer questions and provide coaching proved to be more effective in the areas of (1) intervention appropriateness, (2) program completion, (3) parent intervention fidelity, (4) parent engagement, and (5) parent’s positive perception of their child, when compared to a self-directed program alone. Considering this, the interventions created for families that have limited access to face-to-face therapy could be tailored to meet the needs of the individual parents based on their proximity to services, personal qualities, resources, and preference. Furthermore, interventions clearly benefitted from regular contact with trained professionals throughout the training program.
Defining populations based on their geographical location is challenging due to differing methodologies and definitions adopted by different countries. This disparity in terminology and classification systems makes trying to understand the unique characteristics of families having a child with ASD and living in regional and remote areas difficult due to the wide variability of proximity and access to appropriate services. This is confounded when trying to compare populations from different countries that use vastly different classification systems. The review highlights the importance for researchers to use the relevant geographical classification system in their country to make defining study populations more clearly thereby providing better context for their study.
Finally, evidence is emerging that suggests there is indeed a significant difference in the characteristics and needs of families having a child with ASD residing in urban areas and those residing in rural areas, but further investigation is needed [
Further research into the feasibility, efficacy, and appropriateness of the methods of delivery for this unique population will help inform clinical decisions. This systematic review provides preliminary evidence on the effectiveness of remotely delivered parent-mediated intervention training. However, more research is needed to determine the most effective balance between parent-mediated intervention and therapist support via Web-based or distance training to provide the best outcome for a child with ASD, while considering the family’s proximity to traditional services. Furthermore, investigation into the effectiveness of the parent-mediated intervention training should not only measure parents’ knowledge and skill attainment but also the intervention effectiveness in improving social behavior and communication skills of children with ASD.
Future experimental studies on the effectiveness of parent-mediated interventions, including training programs, should include (1) larger sample sizes, (2) RCTs, (3) improved controls for bias, and (4) use of standardized outcome measures. A lack of comparison groups prevented a meta-analysis in this review. Standardized outcome measures should be employed wherever possible, as these were seldom used in the included studies in this review, with nonvalidated measures often created by the researchers to evaluate the effectiveness of their own intervention. This increased the risk of bias in the studies, thus limiting the impact of the studies’ findings. Further research could be focused on comparing different parent training interventions, their components, dosage, and the methods of delivery to determine a superior strategy in increasing parent knowledge and intervention fidelity while improving social behavior and communication skills of their children with ASD.
Despite the studies reporting on the parents’ perceived appropriateness and overall satisfaction of the intervention, there was limited investigation into the influences of parent engagement in the parent-mediated interventions. Further research in relation to the factors surrounding parent engagement in the intervention could help inform clinicians when devising training interventions related to content, parent commitment, and methods of delivery.
There is emerging evidence that interventions delivered remotely can improve the socioemotional and communication skills of children with ASD and may be an alternative to traditional models of therapy [
The unique context in which families having children with ASD and living in nonurban settings needs to be further researched. Emerging evidence suggests that the nonurban context is different, yet, the unique enablers and barriers in relation to service delivery that these families experience are yet to be fully understood. Furthermore, there is a need for comparison studies between urban and nonurban populations to better develop effective, appropriate, and feasible interventions to improve the social behavior and communication skills in children with ASD; thus allowing the development of tailor-made interventions for each population.
A rigorous process involving (1) the searching of 5 databases, (2) establishing interrater reliability between 2 independent researchers for inclusion or exclusion agreements, (3) standardized data extraction forms, and (4) methodological assessment using the Kmet appraisal checklist was conducted in this study. Despite this, there are some limitations in the review that should be noted. Defining the population was challenging given the poor use of standardized geographical classification systems by authors. Inclusion was based on author report of the participants living in areas described as nonurban, rural, or remote, and as having limited access to services. This could have led to some studies being excluded if this description was not provided by the authors. Additionally, the small number of articles included limits the generalizability of findings to the target population.
Overall, there is preliminary evidence that parent-mediated intervention training delivered remotely can improve parents’ knowledge in ASD, parent intervention fidelity, and subsequently improve the social behavior and communication skills of their children with ASD. The studies included in this review had an unclear or high risk of bias due to a lack of control groups and paucity of using standardized outcome measures. Additionally, difficulties in defining the participant characteristics limited the translatability to the target population. Few studies reported on the feasibility and appropriateness of the interventions and the factors of parent engagement in the interventions were evident in most studies. Future research should aim to use RCT designs, incorporate standardized outcome measures, and describe participant characteristics in greater detail. Furthermore, the review highlighted the need to investigate the feasibility and appropriateness of the interventions in addition to the factors influencing parent engagement in the interventions.
Autism spectrum disorder
diagnostic and statistical manual of mental disorders
information communication technology
randomized controlled trial
The authors received no funding to conduct this review or have any financial interest in the interventions included within this review.
None declared.