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Self-Directed Web-Based Parent-Mediated Interventions for Autistic

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DOI: 10.1007/s40489-022-00307-9

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Review Journal of Autism and Developmental Disorders
https://doi.org/10.1007/s40489-022-00307-9

REVIEW PAPER

Self‑Directed Web‑Based Parent‑Mediated Interventions for Autistic

Children: A systematic review
Elizabeth Glenn1   · Abiola Taiwo1 · Stacy Arbuckle1 · Hannah Riehl2 · Laura Lee McIntyre1

Received: 20 March 2021 / Accepted: 5 February 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Background  Self-directed web-based parent-mediated intervention programs may help counter some barriers associated
with access to evidence-based practices.
Methods  The current study is a systematic review of 14 studies that included parent-mediated intervention programs for chil-
dren with Autism Spectrum Disorder (ASD), reported on child outcomes, and included a self-directed, web-based component.
Results  Online interventions with self-directed components were efficacious in increasing parent fidelity, child social-
communication behaviors, adaptive behaviors, and decreasing anxiety. Studies reviewed were of moderate to high quality
and varied in experimental design, inclusion of representative samples, and fidelity reporting.
Conclusions  Web-based parent-mediated interventions are establishing a promising evidence-base in the literature and may
expand access to evidence-based treatment for autistic children. Future research in this area calls for additional investigation
on the effect of coaching, implementation with community samples, instructional design features, and use of multimodal
outcome measures.

Keywords  Autism · Intervention · Parenting · Telehealth · Systematic review

It is well established that existing intervention services
do not always meet the needs of children diagnosed with
Autism Spectrum Disorder (ASD; Ingersoll et al., 2016;
Law et  al., 2018) and their families. Parents encounter
several challenges when attempting to obtain services for
their autistic children, including difficulty obtaining infor-
mation, long wait lists, insurance eligibility, financial and
logistic barriers, and local unavailability of providers with
appropriate services or training (Montes et al., 2009). These
issues are exacerbated for non-White parents, families with
incomes below the poverty line, and parents in rural areas
(Liptak et  al., 2008). Parent-mediated intervention pro-
grams delivered via websites or mobile applications serve
as a potential cost-effective and ecologically valid avenue
to increase access to evidence-based intervention (Ingersoll
et al., 2016).

* Elizabeth Glenn
eglenn2@uoregon.edu Parent‑Mediated Intervention
Abiola Taiwo
ataiwo@uoregon.edu Parent-mediated intervention is an approach to support-
Stacy Arbuckle ing parents in directly fostering children’s development,
stacya@uoregon.edu through providing parents with the knowledge and skills
Hannah Riehl to implement evidence-based strategies, often through a
hannah.riehl@cidd.unc.edu mixture of teaching and coaching (Tomeny et al., 2019).
Laura Lee McIntyre Parent coaching within the context of parent-mediated
llmcinty@uoregon.edu intervention refers to the process by which profession-
als support parents to facilitate children’s learning using
1
Special Education and Clinical Sciences, University a variety of training practices (Rush & Shelden, 2011).
of Oregon, Eugene, OR, USA
Coaching practices utilized in current parent-mediated
2
Carolina Institute for Developmental Disabilities, University intervention research include collaborative planning,
of North Carolina Chapel Hill, Carrboro, NC, USA

