744078

research-article2017
AUT0010.1177/1362361317744078AutismPickard et al.

Original Article

Autism

Understanding the impact of adaptations 2019, Vol. 23(2) 338–349

© The Author(s) 2017
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DOI: 10.1177/1362361317744078
https://doi.org/10.1177/1362361317744078

parents’ ratings of perceived barriers, journals.sagepub.com/home/aut

program attributes, and intent to use

Katherine Pickard, Seth Rowless and Brooke Ingersoll

Abstract
Within the autism spectrum disorder field, rates of attrition in parent-mediated interventions have highlighted the need
to engage families around improving the delivery of these services. The primary goal of this study was to approximate
the impact of adaptations to an evidence-based, parent-mediated intervention, Project ImPACT (Improving Parents
as Communication Teachers), that had been made in collaboration with families in a Medicaid system. A total of 103
parents of a child with autism spectrum disorder were randomized to watch a presentation of either the original or
adapted Project ImPACT program. After watching the presentation, participants rated (1) demographic information, (2)
perceived structural barriers, (3) Project ImPACT attributes, and (4) intent to use the program. Results from hierarchical
linear regression models demonstrated that program type alone predicted parents’ ratings of perceived structural
barriers. Additionally, both program type and the interaction of program type and annual household income were unique
predictors of parents’ ratings of program attributes and intent to use. Qualitatively, although many parents reflected
positively on both Project ImPACT programs, parents who viewed the adapted program appeared more likely to report
positive program attributes. Results suggest the importance of engaging families in improving the fit of parent-mediated
interventions for use within a variety of community settings.

Keywords
adaptation, autism spectrum disorder, parent-mediated intervention, Rogers’ diffusion of innovations theory, theory of
planned behavior

Introduction
Given their growing evidence base (Nevill et al., 2016;
Wong et al., 2015), parent-mediated interventions are one
means to increase access to important early intervention
services for young children with autism spectrum disorder
(ASD) and their families. Despite their important role in
early intervention services, parent-mediated interventions
are underutilized across a variety of community settings
(Hume et al., 2005; Thomas et al., 2007) and particularly
within low-socioeconomic status (SES) settings. Within
low-SES settings, rates of attrition in parent-mediated
intervention programs have been relatively high and
concerns have been raised that the way in which these pro-
grams are currently designed may prohibit parent learning
and engagement (Carr and Lord, 2016; Kasari et al., 2014;
Stahmer and Pellecchia, 2015).
Gaps in the use of parent-mediated interventions within
low-SES communities may reflect a mismatch between
these programs and the needs, values, and preferences of
families within these settings, as parents’ perceptions of
ASD treatment varies across distinct SES and cultural
groups (Burkett et al., 2015; Herbert, 2014; Zuckerman
et al., 2015). To address this gap, research has advocated
for more collaborative and ecologically valid models of
Michigan State University, USA
Corresponding author:
Katherine Pickard, Department of Psychology, Michigan State
University, 316 Physics Road, East Lansing, MI 48824, USA.
Email: kepickard@gmail.com
Pickard et al.
parent-mediated intervention that have reduced intervention
complexity, improved parent-professional collaboration,
more explicit use of family-centered goals, and better adult
learning strategies (Stahmer and Pellecchia, 2015). This
research has also noted that research-community partner-
ships are an important method to understand how these
more ecologically valid strategies could be embedded
within existing parent-mediated interventions (Stahmer
and Pellecchia, 2015). However, to date, only a handful of
studies within the ASD field have used these types of
partnerships to improve the fit parent-mediated interven-
tions within low-SES settings (Divan et al., 2015; Ratto
et al., 2017; Stahmer et al., 2017).
Outside the ASD field, research-community partner-
ships have been used more consistently to selectively
adapt parent-mediated intervention programs and to under-
stand the impact of these adaptations (Barrera and Castro,
2006; Baumann et al., 2015; Lau, 2006; Parra-Cardona
et al., 2015). A recent review of these studies within the
disruptive behavior disorder field suggested that adapted
parent-mediated intervention programs tend to have rela-
tively high rates of satisfaction, retention, and efficacy
when implemented within culturally diverse and under-
served settings (Baumann et al., 2015). Importantly, many
of the common adaptations made to the reviewed parent-
mediated intervention programs were similar to those
recently suggested within the ASD field (Stahmer and
Pellecchia, 2015). These adaptations included the use of
more accessible program language and metaphors,
increased program session time and flexibility, and better
use of family-centered goals and parent-professional
collaboration (Baumann et al., 2015).
Taken together, research within and outside the ASD
field has supported the process of adapting parent-medi-
ated intervention programs to better reflect the needs, val-
ues, and preferences of families from culturally diverse
and underserved backgrounds (Baumann et al., 2015;
Divan et al., 2015; Ratto et al., 2017; Stahmer and
Pellecchia, 2015). However, one challenge with this
research, as highlighted in the review by Baumann et al.
(2015), is the difficulty understanding the need for and
benefit of these adapted programs, as few research studies
within and outside the ASD field have directly compared
adapted parent-mediated interventions to their non-adapted
counterparts (Baumann et al., 2015). With this in mind,
this study aims to empirically examine the effect of adap-
tations to a parent-mediated intervention program for ASD
on parents’ ratings of perceived program barriers, program
attributes, and intent to use the program.
Parent-mediated intervention of interest
Project ImPACT (i.e. Improving Parents as Communication
Teachers) is an evidence-based, parent-mediated interven-
tion that teaches parents of young children with ASD to
promote their child’s social communication development
339
through the use of naturalistic, developmental, and behav-
ioral intervention strategies (Ingersoll and Dvortcsak,
2010). Research studies examining the efficacy of Project
ImPACT have demonstrated that parent participation
results in parent learning of the intervention strategies,
improved parent empowerment and self-efficacy, and
increased child social communication skills (Ingersoll
et al., 2016; Ingersoll and Wainer, 2013; Stadnick et al.,
2015).
Adaptations to Project ImPACT were made as part of a
research-community partnership with families and provid-
ers in a Medicaid system in Metro Detroit (see Pickard
et al., 2016). This partnership was created due to concern
regarding the fit of Project ImPACT within this specific
Medicaid system, a concern that paralleled those raised
within the ASD field broadly. Given this, the goal of the
partnership was to use Rogers’ diffusion of innovations
theory to understand the fit of Project ImPACT within this
particular Medicaid setting (Rogers, 2003). Rogers’ theory
states that the perceived attributes of an intervention influ-
ence its uptake and use in a given setting. These attributes
include the intervention’s compatibility (i.e. fit with the
values, preferences, and lifestyle of a community and/or
family), its overall complexity (i.e. ease of use), and its
relative advantage when compared to other services being
used. The relevance of Rogers’ theory as a framework to
understand and adapt parent-mediated interventions has
been supported by research demonstrating that parents’
treatment perceptions and perceived barriers to treatment
predicts their engagement in parent-mediated interven-
tions (Axford et al., 2012; Herbert, 2014; Kazdin et al.,
1997a; Nock and Kazdin, 2005).
After understanding the compatibility, complexity, and
relative advantage of Project ImPACT, as well as the struc-
tural barriers to its use and suggestions to improve its fit
within this Medicaid system (Pickard et al., 2016), adapta-
tions to Project ImPACT were made in continued collabo-
ration with our community partner and the intervention
developers. Final adaptations to Project ImPACT are sum-
marized within the context of Rogers’ diffusion of innova-
tions theory in Table 1. Many of these adaptations aligned
with those recently called for within the ASD field
(Stahmer and Pellecchia, 2015), in addition to those previ-
ously made to parent-mediated interventions for specific
cultural groups (Baumann et al., 2015; Divan et al., 2015).
This study
This study attempted to better understand the impact of
these adaptations through the use of two theories. First,
given that the initial adaptations to Project ImPACT were
grounded in Rogers’ diffusion of innovations theory
(Pickard et al., 2016; Rogers, 2003), one way to test the
impact of the adaptations was to understand whether
parents from lower SES backgrounds rated the adapted
program attributes (i.e. compatibility, complexity, and
340
relative advantage) and perceived structural barriers more
favorably than those of the original program. Given the
importance of Rogers’ attributes on intervention uptake
and use, this research suggests that more positive percep-
tions of the adapted Project ImPACT program could lead
to greater uptake and use of the program for low-SES
families. This finding would be pertinent given the high
rates of attrition when parent-mediated programs have
been delivered in Medicaid settings (Carr and Lord, 2016;
Kasari et al., 2014).
In addition to understanding possible differences in par-
ents’ perceptions, a second goal of this study was to
approximate the impact of the adaptations on Project
ImPACT use. To do this, theory of planned behavior (TPB;
Ajzen, 1991) was used to test the impact of the adaptations
on parents’ intent to use Project ImPACT. Intentions, a key
component of TPB, are thought to encompass the motiva-
tional factors that drive behavior (Ajzen, 1991; Sheeran,
2002; Webb and Sheeran, 2006) and are associated with
and predictive of both the adoption and sustained use of
health behaviors across a variety of fields (Eccles et al.,
2006; Godin et al., 2008; Quine et al., 2001; Scott et al.,
2008). Although they are more highly associated with self-
reported use of health behavior, intentions also predict the
objective use of health behavior with similar but smaller
effects (Eccles et al., 2006; Godin et al., 2008). Taken
together, these studies suggest that behavioral intentions
are an appropriate proxy for actual behavior and that
meaningful changes in intention could support behavior
change (Webb and Sheeran, 2006). Therefore, prior to tri-
aling the adapted Project ImPACT program within low-
SES settings, TPB can be used to understand whether
parents’ intentions to use Project ImPACT differ across the
original and adapted programs, thereby representing dif-
ferences in how the two programs might be used.
Using Rogers’ diffusion of innovations theory and TPB,
this study had specific aims to examine whether Project
ImPACT program type (i.e. original or adapted) and par-
ents’ annual household income influenced parents’: (1)
perceived structural barriers to using Project ImPACT; (2)
ratings of program attributes (i.e. compatibility, complex-
ity, and relative advantage); and (3) intent to use Project
ImPACT. An additional goal was to use qualitative meth-
ods to compliment quantitative analyses by examining
specific differences in how parents qualitatively discussed
the strengths and limitations of the original versus adapted
Project ImPACT programs.
Method
Participating community agencies and
recruitment
Recruitment for this study was conducted in collaboration
with a number of agencies that provide services to families
Autism 23(2)
of young children with ASD who qualify for Medicaid
insurance based on their family income within Michigan.
In addition to partnering with Medicaid agencies, this
study was also open to families from both high- and low-
SES backgrounds through ASD list serves within and
outside the State of Michigan.
Experimental design and study procedure
All parents were able to participate remotely if they had
access to the Internet and a computer, smart phone, or tablet.
Interested participants without access to a computer and/or
Internet were provided with a laptop, tablet, or computer
through the Medicaid agency where they received
services.
Participating parents were randomized so that they
watched either a 13-min video-based presentation of the
original Project ImPACT program or the same 13-min
video-based presentation of the adapted Project ImPACT
program. Videos included key information and visuals
about the format, structure, and requirements of the relevant
program (see Table 1). After watching the presentation,
parents completed an online questionnaire that assessed:
(1) demographic information, (2) perceived barriers to
program use, (3) perceptions of Project ImPACT attrib-
utes, (4) intent to use Project ImPACT, (5) other relevant
mental health characteristics, and (6) open-ended feedback
regarding Project ImPACT.
Participants
A total of 103 parents of a child with an ASD diagnosis
participated in this study. All participating parents had at
least one child with ASD between the ages of 18 months
and 8 years (M = 4.14 years, standard deviation (SD) = 1.50).
In all, 67% of participating parents reported using Medicaid
or other federal assistance to pay for their child’s ASD
services. Parents were an average age of 32.69 years
(SD = 4.99) and were 84.70% female. All demographic
information, by study group, is presented in Table 2.
Video stimuli
Videos of the original and adapted Project ImPACT
program were designed to be identical in format, visuals,
length, and the majority of word content. The primary dif-
ferences across the two videos were in descriptions of the
program delivery related to the major program adaptations
noted in Table 1. Both videos were (1) 13 min and 30 s in
length, (2) approximately 1600 words in length, and (3)
dictated at roughly an eighth-grade reading level as meas-
ured by the Flesch–Kincaid grade level.
In order to ensure that the two videos were similar in
visual appeal and viewer comprehension, 108 undergraduate
college students participated in an online study in which
Pickard et al. 341