13
Vol.:(0123456789)

modeling, guided practice, feedback, video review, and
reflection (Sone et al., 2021; Tomeny et al., 2019).
Parent-mediated intervention models vary considera-
bly across the literature (Bearss et al., 2015; Nevill et al.,
2018) and can be further characterized by delivery format,
intensity, and intervention targets (Bearss et al., 2015).
Delivery may vary from self-directed content such as
books or webpages to individual or group-based therapist-
led content, and intensity may vary from a brief consulta-
tion to in-home coaching sessions. Bearss et al. (2015)
also delineate parents’ role in the intervention’s mecha-
nism of change for the child, with either the parent taking
a primary role as the agent of change, or a supplementary
role in models with the therapist as the primary agent of
change. Intervention targets have been conceptualized
across two categories, 1) core symptoms of ASD, such
as social communication, and 2) maladaptive behaviors,
such as disruptive behaviors, or adaptive behavior skills
(Bearss et al., 2015).
Parent-mediated interventions for autistic children his-
torically have been implemented within the context of early
intervention (Nevill et al., 2018). As such, many parent-
mediated interventions have been modeled after estab-
lished early intervention programs, which tend to emphasize
developmental and behavioral theoretical approaches, and
developmentally sensitive targets such as communication
and adaptive behaviors. Research-based evidence is also
emerging for parent-mediated interventions in school-age
youth, with a greater emphasis on adaptive behaviors and
reduction of disruptive behavior (Ratliff-Black & Therrien,
2020). Across both age groups, recent meta-analyses have
established parent-mediated interventions lead to improve-
ments in social-communication abilities and adaptive behav-
iors (Nevill et al., 2018; Ratliff-Black & Therrien, 2020).
While parent-mediated interventions provide the potential
to bolster developmental outcomes and are largely perceived
as efficacious by parents, these programs have historically
been underutilized in community settings (Hume et  al.,
2005; Thomas et al., 2007). Common barriers to imple-
mentation underscore the historically fragmented nature of
intervention development and community concerns, such
as parents’ ability to engage with the delivery format and
demands of a specific intervention, fit with family values
and routines, and need for collaborative, family-centered
coaching practices (Pickard et al., 2016; Rieth et al., 2018).
Pickard et al. (2019) found adapting their intervention to
specifically address such barriers increased parents’ positive
impressions and interest, particularly for parents with lower
household income. However, even with these adaptations,
parents continued to report concerns related to structural
barriers, such as location, scheduling, and cost. Therefore,
in addition to intervention models that integrate scientific
understanding with community values, research must also
13
Review Journal of Autism and Developmental Disorders
consider innovative delivery models to minimize structural
barriers.
Technology is one such mechanism that could broaden
access to parent-mediated intervention trainings. Addi-
tionally, with mixed evidence on maintenance of parent-
implemented strategies with parent-mediated interventions,
web-based and self-directed modalities have the potential to
address this concern through long-term access to evidence-
based strategies. Technology can be used to individualize
interventions to families’ needs for intensity of support,
ultimately optimizing developmental outcomes for autistic
children.
Telehealth
Telehealth includes providing intervention or consultation
services via the internet or other electronic mediums. For
parent-mediated interventions, telehealth often entails tele-
coaching or using videoconferencing technology to teach
intervention strategies and provide coaching on intervention
implementation (Sutherland et al., 2018). Multiple system-
atic reviews have found overall, telehealth has demonstrated
equivalent efficacy and treatment satisfaction compared to
face-to-face services for parents of autistic children (Knut-
sen et al., 2016; Murphy & Ruble, 2012; Sutherland et al.,
2018). Telehealth programs especially help to remove bar-
riers of access for families in rural areas, where specialized
service providers may be locally unavailable (Stuckey &
Domingues-Montanari, 2017). These programs also provide
improved access to parents who face structural barriers to
clinic-based services, such as unreliable transportation and
scheduling constraints.
While most telehealth interventions address barriers of
local availability of specialized service providers, many
have yet to address barriers involving relative availability of
clinicians. Parents of autistic children may frequently find
themselves on a waitlist for services, and while most consult
the internet in search of intermediary resources, most do
not encounter evidence-based strategies (Grant et al., 2015).
Web‑Based Intervention
Differing from telehealth, where clinician contact is a core
component, web-based intervention includes approaches
where psychoeducational or intervention content is delivered
primarily by internet or mobile application technology with
limited or no clinician contact (Mohr et al., 2013). Similar
to therapist-delivered content, self-directed content is pre-
sented across multiple sessions, with the expectation parents
apply the newly learned skills with the context of their daily
routines and natural environments. Self-directed, web-based
Review Journal of Autism and Developmental Disorders
intervention has the potential to: (a) increase the dissemina-
tion of evidence-based interventions to families who experi-
ence barriers to accessing services associated with waiting
lists and provider availability; and (b) provide supplemental
training for families who are currently or who have previ-
ously received intervention services (Ibañez et al., 2018).
Self-guided approaches have greater potential for dis-
semination, as they do not require support from a trained
professional and can typically be delivered at a reduced
cost (Ingersoll et al., 2016). These approaches could also
be implemented within a “stepped-care” approach to inter-
vention, matching the individual’s level of need to level of
support (McIntyre & Phaneuf, 2008). Parents who have dif-
ficulty independently implementing intervention strategies
could receive coaching, which has been shown to improve
adherence and outcomes for web-based as well as parent-
mediated interventions (Kaminski et al., 2008; Mohr et al.,
2013).
Meta-analyses demonstrate online-based interventions
can improve both parent knowledge and skills, as well as
child skills, with medium to large effect sizes (d’s = 0.41
– 0.67; Breitenstein et al., 2014; Nieuwboer et al., 2013).
Research on telehealth in ASD is an emerging space, with
a recent systematic review showing about 52% of studies
have consisted of feasibility and acceptability pilot studies,
which may focus more on parent perceptions and skills and
less on child outcomes (Knutsen et al., 2016). Parsons et al.
(2017) reported initial evidence of efficacy for web-based
parent-mediated interventions on child outcomes, finding all
3 studies reporting on child outcomes demonstrated positive
changes in social communication.
While there have been systematic reviews on general
telehealth parent-mediated interventions for autistic youth
(Hall et al., 2016; Parsons et al., 2017), there has yet to be
a review that specifically focuses on telehealth approaches
that include self-directed, parent trainings not solely reliant
on tele-coaching. Additionally, while many reviews have
established sufficient evidence that parent training increases
parent knowledge, there is limited evidence on how changes
in parenting behavior translate into improved child out-
comes (Knutsen et al., 2016; Parsons et al., 2017). Online,
telehealth interventions with self-directed components theo-
retically have the potential to broaden access to care for the
autism community; however, additional review for evidence
of improved child outcomes is needed. Documenting inter-
vention effects on core mechanisms such as parent knowl-
edge, parent intervention use, and intended child outcomes
is critical if this modality of web-based, parent-mediated
intervention is to be scaled into dissemination efforts and
practice. Additionally, descriptive analysis of barriers and
core components to efficacy with this online format is also
critical to maximize the potential of future studies to create
sustainable positive impacts.
To address this gap in the literature, we present a sys-
tematic review of web-based (online and application-based)
parent-mediated interventions that include a self-guided
training element and report outcomes for autistic children.
As this modality is in its early stages, we evaluate studies
with quasi-experimental and experimental designs, across
intervention targets employing this modality. This work
will provide other researchers with current knowledge of
study design elements that best predict positive outcomes,
and suggestions of how this burgeoning area of online inter-
vention research can continue to grow to connect families
with evidence-based resources. The aims of this systematic
review were as follows:
1. Summarize common study and intervention design ele-
ments
2. Summarize the outcomes for parents and children
3. Investigate the overall quality of study design and report-
ing
4. Identify and describe critical elements or common bar-
riers to disseminating parent-mediated interventions in
a digital format
Methods
Article Identification
Articles were located using the following 6 databases: Aca-
demic Search Premier (EBSCO), Psychological and Behav-
ioral Sciences Collection (EBSCO), ProQuest Social Sci-
ences, PsycInfo, PubMed, and Web of Science, using search
terms for key terms within abstracts: autism (autis*, ASD,
asperger*, PDD*), interventions (intervention, therapy,
training), online or phone (digital, tele*, electronic, mobile,
phone, ehealth, web, online), parents (parent*), and children
(child*). Articles published online up to the month of July
2020 were included in this search. The search yielded 959
records across the six databases, with 567 unique records
after duplicate records were removed (Fig. 1).
Abstracts were first screened for the following criteria,
and then the full-text of eligible abstracts was read in depth
to ensure they met each of the following inclusion criteria: 1)
published in English, 2) published in a peer-reviewed jour-
nal, 3) included a parent-mediated intervention or training,
4) intervention was disseminated at least partially online
or in an app, 5) contained an online element besides tele-
coaching, 6) evaluated the effect of the intervention on child
outcomes, and 7) were tested with an ASD population. For
this review, parent-mediated interventions were defined as
interventions where the parent uses evidence-based strat-
egies to improve their child’s development or well-being.
13