Table 1. Summary of adaptations to Project ImPACT within the context of Rogers’ diffusion of innovations theory.

Theme Original version Adapted version

Compatibility with values and lifestyle
Required practice was too time
intense
Difficulty practicing the
intervention primarily within play
Program length and delivery was
too rigid
Complexity of learning
Reading materials too complex
and dense
Too many intervention
techniques taught
Writing requirements not
feasible for many families
Relative advantage compared to current practice
Option for group delivery model
Structural barriers to participation
Difficulty managing the home
environment to practice the
intervention
Addressing parents’ basic needs
was not a focus
Suggestions for program enhancement
Explicit strategies for family and
sibling inclusion in program
Need for emphasis on creating
parent-professional partnerships
Challenging behavior should be
addressed
Emphasis on focused practice time
during play for 15–20 min/day
Practice primarily during play
Program delivered twice a week for 1 h
for 12 weeks
Written materials presented in
paragraph form with minimal graphics
14 separate intervention techniques
taught
Homework required written responses
to extended reflection questions
Emphasis on individual delivery model
No specific emphasis on parent
problem-solving around home
environment
No specific emphasis on collaboration
with child’s treatment team
No emphasis on including other family
members
No emphasis on alliance building
strategies for therapists
No lesson on strategies to address
behavior problems
Emphasis on practice time occurring 5–10
min/day across pre-existing routines
Additional videos and emphasis on practicing
within daily routines
Flexibility in delivery of teaching content (i.e.
ability to repeat lessons as needed)
Written materials bullet-pointed and
reduced to read at an eighth grade level;
graphics added to illustrate key concepts
Emphasis on teaching prioritized intervention
techniques in each core lesson
Written homework eliminated and replaced
with visual practice plan
Group option emphasized as a possible
delivery format
Additional emphasis and problem-solving
around home environment
Additional emphasis on case managers as
collaborators
More explicit conversation around how to
include other family members
The addition of specific strategies for
therapists to build alliance
Added optional lesson that includes
strategies to address behavior problems

they were randomly assigned to watch either the original
or adapted Project ImPACT video. Following this, partici-
pants rated the video using a 7-point Likert scale on the
following dimensions: (1) clarity of the presentation mate-
rial, (2) visual appeal, (3) general interest in video content,
(4) confusion about the material presented, (5) attention/
engagement in the presentation, and (6) whether the mate-
rial was presented clearly. Results from one-way analysis
of variances (ANOVAs) highlighted no group differences
in video ratings (all p values >0.40; all Cohen’s d values
<0.08).
Measures
Demographic information was assessed using measures of
parent age, gender, racial/ethnic background, highest
educational degree obtained, marital status, annual house-
hold income, occupation, partner occupation if applicable,
primary language spoken, health insurance status, and
number of household members.
Child demographic information was assessed using
measures of child age and gender. The Autism Behavior
Checklist (ABC; Krug et al., 1980) was used as a measure
of child ASD symptom severity. The ABC consists of 57
questions that ask about behaviors that are specific to
ASD, as well as other general behavior problems. Total
scores were summed with higher total scores indicating
more severe ASD symptoms. Cronbach’s alpha for the
ABC demonstrated strong internal reliability for this study
(α = 0.86).
Parenting stress was assessed using the Parenting
Stress Index-Short Form (PSI-SF; Abidin, 1990). The
PSI-SF is a 36-item self-report questionnaire that reflects
the amount of stress that parents experience in their rela-
tionship with their child. Parents indicated the degree to
which they agreed with each of the questionnaire state-
ments using a 5-point Likert scale. A high “Total Score” on
the PSI-SF indicates significant stress in the parent–child
relationship. The PSI-SF demonstrated strong internal reli-
ability across subscales (α = 0.88).
Perceived structural barriers was assessed using the
20-item “stressors and obstacles scale” of the Barriers to
Treatment Participation Scale (BTPS; Kazdin et al.,
1997b). The BTPS is a 44-item checklist of perceived
342 Autism 23(2)

Table 2. Parent demographic information.

Original program (N = 51) Adapted program (N = 52)

% Mean (SD) % Mean (SD)

Parent
Gender (% female) 87.50 82.10
Age in years 32.45 (5.40) 32.84 (4.76)
Number of household members 4.35 (1.43) 4.39 (1.23)
Marital status
Married/living with partner 23.10 19.60
Single, widowed, divorced 76.90 80.40
Ethnicity
White/Caucasian 61.50 66.70
Black/African American 13.50 15.70
Hispanic/Latino 7.70 9.80
Middle Eastern 5.80 2.00
Asian/Pacific Islander 5.80 2.00
Biracial/other 5.80 3.90
Education
Less than high school 3.80 3.90
High school degree 17.30 13.70
Some college/specialized training 38.50 37.30
Bachelor’s degree 28.80 27.50
Graduate degree 11.50 17.60
Average annual household income
<US$20,000 19.20 23.50
US$20,001–US$30,000 9.60 11.80
US$30,001–US$40,000 19.20 11.80
US$40,001–US$50,000 7.70 19.60
US$50,001–US$60,000 17.30 9.80
US$60,001–US$70,000 11.50 9.80
>US$70,000 15.40 13.70
Child with ASD
Age in years 4.27 (1.68) 4.05 (1.38)

ASD: autism spectrum disorder.