Fig. 1  PRISMA study inclusion
diagram
Parents were defined as adults assuming a major familial
role in caregiving for a child in a home context.
Abstracts where at least one of these criteria was clearly
absent from the study were excluded. Full-text articles that
did not meet all 7 criteria were excluded. Each abstract and
article were screened by two independent reviewers. All
abstracts which at least one reviewer found eligible were
included in full-text screening. Full-text screening resulted
in the inclusion of 14 articles that met inclusion criteria.
Using the snowball method, we also scanned the references
of included articles (n = 20, Fig. 1) but failed to find addi-
tional articles that met inclusion criteria.
Data Extraction
A minimum of 2 reviewers per study extracted information
according to the primary research aims. Study and interven-
tion design elements included 1) study design, 2) recruit-
ment methods, 3) sample demographics (age, gender, race/
ethnicity, income, parental education), 4) study location, 5)
intervention description, and 6) delivery format (i.e., smart-
phone app versus website), and 7) design features (video
models, quizzes, discussion boards, messaging, coach-
ing, and child-directed content). Outcome data extracted
included 1) operational of measure (e.g., assessment, or
operational definition for observational tools), 2) parent out-
come and child outcomes measured, 3) type of analysis used,
13
Review Journal of Autism and Developmental Disorders
4a) reported effect size or group size (n), mean, and standard
deviation for computation of Cohen’s d effect size for group-
design studies, or 4b) screenshots of graphed outcome data
in SCD studies, and 5) statistical and descriptive treatment
moderators. Data extracted according to quality design and
reporting indicators are described below.
Quality Indicators
A quality indicator inventory was adapted from criteria set
forth in Reichow (2011) and Thomas et al. (2003). This
measure was carefully devised to evaluate quality standards
in the context of autism research, with both group design and
single-case design (SCD). This measure was also designed
specifically to not account effect sizes in quality reporting
and to focus primarily on quality study design and replicable
reporting. A copy of this inventory and scoring procedures
can be found in the online supplementary materials.
The quality indicators were split into categories of primary
and secondary indicators. Primary indicators for group
design consisted of the following categories: 1) participant
characteristics, 2) independent variable, 3) dependent variable,
4) random assignment, and 5) comparison condition. Primary
indicators for SCD included the following categories: 1)
participant characteristics, 2) independent variable, 3) dependent
variable, and 4) baseline. Secondary indicators included the
following categories: 1) fidelity, 2) social validity, 3) attrition,
Review Journal of Autism and Developmental Disorders
4) inter-observer agreement, 5) blinding, and 6) follow-up,
maintenance, or generalization data. Studies were rated on each
of these criteria as showing strong, moderate, or weak quality in
these categories using defined criteria, which is documented in
the supplementary material. Overall study quality was also rated
as strong, moderate, or weak. An overall strong rating was given
if a study’s primary quality indicators were all rated as strong,
and at least 4 secondary indicators were rated as strong. An
overall moderate rating was given if all quality indicators were
rated as strong, or moderate, and at least 2 secondary indicators
were rated as strong. Overall weak ratings were given to studies
with more than one weak primary indicator rating or less than 2
secondary indicators with a strong rating. Two reviewers rated
each study, with final ratings reflecting consensus scores.
Effect Sizes
Effect sizes for group design studies are reported based on the
metrics reported in the study (e.g., Cohen’s d, ηp2), or Cohen’s
d calculated from group mean, sample size, and standard devi-
ation (d = (M2—M1) ⁄ SDpooled, where ⁄ SDpooled = sqrt((SD12  et al. (2020) recruited parents through posting in 7 ASD-
+ ­SD12)/2). Large effect sizes were quantified as d = 0.80 or
ηp2 = 0.14, medium effects as d = 0.50 or ηp2 = 0.06, and small
effects as d = 0.20 or ηp2 = 0.02. Due to our broad inclusion cri-
teria in terms of study design, intervention target, and outcome
measure, we chose to descriptively report these effects, rather
than quantify with meta-analytic techniques.
Effect sizes for single-case design studies are reported based
on visual analysis of graphically displayed outcome data, com-
paring baseline to intervention and follow-up or maintenance
phases. The following visual analysis indicators were used to
examine effects: level, trend, variability, immediacy of effect,
and overlap, as specified as indicators of single-case interven-
tion effects for What Works Clearinghouse (Kratochwill et al.,
2013). Outcomes were rated as having a large effect if there
was minimal overlap (less than 25% of points), and a strong
visual change in level or increase in trend associated with the
intervention or follow-up phase across 3 or more participants.
Medium effects were quantified if there was significant over-
lap (25–50%), or smaller changes in level or trend across 3 or
more participants. Small effect sizes were quantified as these
indicators being present in 2 or less participants, or high over-
lap (over 50%) across phases. Two reviewers trained in visual
analysis for single-case design rated each study’s effect, with
final consensus ratings reported.
Results
Study Designs
Figure 1 details the flow of articles from identification to
inclusion in this review. We reviewed 597 unique abstracts
and found 79 abstracts that did not violate our inclusion cri-
teria. After full-text review, we found 14 studies that met our
inclusion criteria. Within the 14 articles selected for review,
six were randomized control trials (RCTs), three were quasi-
experimental pre-post group design, and five were single-
case designs (SCDs) employing a multiple baseline design.
More information on study design, and interventions can be
found in Table 1.
Recruitment
Recruitment methods were reported by all studies and a
majority centered around referrals from local psychiatric
divisions of hospitals, ASD clinics, and universities. Respec-
tive referrals occurred through general practitioners, mental
health professionals, school guidance officers, and parents.
Some examples include recruiting recently diagnosed chil-
dren (Whitehouse et al., 2017), children on waitlist for ser-
vices (Law et al., 2018), or participants in rural areas (Healy
& Marchand, 2020; Wainer & Ingersoll, 2015). Turgeon
specific Facebook groups and on the lab’s page, resulting in
almost 300 shares.
Demographics
A summary of demographic information describing par-
ticipant characteristics in the included studies can be found
in Table 2. Studies reported varying levels of demographic
information regarding their participants. Overall, there was
a higher rate of White participants in five of the nine studies
reporting race (Healy & Marchand, 2020; Ibañez et al., 2018;
Ingersoll et al., 2016; Vismara et al., 2013; Whitehouse
et al., 2017). SCDs had an increased sampling of diversity
in their participants; however, these studies included very
few total participants (Douglas et al., 2018; Law et al., 2018;
Wainer & Ingersoll, 2015). All studies that reported gender
representation (n = 12) within their sample demonstrated
more males than females in their studies, which is in line
with the prevalence rates for ASD (male:female = 4.3:1;
Maenner et al., 2020). Child age ranged from 1.5 to 16 years
old. Of the studies reporting income (n = 6), the majority of
participants were earning at or over an average range. While
parent education levels were quite diverse across some stud-
ies (Conaughton et al., 2017; Ibañez et al., 2018; Ingersoll
et al., 2016; Law et al., 2018; Whitehouse et al., 2017), most
parents had at least a college degree or some higher educa-
tion experience.
Interventions
Studies examined covered a variety of topics and primarily
were adapted from existing evidence-based interventions.
13
 Review Journal of Autism and Developmental Disorders