barriers to participation in parent-mediated intervention
programs. Parents rated each of the 20 external stressors
and obstacles using a 5-point Likert scale. Higher total
scores reflect a greater number of structural barriers likely
to impede engagement in parent-mediated intervention
programs. The BTPS demonstrated strong internal reliability
in this study (α = 0.89).
Project ImPACT attributes were assessed using Moore
and Benbasat’s (1991) measure of an innovation’s attrib-
utes specific to Rogers’ theory (Lewis et al., 2015; Moore
and Benbasat, 1991). The original measure contained 41
items. Five of these items measured an innovation’s com-
patibility, five measured its “ease of use” (i.e. complex-
ity), and five measured its relative advantage. The
remaining items in the original scale captured other con-
structs such as an innovation’s visibility, trialability,
result demonstrability, voluntariness, and image. Items
that captured these other constructs were not included in
this study. The original measure was also modified so
that items were specific to Project ImPACT. The 14-item
short form included 5 items each specific to Project
ImPACT compatibility and complexity, and 4 items spe-
cific to Project ImPACT relative advantage. Participants
rated how much they agreed with each item using a
7-point Likert scale, with maximum scores equaling 98.
A principal component analysis (PCA) with an oblique,
promax rotation was used to examine factor structure.
Nearly all items loaded distinctly onto the first factor.
Thus, the total score on the Project ImPACT Attributes
scale was used rather than scores from each of the hypoth-
esized subscales. The modified measure had strong inter-
nal reliability (α = 0.85).
Intent to use Project ImPACT was assessed using the
question, “How likely is it that you would use the Project
ImPACT program if it were made available to you?”
Participants were asked to give a percent (ranging from
0% to 100%) likelihood that they would use the program
(Scott et al., 2008).
Pickard et al.
Open-ended, qualitative feedback. All parents responded to
the following open-ended questions: “What are some
things that you like about the Project ImPACT program?”
and “What are any concerns that you have about Project
ImPACT?”
Data analysis
Independent samples t-tests were used to examine possible
group differences in parent age, child age, annual house-
hold income, parenting stress, and child ASD symptom
severity across parents in the original and adapted video
groups. No statistically significant group differences were
observed, with all p values >0.31. To better understand the
impact of adaptations to Project ImPACT, separate hierar-
chical linear regressions were run to examine whether pro-
gram type (i.e. original vs adapted), annual household
income, and their interaction were unique predictors of
parents’ ratings of perceived structural barriers, program
attributes, and intent to use. Within the regression models,
control variables were chosen based on preliminary bivari-
ate correlational analyses and defined as any variable that
was significantly associated with the outcome variable of
interest. These variables were entered in the first step of
each linear regression model. For all models, control vari-
ables included child age, parenting stress, and child ASD
severity. For all models, annual household income and
program type were entered into the second step. Finally, to
understand whether the impact of the program adaptations
was specific to parents from lower SES backgrounds, the
interaction of annual household income and program type
was entered into the third step.
Qualitative methods were collected alongside quantita-
tive data and were used to compliment quantitative find-
ings by examining specific differences across parents’
open-ended responses regarding the strengths and weak-
nesses of the original versus adapted Project ImPACT pro-
grams. Miles and Huberman’s (1994) approach to
qualitative analysis was used to analyze open-ended
responses within the same framework that was used to
analyze the initial focus group data (Pickard et al., 2016).
Prior to analyzing data, all responses were uploaded into
Dedoose and categorized by whether the response was
from a participant in the original versus adapted group. In
order to be consistent with the framework that was used to
adapt the Project ImPACT program (Pickard et al., 2016),
first-cycle codes were categorized into the following
domains: (1) aspects of the program that were compatible
or not compatible with parents’ beliefs, values, and life-
style; (2) comments or concerns related to the complexity
of the program material; (3) the relative advantage or dis-
advantage of Project ImPACT compared to other services;
(4) perceived structural barriers to using Project ImPACT;
and (5) other positive or negative aspects of the program
that did not fall into one of the pre-existing domains.
343
Consensus coding was used for all parent responses and
both coders were blind to participant randomization.
Finally, given that qualitative data were collected individu-
ally, via computer, and at a single time point (i.e. rather
than in focus groups), codes were rated as present or absent
for each parent capturing code frequency rather than
salience.
Results
Parents’ quantitative ratings
All results from hierarchical linear regression models are
displayed in Table 3. Program type (β = −0.71, p < 0.001)
was a unique predictor of parents’ ratings of perceived
structural barriers to using Project ImPACT, with the final
model explaining 29% of the variance in perceived barri-
ers. Specifically, parents who viewed the adapted program
reported fewer structural barriers to program use. Both
program type (β = 0.63, p = 0.03) and the interaction of
program type and annual income (β = −0.77, p < 0.02)
were unique predictors of parents’ ratings of program
attributes, with parents generally rating the adapted pro-
gram more favorably and parents with lower annual
incomes rating the adapted program most favorably. The
final model explained 29% of the variance in parents’ rat-
ings. Similarly, both program type (β = 0.86, p < 0.001)
and the interaction of program type and income (β =
−0.98, p < 0.001) predicted a significant amount of the
variance in parents’ ratings of intent to use Project ImPACT
with the final model explaining 25% of the variance in par-
ents’ ratings of intent to use.
Qualitative feedback
A summary of themes and their frequency by group are
displayed in Table 4. Parents in both groups spontaneously
reported a number of aspects of Project ImPACT that made
it compatible with their values and lifestyle. Parents in
both the original and adapted Project ImPACT groups
reported liking that the program attempts to empower par-
ents by supporting them in using a set of strategies to better
engage and teach their child:
[I like] that it would teach me how to play with my child with
autism. I am very much like that mom shown in the first video
who struggles to play with her child. (Original parent)
I like the parent teaching component. It’s something that
parents can feel empowered to do and do when the therapists
are not around. It’s a way for the parent to connect to their
child as well. (Adapted parent)
Similarly, parents reported with about equal frequency
that both the original and adapted Project ImPACT pro-
grams were compatible with their lifestyle given the
344 Autism 23(2)

Table 3. Multiple linear regression models predicting perceived barriers, program attributes, and intent to use.

Predictor Perceived barriers to program use Ratings of program attributes Ratings of intent to use

β t R2 F change β t R2 F change β t R2 F change

Step 1 0.02 0.30 0.08 1.34 0.04 0.64
Child age −0.09 −0.64 −0.06 −0.44 −0.12 −0.86
Parenting stress −0.09 −0.64 0.23 1.59 0.11 0.78
ASD symptom 0.05 0.31 0.12 0.86 0.09 0.61
severity
Step 2 0.25 10.33*** 0.20 3.25 0.08 1.09
Child age −0.06 −0.50 −0.07 −0.54 −0.13 −0.92
Parenting stress 0.04 0.28 0.11 0.77 0.07 0.45
ASD symptom 0.19 1.47 0.06 0.45 0.03 0.20
severity
Annual income 0.49 3.73** −0.36 −2.47 −0.18 −1.15
Program type −0.31 −2.36* 0.06 0.45 0.13 0.85
Step 3 0.29 3.50 0.29 5.74* 0.25 9.96**
Child age −0.04 −0.36 −0.10 −0.76 −0.17 −1.27
Parenting stress 0.07 0.53 0.07 0.48 0.13 0.91
ASD symptom 0.22 1.69 0.03 0.23 −0.02 −0.11
severity
Annual income 0.16 0.73 0.10 0.41 0.44 1.81
Program type −0.71 −2.83** 0.63 2.31* 0.89 3.20**
Income × 0.56 1.87 −0.77 −2.40* −0.98 −3.16**
program type

ASD: autism spectrum disorder.