Table 1  Intervention targets, coaching dosage, intervention dosage, and design methodology of studies (N = 14)
Paper Intervention Name and Dosage: Therapist coaching Dosage: Intervention Study design
Description (mins/wk) Online Length (wks)
training
(mins/wk)

Conaughton et al., 2017 BRAVE-ONLINE: Train- 30 min total 30 Ix: 12 RCT: WLC
ing on child anxiety, FU: 12
contingency management,
relaxation training, cogni-
tive restructuring, graded
exposure, and problem
solving
Healy & Marchand, 2020 CHASE: Content included NA NR Ix: 4 Pre-post
a) benefits of physical FU: -
activity, b) barriers to
physical activity and solu-
tions, c) physical activity
community opportuni-
ties, d) instructional and
motivational strategies to
increase physical activity
Ibañez et al., 2018 Enhancing Interactions: NA 90 Ix: 4 RCT: WLC
Utilization of everyday FU: 4
routines as opportunities
for learning through use
of strategies like simple
instructions and visual
supports to systematically
increase child’s engage-
ment
Ingersoll et al., 2016 Project ImPACT: Content 60a 75 Ix: 12 RCT: Online vs
targets include 1) Mak- FU: 12 online + coaching
ing play interactive, 2)
modeling, 3) expanding
upon child’s language,
4) creating opportunities
for initiation, 5) using
prompts and reinforce-
ment, 6) pacing
McGarry et al., 2019 PRT Online: interven- NA 15–30 Ix: 6 Pre-post group
tion designed to increase FU: -
child’s social communica-
tive behaviors through
naturalistic behavior
strategies
Turgeon et al., 2020 IWT: training designed to NA 60 Ix: 4 RCT: WLC
reduce challenging behav- FU: 4, 8
iors through teaching
parents how to 1) define
a challenging behavior
and identify its function,
2) modify antecedents, 3)
change consequences, 4)
teach alternative behav-
iors, 5) implementation
strategies

13
Review Journal of Autism and Developmental Disorders

Table 1  (continued)
Paper Intervention Name and Dosage: Therapist coaching Dosage: Intervention Study design
Description (mins/wk) Online Length (wks)
training
(mins/wk)

Vismara et al., 2018 ESDM anywhere: targets Ix: 90 25 Ix:12 RCT: ATTN
increasing a) attention and Ctrl: 22.5 FU: 12
motivation, b) sensory
social routines, c) dyadic
engagement, d) non-verbal
communication, e) imita-
tion, f) joint attention,
g) speech development,
h) antecedent-behavior-
consequence relationships,
i) prompting, shaping, and
fading, j) use of functional
behavior assessments for
intervention development
Waligórska et. al 2012 AutismPro: website and 66 600 Ix: 24 Pre-post group
training includes 1) FU: -
Assessing the child’s
functioning, 2) developing
an adapted intervention,
3) interaction strategies,
4) preparing the learning
environment, 5) challeng-
ing behaviors, 6) activity
schedules, 7) measuring
progress
Whitehouse et al., 2017 TOBY: targets increas- 2 h at beginning 80 Ix: 12 RCT: WLC
ing child’s 1) visual and FU: 12
auditory understanding,
2) imitation skills, 3)
receptive and expressive
language, 4) social skills
through naturalistic behav-
ioral strategies
Douglas et al., 2018 POWR: 1) Prepare the NA 3 h total Ix: 2–84 days MBL: 5 probe baseline
activity and AAC, 2) Offer
opportunities for com-
munication, 3) Wait for
child’s communication, 4)
Respond to child’s com-
munication
Law et al., 2018 Map4speech: (a) follow Ix: 45 NR Ix: 6 MBL: 1–7 day baseline
your child’s lead (b) imi- FU: 15 FU: 1.2
tate and animate, (c) make
moments for togetherness,
and (d) prompt, reward,
and expand
Wainer & Ingersoll, 2015 Telehealth RIT: 1) arrange 90 4 lessons Ix: NR MBL: 4–8 week baseline
environment for suc- FU: 12
cessful parent–child play
interactions, 2) contingent
imitation, 3) simplified
language to describe
objects child attends to, 4)
prompting and reinforce-
ment to elicit imitation

13
 Review Journal of Autism and Developmental Disorders

Table 1  (continued)
Paper Intervention Name and Dosage: Therapist coaching Dosage: Intervention Study design
Description (mins/wk) Online Length (wks)
training
(mins/wk)

Wainer & Ingersoll, 2013 Distance Learning RIT: 30 min ­totalb 5 modules Ix: 2 MBL:
See description for Wainer 4–40 min FU: - 3–6 week baseline
& Ingersoll, 2015 each
Vismara et al., 2013 ESDM anywhere: See Ix: 90 60–390 Ix:12 MBL: 3–8 probe baseline
description for Vismara FU: 22.5 FU: 12
et al., 2018

Note. CHASE = Children with Autism Supported to Exercise; EDSM = Early Start Denver Model; TOBY = Therapy Outcomes by You;
ImPACT  = Improving Parents as Communication Teachers; RIT  = Reciprocal Imitation Teaching; PRT  = Pivotal Response Treatment;
min = minutes; wk = week; NA = not applicable; NR = not reported;  Ix = Intervention; Ctrl = Control group; FU = Follow-up; RCT = Rand-
omized-control trial; ATTN = Attention placebo; WLC = Wait-list control; MBL = Multiple baseline
a
 Only for those randomly assigned to coaching group; bOnly for parents who failed to reach fidelity criteria

Table 2  Demographic data of included study samples

Study N Range (M) Male White Hispanic or $50-75 K +  College Country
Child Age Latinx or Average +  Education
Income

Conaughton et al., 2017 42 8 – 12 86% - - 87% 38% AUS

(9.74)
Healey & Marchand 2020 13 6 – 16 (9.38) 69% 85% - - 69% USA
Ibañez et al., 2018 104 1.5 – 5 (3.65) 73% 86% - - 63% USA
Ingersoll et al., 2016 28 2–6 70% 78% - - 56% USA
(3.64)
McGarry et al., 2019 11 1.5 – 4 74% 27% 36% - 100% USA
(3.07)
Turgeon et al., 2020 47 3.5 – 12 (7) 89% - - 72% 79% CAN
Vismara et al., 2018 24 1.5 – 4 (2.49) 71% - 17% 50% 75% USA
Waligórska et al., 2012 9 3 – 7 (4.84) 89% - - 88% 94% POL
Whitehouse et al., 2017 75 0 – 4.5 (2.90) 79% 74% - 87% 56% AUS
Douglas et al., 2018 3 4 – 5 (4.67) 100% 33% 0% - 100% USA
Law et al., 2018 3 2.5 – 4.5 (3.5) 67% 0% 0% - 33% SGP
Wainer & Ingersoll, 2015 5 2.5 – 5 (3.50) - 20% 20% - 100% CAN
Wainer & Ingersoll, 2013 3 2 – 8 (5.08) 100% - - - 67% USA
Vismara et al., 2013 8 1.5 – 4 - 75% 25% 88% 100% USA
(2.29)

Note. K = thousand; M = Mean;  CAN = Canada; USA = United States of America; SGP = Singapore; POL = Poland; AUS = Australia.
“-” = study did not report this information

Three studies (Law et al., 2018; Waligórska et al., 2012;
Whitehouse et al., 2017) were based on Applied Behavior
Analysis (ABA; Lovaas, 1987), a behavioral therapy to
help autistic individuals to improve and maintain positive
behaviors and skills, and decrease the occurrence of problem
behaviors, while also working to generalize skills. Turgeon
et al. (2020) based intervention content on function-based
assessment and treatment, a similar behavioral approach.
Six studies were based on manualized naturalistic behav-
ioral interventions (Schreibman et al., 2015), defined as
behavioral interventions implemented in natural settings,
that utilize everyday learning opportunities to teach devel-
opmentally appropriate skills. Vismara et al., (2013, 2018)
adapted Early Start Denver Model (ESDM; Rogers & Daw-
son, 2010) for telehealth, Wainer and Ingersoll (2013, 2015)
delivered an intervention based on Reciprocal Imitation
Training (RIT; Ingersoll & Schreibman, 2006), Ingersoll
et al. (2016) adapted Project ImPACT for online use, and
McGarry et al. (2019) adapted Pivotal Response Treatment
(PRT) for online delivery. Ibañez et al. (2018) developed

13
Review Journal of Autism and Developmental Disorders

tutorials to promote engagement during daily routines, based
on naturalistic behavioral intervention principles. Douglas
et al. (2018) paired an augmentative and alternative com-
munication (AAC) for the child with teaching the parent
strategies to prompt communication.
Conaughton et al. (2017) tested an intervention based on
Cognitive Behavioral Therapy (CBT), which aims to reduce
distorted cognitions and avoidance behaviors, for treatment
of anxiety. Therapeutic targets and content for these inter-
ventions are further detailed in Table 1.
Delivery Format
Studies reviewed implemented various technology modali-
ties to supplement or provide intervention to parents and
children. Whitehouse et al. (2017) and Law et al. (2018)
both utilized applications on iPads. The remaining studies
(n = 12) used a website to provide parents with intervention
training and materials. Two studies (Douglas et al., 2018;
Wainer & Ingersoll, 2013) embedded the trainings within
an online course management system. McGarry et al. (2019)
utilized Qualtrics to deploy their online modules. Healy and
Marchand (2020) deployed their intervention on Facebook.
Further information on online components can be found in
Table 3.
Parent Coaching
Nine articles included parent coaching, which we broadly
define as trained clinicians providing training or support to
parents to implement intervention strategies. While dosage
of parent coaching varied, all studies utilizing coaching
provided less than an hour and a half of coaching each
week. Studies examined implemented varying levels of
parent coaching through use of different modalities. Parent
coaching on the intervention occurred online through web
platforms in five of the nine articles employing coaching
(Conaughton et al., 2017; Ingersoll et al., 2016; Vismara
et al., 2013, 2018; Wainer & Ingersoll, 2015). Ingersoll et al.
(2016) randomly assigned half of the participants to receive
coaching via videoconferencing, whereas the other half
received no coaching. Waligórska et al. (2012) conducted
parent coaching in person at two local treatment centers.
Wainer and Ingersoll (2013) provided live coaching for one
session for one participant who had not yet reached fidelity.
Whitehouse et al. (2017) provided coaching via phone calls
and messages. Five studies (Douglas et al., 2018; Healy &
Marchand, 2020; Ibañez et al., 2018; McGarry et al., 2019;
Turgeon et al., 2020) did not provide coaching to their par-
ticipants. Therapists provided live feedback in four studies
(Ingersoll et al., 2016; Vismara et al., 2013, 2018; Wainer &
Ingersoll, 2015) through video conferencing.
Other Features
To assess parent understanding of intervention information,
comprehension quizzes were used in most studies examined
(n = 8; Conaughton et al., 2017; Douglas et al., 2018; Inger-
soll et al., 2016; Law et al., 2018; McGarry et al., 2019;
Turgeon et al., 2020; Wainer & Ingersoll, 2013, 2015). Five
of the studies involved varying forms of communication
with the therapist, including email (Vismara et al., 2018),

Table 3  Online website design characteristics

Paper Web or Video Models Quizzes Discussion Therapist Messages Child-directed “Live”
App boards content Coach-
ing

Conaughton et al., 2017 Web X X X X

Healy & Marchand, 2020 Web X X
Ibañez et al., 2018 Web X X NA
Ingersoll et al., 2016 Web X X X One ­waya X
McGarry et al., 2019 Web X X X NA
Turgeon et al., 2020 Web X X NA
Vismara et al., 2018 Web X X X X
Waligórska et al., 2012 Web X X NA
Whitehouse et al., 2017 App X NA
Douglas et al., 2018 Web X X One way NA
Law et al., 2018 App X X
Wainer & Ingersoll, 2015 Web X X X
Wainer & Ingersoll, 2013 Web X X
Vismara et al., 2013 Web X X X X

Note. aOne-way messages include messages where the therapist messaged the parent, but the communication was not two way in nature (e.g.,
reminders). X = study involved corresponding component