***p < 0.001, **p < 0.01, and *p < 0.05.

naturalistic focus of the intervention. In particular, parents
voiced liking that the program could be embedded into the
activities and routines that they were already doing with
their child:
[The program is] simple, easy to learn, easy implementation,
does not require a lot of time, can be done anywhere. (Original
parent)
It looks as if Project ImPACT really helps parents to get more
involved with helping their child to learn new skills. I think
that it would fit right into our lives and that it would be of
great benefit to me and my children. We’re really struggling
now with some communication and behavioral issues. It looks
as if it would make our lives easier and our time together more
productive. (Adapted parent)
Although a percentage of parents in both Project ImPACT
groups reported that the program goals were important to
them, parents who viewed the adapted program were more
likely to indicate that the social communication and added
behavioral goals were strengths of the program. Finally,
regarding program compatibility, parents who watched the
adapted Project ImPACT program were both more likely to
indicate that the required practice time was feasible and less
likely to voice concern about setting aside time to practice
the learned intervention techniques at home:
With 3 kids, it will/would be almost impossible to set
aside 20-30 minutes each day for just 1 child. It would be
even harder for me because my husband is usually at work
and it is me by myself with all 3 kids at night. (Original
parent)
I like that you can integrate [the program] into your daily
routine without having to set aside a lot of extra time to do the
therapy. I also think it’s helpful to have a visual reminders and
homework on one page. (Adapted parent)
In their open-ended responses, many parents reported
themes regarding the complexity of the Project ImPACT
program. At least a quarter of parents in both groups
reported that the intervention techniques were taught in a
way that would be relatively easy to learn, and few parents
spontaneously reported concerns regarding their ability to
learn the program. However, across responses, parents
who viewed the adapted Project ImPACT program were
more likely to comment on the ease of learning the pro-
gram, less likely to report concern regarding the program’s
complexity, and more likely to comment on the accessibil-
ity of the program manual:
It seems fairly easy to learn. I also like that there are visual
reminders and practice plans in the workbook that was shown.
(Adapted parent)
Pickard et al. 345

Table 4. Percent of parents who spontaneously report each theme by program type.

Positive comments Original (%) Adapted (%) Concerns Original (%) Adapted (%)
Compatibility of Project ImPACT Compatibility of Project
ImPACT
Positive perception of program 5.88 10.20 Age/severity limitation of 0 4.08
goals program
Parent learning and 49.02 51.02 Required practice time not 13.73 4.08
empowerment feasible
Required practice time is 1.96 6.12 Rigid program delivery 5.88 4.08
feasible (session)
Positive view of behavioral and 11.76 6.13
developmental strategies
Emphasis on practice in daily 5.88 14.28 Complexity of Project ImPACT
routines
Challenging to learn 9.80 6.12
techniques
Complexity of Project ImPACT
Ease of learning techniques 15.69 22.45 Structural barriers
Visual appeal of parent 0 6.13 Location 1.96 4.08
workbook
Scheduling barriers 5.88 6.12
Cost/insurance coverage 5.88 6.12
Relative advantage
Would enhance other services 0 3.92
Observability
Observability Not clear that child would 3.92 0
benefit
Benefits of the program are 5.88 8.16
obvious
Other
Other Difficulty managing other sibs 3.92 0
Strategies for sibling 0 8.16 No concerns about program 33.33 53.06
involvement
Quality of therapists 5.88 6.12

ImPACT: Improving Parents as Communication Teachers.

I’m worried about how long it would take me to learn the government insurance and I had to save money to pay for it.
techniques. (Original parent) (Original parent)