13

motivational messages (Healy & Marchand, 2020), check-
ins if materials had not been accessed recently (Douglas
et al., 2018), and a “Tip of the week” email (Ingersoll et al.,
2016). Discussion boards were used in five studies (Healy &
Marchand, 2020; Ingersoll et al., 2016; Vismara et al., 2013,
2018; Waligórska et al., 2012).
Parent Outcomes
Parent Fidelity and Knowledge
Parent fidelity was assessed in nine of the studies. Fidel-
ity assessments included fidelity checklists, observed use of
intervention strategies, and knowledge quizzes. The modal-
ity of these assessments included rating scales, open-ended
questions, and behavioral observations of parent–child inter-
actions. Parents had high and improved fidelity from base-
line to follow-up in all 6 studies measuring fidelity through
scoring videotapes with an observational coding scheme
(Ingersoll et al., 2016; McGarry et al., 2019; Vismara et al.,
2013, 2018; Wainer & Ingersoll, 2013, 2015). Douglas
et al. (2018) coded parent communication opportunities
and found medium changes in level for all 3 participants.
Douglas et al. (2018) also examined parent perception of
strategy use and found parents rated themselves in a range of
average to excellent upon the end of the study. For the four
RCTs that measured parent fidelity, parents in experimental
groups were significantly more likely than parents in control
groups to meet fidelity, or improve fidelity strategies, with
medium to large effect sizes (Ibañez et al., 2018; Ingersoll
et al., 2016; Turgeon et al., 2020; Vismara et al., 2018).
Secondary Parent Outcomes
Only three studies examined parental factors outside of fidel-
ity, specifically parent stress, parenting self-efficacy, overall
parenting practices, and parent positive perceptions of the
child (Ibañez et al., 2018; Ingersoll et al., 2016). Parents
exhibited decreased parenting stress after a fully self-guided
online training in one study with medium effect sizes (Ibañez
et al., 2018), whereas in another (Ingersoll et al., 2016) only
parents in the group that received coaching experienced a
decrease in stress and positive perceptions of their child with
medium effect sizes. Parents in both studies also experi-
enced an increase in feelings of parenting self-efficacy, with
medium to large effect sizes from pre- to post-intervention.
In Ingersoll et al. (2016) only parents who received coaching
reported an increase in positive perceptions of their child.
Turgeon et al. (2020) failed to detect differences in global
parenting practices after exposure to a 4-week functional
behavior training. More detailed information related to
measurement and effects is detailed in Table 4.
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Review Journal of Autism and Developmental Disorders
Social Validity Outcomes
Social validity outcomes data, including acceptability, feasi-
bility, usability, and satisfaction, were collected from parents
via questionnaires in ten studies. Parents reported moderate
to high levels of satisfaction, reporting that the online- or
app-based trainings were effective for teaching their children
new skills (Conaughton et al., 2017; Douglas et al., 2018;
Ibañez et al., 2018; McGarry et al., 2019; Turgeon et al.,
2020; Vismara et al., 2018). Six of the studies found that
parents experienced technical difficulties when accessing
the programs, like being unable to log on or having diffi-
cult accessing features of the website (Douglas et al., 2018;
McGarry et al., 2019; Vismara et al., 2018; Wainer & Inger-
soll, 2013, 2015; Waligórska et al., 2012). Overall, parents
found programs to be useful and reported improvements in
their child’s skills.
Child Outcomes
Social Communication
Intervention effectiveness for child outcomes related to
communication was measured by standardized assessments,
behavioral observation of parent–child interactions, and par-
ent report questionnaires. General communication abilities
(i.e., receptive communication, expressive communication,
language, vocabulary) were the most common outcome
measures among the studies (n = 7). Positive effects of inter-
vention on general communication abilities were reported in
six of the studies, with gains of at least moderate effect sizes
in expressive communication, non-verbal communication,
and receptive communication (Douglas et al., 2018; Ibañez
et al., 2018; Law et al., 2018; McGarry et al., 2019; Vismara
et al., 2013; Whitehouse et al., 2017).
Social communication behaviors (i.e., imitation, verbal
and non-verbal joint attention, and social relating during
interaction with an adult) were measured as outcomes in five
studies (Ibañez et al., 2018; Vismara et al., 2013; Wainer &
Ingersoll, 2013, 2015). McGarry et al. (2019) found large
effect sizes from pre-intervention to post-intervention for
eye-contact and positive affect. Significant gains of medium
effect size in social relating were reported in one RCT
(Ibañez et al., 2018), while only variable and mild increases
in non-verbal joint attention and imitation behaviors were
observed in SCDs, based on visual analysis (Vismara et al.,
2018; Wainer & Ingersoll, 2013, 2015).
Functional communication behaviors (i.e., using words,
utterances, or gestures to request) were included as outcomes
in two SCDs (Law et al., 2018; Vismara et al., 2013). Both
studies found moderate increases in these behaviors from
baseline to follow-up, with Law et al. (2018) reporting an
Review Journal of Autism and Developmental Disorders

Table 4  Parent and child outcomes quantified by effect size or visual analysis, as well as quality indicator rating, accompanied by basic study
information (design, N)
Study Design N Parent Outcomes Measures Child Outcomes Measures Quality Rating