A handful of parents in both the original and adapted
groups voiced that the benefits of using the program were
observable. However, when asked what concerned them
about the program, parents in both groups reported per-
ceived structural barriers to using Project ImPACT. A
small number of parents in both groups voiced concern
that scheduling the program appointments would be diffi-
cult due to their family’s hectic schedule of work, outside
therapy, and other activities. Additionally, a number of
parents in both program groups raised concerns over the
possible cost of the program, emphasizing that it would be
difficult to access the program if it were not covered by
insurance:
[I’m concerned about] the possible cost to parents if it’s not
covered by private insurance. This is similar to a program
that came to me and my son prior to him being enrolled in
Cost! Is this covered by my insurance? (Adapted parent)
Finally, in their open-ended responses, parents men-
tioned several other themes that did not directly map
onto the Rogers’ attributes or perceived structural barri-
ers to program participation. For example, when asked
about concerns, over a quarter of parents in the original
video group and well over half of parents in the adapted
group reported that they had no concerns regarding the
Project ImPACT program. Additionally, several fami-
lies in each group emphasized that the program would
only be beneficial when delivered by high-quality thera-
pists who were empathic and well trained in the pro-
gram content. Finally, parents in the adapted group
spontaneously reported that the added strategies to
involve siblings and the extended family in the program
were greatly beneficial:
346
Like with any program we’ve done my concern is the quality
of the therapists. (Original parent)
I like that it involves both the child and the parent. I think it
would also be easy for other children to help too, which is
important. (Adapted parent)
Discussion
The primary goal of this study was to approximate the
impact of adaptations to an evidence-based, parent-
mediated intervention that had been made in collaboration
with families and providers in a Medicaid system. To do
this, a mixed-methods approach was used that was guided
by both Rogers’ diffusion of innovations theory and TPB.
Quantitatively, program type alone predicted parents’ rat-
ings of perceived structural barriers, with parents who
viewed the adapted program rating fewer perceived struc-
tural barriers. Similarly, both program type and the interac-
tion of program type and annual household income (i.e. a
proxy for SES) were each unique predictors of parents’ rat-
ings of program attributes and intent to use the program.
Specifically, all parents who viewed the adapted program
tended to rate program attributes and intent to use more
favorably, but parents with lower annual incomes rated the
adapted program’s attributes and intent to use most
favorably.
Open-ended responses were used to compliment quan-
titative findings by elaborating on specific differences in
the ways that parents viewed the two programs (Palinkas
et al., 2011). Using Rogers’ diffusion of innovations theory
(Rogers, 2003) as a framework to guide qualitative analy-
sis, it was also possible to understand whether parents’
responses reflected the feedback that had guided the initial
adaptations to Project ImPACT (Pickard et al., 2016). In
their responses, the majority of parents reported that both
the original and adapted Project ImPACT programs were
compatible with their lifestyle. Many parents indicated
that the naturalistic focus of Project ImPACT and its
emphasis on empowering parents through explicit teach-
ing were strengths of the program. Parents who viewed the
adapted program specifically were more likely to indicate
that the required practice time of the program was feasible,
that the program manual would facilitate learning, and that
the explicit inclusion of other family members was a
strength. Finally, for both the original and adapted pro-
grams, parents reported continued concern regarding insur-
ance coverage, scheduling barriers, and therapist quality.
Implications
Within the ASD field, there has been recent emphasis on
using research-community partnerships to improve the fit
and relevance of evidence-based practices, including par-
ent-mediated interventions, for use within a variety of
Autism 23(2)
culturally diverse and underserved community settings
(Brookman-Frazee et al., 2012; Divan et al., 2015; Ratto
et al., 2017; Stahmer and Pellecchia, 2015; Wright et al.,
2014). Importantly, research from other behavioral health
fields has demonstrated that community-partnered research
aimed at adapting parent-mediated interventions can result
in relatively high rates of parent satisfaction and retention
when these programs are delivered in culturally diverse
and underserved settings (Baumann et al., 2015). Despite
emerging interest in improving the fit of parent-mediated
interventions within the ASD field (Divan et al., 2015;
Ratto et al., 2017; Stahmer et al., 2017; Wright et al.,
2014), this study is the first that we are aware of that
directly compared parents’ perception of an adapted par-
ent-mediated intervention program to that of the original
program, while also collecting continued feedback regard-
ing program adaptations.
Results from this study highlighted the benefit of pro-
gram adaptations both quantitatively and qualitatively.
Although all parents tended to rate the program attributes
and their intent to use more highly for the adapted pro-
gram, the benefits of the adapted program also appeared to
be more robust for parents with lower annual incomes.
These findings may have implications regarding the gener-
alizability of adapted intervention programs. For example,
given that the sample in this study included lower SES,
Medicaid families both from within and outside our initial
partnership, our findings suggest that the positive impact
of the program adaptations can generalize to other low-
SES families outside of Metro Detroit. Additionally, given
the similarity between the adaptations made to Project
ImPACT and those that suggested or actually made by
ASD researchers (Divan et al., 2015; Stahmer and
Pellecchia, 2015), our findings substantiate the general
benefit of these strategies for both low-SES families and
families from higher SES backgrounds.
Qualitative results expanded our quantitative findings
by providing a more nuanced understanding of how par-
ents perceived the program attributes and structural barri-
ers differently across the two programs. In the absence of
probes, parents’ open-ended feedback suggested some
group differences that were reflective of the initial adapta-
tions to Project ImPACT (Pickard et al., 2016). Parents
qualitatively reported that the adapted program was both
more compatible and less complex than the original Project
ImPACT program. The consistent differences found across
methodologies are important, as these differences in per-
ceptions and attitudes have been shown to facilitate the
adoption of novel health innovations (Henggeler et al.,
2008; Rogers, 2003; Scott et al., 2008). Therefore, when
implemented in low-SES community settings, the results
of this study suggest that the adapted Project ImPACT pro-
gram may have higher rates of adoption than the original
program. This is a crucial implication given the noted rates
of attrition when parent-mediated intervention programs
Pickard et al.
for ASD have been implemented within lower SES set-
tings (Carr and Lord, 2016; Kasari et al., 2014).
Finally, in addition to highlighting ways in which par-
ents and providers viewed the adapted Project ImPACT
program more positively, this study also re-emphasized
two key concerns related to using Project ImPACT within
the Medicaid system. The first concern was rooted in
insurance coverage for Project ImPACT, with parents
reporting that paying out of pocket for the program would
be prohibitive. In general, this concern is consistent with
other research within the ASD field that has demonstrated
that cost is one barrier to participating in parent-mediated
intervention programs (Carr et al., 2015; Kasari et al.,
2014). Unfortunately, the qualitative analyses did not
examine responses by participant SES, so it was not pos-
sible to know whether insurance type may have influenced
parents’ report of this barrier. Recent research has demon-
strated that families with Medicaid insurance have greater
access to ASD services and fewer out-of-pocket expenses
(Leslie et al., 2017; Zhang and Baranek, 2016). Therefore,
it may be that families with private insurance or no insur-
ance were more likely to report insurance-related concerns
for the program. Regardless, these findings highlight the
continued difficulty for some families in being able to
access insurance coverage for ASD services.
Limitations
There are several important limitations within this study.
The first is related to the experimental manipulation used
to test the impact of program adaptations. Although exten-
sive effort was made to ensure that participating parents
were provided access to computers and/or tablets, this
study was limited to parents with computer literacy.
Additionally, given that parents did not participate in the
Project ImPACT program, all ratings were based on their
perceived experience of the program and their intention to
use the program if they had access to it. Although inten-
tions are predictive of both the adoption and sustained use
of health behaviors (Eccles et al., 2006; Godin et al., 2008;
Liao and Lu, 2008; Quine et al., 2001), the hypothetical
nature of participant “engagement” in the program may
reflect the universally positive ratings of intent to use
across both Project ImPACT programs.
A few additional limitations relate to measurement of
parents’ ratings of Rogers’ attributes and intent to use
Project ImPACT. Although the attributes scale used was
adapted from a well-cited measure, the subscales reported
in the original measure (i.e. compatibility, complexity,
and relative advantage; Moore and Benbasat, 1991) were
not confirmed in the present data set. Instead, many of the
items loaded onto a single factor and, thus, scores were
summed across all items to represent a “general attrib-
utes” scale. Although representative of parents’ attitudes
toward the two programs broadly, it was not possible to
347
quantitatively understand specific attributes on which the
two programs may have differed. Importantly, only three
of Rogers’ attributes were examined within this study. The
choice to focus on compatibility, complexity, and relative
advantage was based on the focus of our initial commu-
nity partnership, as well as research to demonstrate that
these three attributes are most associated with program
adoption and use (Dingfelder and Mandell, 2011; Taylor
and Todd, 1995; Tornatzky and Klein, 1982). However,
use of an all-encompassing scale, such as that developed
by Cook et al. (2015), would allow for a better under-
standing of how the two programs differed across a greater
number of attributes. Finally, a single item was used to
measure parents’ intent to use Project ImPACT. Although
this type of measurement has been used in other research
examining TPB (Scott et al., 2008), the use of a single
item limited the validity of our intention measurement.
Future directions
Given that the findings from this study were promising,
future directions include piloting the adapted Project
ImPACT program within the Medicaid system as a way to
better understand the perceived attributes and structural
barriers to actual program participation and use. An essen-
tial piece of piloting the adapted program will also be col-
lecting both initial effectiveness data in addition to data
regarding attitudes toward specific program attributes and
other key variables noted to impact the eventual dissemi-
nation and implementation of Project ImPACT within the
Medicaid system (Curran et al., 2012). In addition to pilot-
ing the adapted program, it will be important to understand
parent preferences as they relate to other treatment modali-
ties, including direct intervention. Finally, given the known
role of culture in parents’ treatment decisions for their
child with ASD (Burkett et al., 2015; Mandell and Novak,
2005), future research should examine the role of culture
in shaping parents’ perceptions of participation in parent-
mediated interventions.
In summary, high rates of attrition in parent-mediated
intervention programs within the ASD field have under-
scored the need to engage low-SES communities around
improving the relevance and fit of these programs (Stahmer
and Pellecchia, 2015). Although more ASD researchers are
using research-community partnerships to improve the fit of
evidence-based practices for culturally diverse and under-
served community settings, this study was one of the first to
attempt to understand the impact of adaptations made to a
parent-mediated intervention in direct comparison with the
original program. Taken together, this study suggests that
Rogers’ diffusion of innovations theory and TPB can be used
to estimate the preliminary impact of adaptations on rates of
program adoption and use. Importantly, although the adapted
Project ImPACT program was rated more positively in this
study, the relatively high ratings of both programs is crucial
348
and emphasizes the need to more efficiently disseminate
parent-mediated programs to parents of children with ASD
across a variety of community settings.
Declaration of conflicting interests
B.I. receives royalties from the sale of the Project ImPACT man-
ual, which she donates to her research lab. No other authors have
conflicts of interest to disclose.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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