Conaughton et al., 2017 RCT​ 42 None - Large: Number of ADIS Strong

­diagnosesa, ­Impairmenta, CGAS
Internalizing ­symptomsb, CBCL
Anxiety ­symptomsb SCAS
Healy & Marchand, 2020 Pre-post 13 None - Null: Physical activity l­evelb GLTEQ Weak
Ibañez et al., 2018 RCT​ 104 Null: E ­ fficacyb, RC – PR Small: Non-verbal RC – PR Moderate
Parent–child dysfunctional PES ­communicationb PIA-CV
­interactionb, Difficult PSI Medium: Child
­childb, ­Distressb ­engagementb, Social
Large: Strategy u­ seb ­relatingb
Ingersoll et al., 2016 RCT​ 28 Medium (time): self- RC – PR Null: Daily ­livingb, Motor RC – Obs Moderate
efficacyb, ­stressb, positive PSOC ­skillsb MCDI
­perceptionsb FIQ Small (time*group): VABS
Large (time): ­Fidelitya ­Socializationb
Medium (timec):
­Communicationb
Large (timec): Language
­targetsa, ­vocabularyb
McGarry et al., 2019 Pre-post 30 Large: ­Fidelitya RC – Obs Large (time): Child RC – Obs Moderate
­vocalizationsa, child eye-
contacta, positive a­ ffecta
Turgeon et al., 2020 RCT​ 47 Null: Parenting p­ racticesb APQ-SF Medium: Challenging BPI-01 Moderate
Large: Intervention ­useb RC-PR behavior ­frequencyb/
severityb
Vismara et al., 2018 RCT​ 30 Small: ­Fidelity1 RC – Obs Small: Social-communica- RC – Obs Moderate
tion ­behaviorsa
Waligórska et. al 2012 Pre-post 9 None - Null: Gross ­motora, PEP-R Weak
­Cognitivea, Hand-eye
­integrationa, ­Verbala,
­Imitationa
Large (time): Fine m ­ otora
Whitehouse et al., 2017 RCT​ 80 None - Null: ASD S ­ everity2, ATEC Moderate
Receptive ­Languagea, MSEL
Fine ­motora, Expressive VABS
­Languagea; Adaptive: MCDI
­Totalb, ­Communicationb, RBS-R
­Socializationb, Fine ­motorb, BFRS-R
Gross ­motorb; Words
­producedb, ­Gesturesb,
­RRBsb, Behavioral
­inflexibilityb
Small: Visual ­Receptiona,
Words ­understoodb
Medium: Daily ­Livingb
Douglas et al., 2018 MBL 3 Medium: Parent RC – Obs Medium: Child RC – Obs Strong
­communicationa ­communicationa
Law et al., 2018 MBL 3 Medium: ­Fidelitya RC – Obs Medium: Child functional RC – Obs Moderate
­communicationa
Wainer & Ingersoll, 2015 MBL 5 Medium: ­Fidelitya RC – Obs Small: Spontaneous RC – Obs Weak
­imitationa
Wainer & Ingersoll, 2013 MBL 3 Large: ­Fidelitya RC – Obs Medium: Child imitation RC – Obs Strong
­ratesa

13
 Review Journal of Autism and Developmental Disorders

Table 4  (continued)
Study Design N Parent Outcomes Measures Child Outcomes Measures Quality Rating
Vismara et al., 2013 MBL 8 Large: ­Fidelitya, RC – Obs Null: Initiated joint RC – Obs Weak
­Engagementa MBRS ­attentiona MCDI
Small: Functional
­verbalizationsa
Medium: Words
­understoodb, Words
­producedb

Note. Effect sizes: Small = d > .2, ηp2 > .01; Medium = d > .5; ηp2 > .06; Large = d > .8; ηp2 > .14. Effect sizes are reported as between group or
time*group comparisons unless otherwise specified
Abbreviations: RCT = Randomized-control trial; MBL = Multiple Baseline. ADIS = Anxiety Disorders Interview Schedule; CGAS = Children's
Global Assessment Scale; CBCL = Child Behavior Checklist; SCAS = Spence Children's Anxiety Scale; GLTEQ = Godin Leisure-Time Exer-
cise Questionnaire; RC – PR = Researcher Created—Parent Report; PES = Parent Expectations Survey; PSI = Parenting Stress Index; PIA –
CV = The Parent Interview for Autism-Clinical Version; PSOC = Parenting Sense of Competence; FIQ = Family Impact Questionnaire; RC—
Obs = Researcher Created – Observation; MCDI = MacArthur-Bates Communicative Development Inventories; VABS = Vineland Adaptive
Behavior Scales; APQ-SF = Alabama Parenting Questionnaire-Short Form; BPI-01 = Behavior Problems Inventory – 2001; PEP-R = Psychoe-
ducational Profile – Revised; ATEC = Autism Treatment Evaluation Checklist; MSEL = Mullen Scales of Early Learning; RBS-R = Repetitive
Behavior Scale – Revised; BFRS-R = Behavior Flexibility Rating Scale-Revised
;a
  Observation measure; bParent-report measure

increase in children’s rate of both prompted and spontaneous
pointing to request an object or activity, and Vismara et al.
(2013) reporting overall increases in functional utterances.
Adaptive Behavior
Of the two studies (Ingersoll et al., 2016; Whitehouse et al.,
2017) that included measures of broad adaptive behavior,
only one found medium effects over time, however failed
to yield a group by time effect (Whitehouse et al., 2017).
Ibañez et al. (2018) examined a more specific characteriza-
tion of adaptive behavior, termed child engagement, char-
acterized by active participation in routines, interacting and
communicating during routines, ease with transitions before
and after a routine, and found gains of medium effect sizes
across time compared with the control group. Healy and
Marchand (2020) examined the impact of their intervention
on physical activity level and found no significant pre-post
differences.
Three studies examined intervention effects on motor
skills, both gross and fine motor (Ingersoll et al., 2016;
Waligórska et al., 2012; Whitehouse et al., 2017). How-
ever only two studies found significant effects on fine motor
skills. One found significant pre-post differences in devel-
opmental quotient scores for fine motor skills (Waligórska
et al., 2012), with a large effect size across time, while the
other found a small effect size between groups post-interven-
tion and at 3-month follow-up (Whitehouse et al., 2017). No
effects were seen for gross motor skills.
For the two studies that examined effects on cogni-
tive measures (Waligórska et al., 2012; Whitehouse et al.,
2017), one found significant effects for visual reception
scores between groups post-intervention and follow-up and
however failed to find a group by time interaction (White-
house et al., 2017).
Other Core and Comorbid Symptoms
One study examined effects of an intervention on other core
symptoms associated with ASD, including sensory behav-
iors, restrictive, repetitive behaviors, and behavioral inflex-
ibility, but failed to find any significant effects (Whitehouse
et al., 2017). Turgeon et al. (2020) found intervention usage
resulted in decreases in frequency and severity of chal-
lenging behavior. Another study examined the effects of an
intervention on anxiety diagnoses, impairment, and symp-
toms and found significant effects, such that the interven-
tion group made larger positive gains over time than did the
control group (Conaughton et al., 2017).
Quality Indicators
Using the quality indicator inventory adapted for this review,
studies were rated as having strong, moderate, or weak qual-
ity (Table 5). Two SCDs (Vismara et al., 2013; Wainer &
Ingersoll, 2015) and two group design studies (Healy &
Marchand; Waligórska et al., 2012) were rated as having
weak quality. For these four studies, two primary indicators
were rated as weak. The indicators that were labeled as weak
were rated as such due to not reporting participant character-
istics (age, gender, diagnosis information) and not reporting
baseline information with replicable precision. Five group
design studies (Ibañez et al., 2018; Ingersoll et al., 2016;
McGarry et al., 2019; Vismara et al., 2018; Whitehouse
et al., 2017) were rated as having moderate quality. Common

13
Review Journal of Autism and Developmental Disorders

issues included moderate ratings in primary indicators like gestures or parent-rated receptive language. Wainer and
dependent variable reporting (n = 3), reporting information Ingersoll (2015) found that the specific RIT fidelity com-
about the comparison condition, including other interven- ponents Contingent Imitation and Prompting Sequence, but
tions (n = 2), and reporting of participant characteristics not overall fidelity scores, uniquely predicted spontaneous
(n = 2). One study (Whitehouse et al., 2017) was rated as child imitation rate. Vismara et al. (2018) examined the role
moderate due to poor secondary indicators—not reporting of caregiver gender on fidelity and found that female parents
effects of parent fidelity or demonstrating social validity. were more likely to meet fidelity than were male parents.
Three SCD studies (Douglas et al., 2018; Law et al., 2018; Vismara et al. (2013) explored if website usage predicted
Wainer & Ingersoll, 2013) and one RCT study (Conaughton, parent fidelity or engagement style, and found website usage
et al., 2017) met the criteria for high quality. These three negatively predicted engagement style, and was not related
studies had either 4 or 5 secondary indicators were rated as to parent fidelity.
strong, and all primary indicators rated as strong. Frequency
counts of indicators rated as strong, moderate, or weak qual- Descriptive Predictors
ity are detailed in Table 5.
Studies reported variability in the amount of time parents
used the websites or applications, overall completion of
Predictors of and Barriers to Efficacy modules, and pacing of module completion (Conaughton
et al., 2017; Vismara et al., 2018; Whitehouse et al., 2017).
Statistical Predictors Two studies collecting follow-up information recorded
a decrease in website usage during the follow-up period
Three studies conducted analyses to investigate the rela- (Conaughton et al., 2017; Vismara et al., 2018). Two stud-
tionship between demographic and fidelity characteristics ies also documented potential issues with developmental
and parent or child outcomes (Vismara 2013, 2018; Wainer appropriateness of intervention targets for the child (Douglas
& Ingersoll, 2015). Vismara et al. (2013) found that par- et al., 2018; Wainer & Ingersoll, 2015). Wainer and Ingersoll
ent fidelity and overall engagement style were significantly (2013) mentioned that familiarity in delivery of interven-
predictive of observed and reported expressive language but tions could explain differential success with interventions,
were not significantly predictive of observed child social as the least experienced parent required additional coaching
to reach the fidelity criterion.
The Whitehouse et al. (2017) study thematically iden-
Table 5  Overall frequency counts for strong, moderate, and weak rat- tified barriers parents noted in delivering the intervention
ings for primary and secondary quality indicators over technical assistance telephone calls. These barriers
Quality Rating included variability in parent motivation, the time to build
fluency with using the intervention tool, being busy with
Strong Moderate Weak NA/NR
other commitments, siblings, other therapies, the lack of
Primary Indicators having another adult to help with intervention delivery or
Participant Characteristics 10 2 2 - siblings, life events, family relational issues, child fatigue
Random ­Assignmenta 6 0 3 - after therapy or school, child boredom with the intervention,
Baselineb 4 0 1 - and child challenging behaviors. Waligórska et al. (2012)
Comparison ­Conditiona 3 3 - 3 conducted a survey to identify strengths of their interven-
Independent Variable 14 0 - - tion and found 70% or more of parents reported intervention
Dependent Variable 11 3 - - strengths included provision of support for parents, ability
Secondary Indicators to choose therapeutic objectives, and precise description of
Recruitmenta 2 7 - - activities.
Fidelity 7 3 4 -
Social Validity 8 4 2 -
Attrition 9 3 2 - Discussion
IOA 8 - 2 4
Blinding 4 - 1 9 This review focused on web-based parent-mediated interven-
FU/Maintenance 10 - 4 - tions that included a self-directed training component. We
Generalization 2 - 12 - found fourteen studies meeting our inclusion criteria, with
nine studies being published within the last 4 years, which
Note. aOnly rated for group design studies (n = 9), bOnly rated for
single-case designs (n = 5). Abbreviations: NA  =  Not applicable, suggests this is a new, but growing area of research. The
NR = Not reported; IOA = Inter-observer agreement; FU = Follow-up results of this review suggest that overall, online delivered

13

interventions are effective at increasing parent fidelity,
social-communication behaviors, decreasing anxiety and
problem behaviors, and for some interventions, increasing
adaptive behaviors. Currently, these interventions do not
show effects on other core ASD symptoms (e.g., RRBs and
sensory behaviors). Most studies (n = 10) were of moderate
to high quality, with most common weaknesses including
replicable detail about comparison conditions, representative
sampling, measurement of parent and clinician fidelity, and
collection of maintenance and generalization data. Studies
rated as “weak” may be interpreted with caution in terms
of replicability, due to poor reporting as a common issue.
Although few studies investigated moderators of treat-
ment efficacy, a few reported on the positive contribution
of parent strategy use on child outcomes, mirroring other
studies establishing parent strategy use as a core mechanism
of change for target child behaviors (Eames et al., 2009).
Common barriers included the match of the intervention to
the child’s needs, limitations of parents’ time, and parent
familiarity with delivery of interventions. These barriers
echo previously documented concerns of parents (Pickard
et al., 2019) related to parent-mediated intervention and may
reflect the degree of flexibility built into the intervention,
accessibility of content delivery, complexity of intervention
strategies, and generalizability of intervention content across
contexts and developmental level.
The results of these studies build a promising foundation
suggesting self-directed, online, parent-mediated interven-
tions lead to evidence-based parental strategy use and child
improvements, even in the absence of coaching. Half of the
included studies investigated solely self-directed interven-
tions and found increases in social communication skills
like vocalizations, imitation, conversation turns, language
targets, and vocabulary, as well as adaptive behavior skills
like engagement in routine activities and reduction of chal-
lenging behaviors. Effect sizes were mainly in the small to
medium range, mirroring findings of a recent meta-analysis
of parent-mediated interventions for autistic individuals,
reporting an overall small effect (g = 0.23) across studies
(Nevill et al., 2018). While benefits extended to parent out-
comes such as stress and self-efficacy, results of one study
suggested exposure to coaching may augment these effects
(Ingersoll et al., 2016). Additionally, the methodological
constraints of the studies with self-directed only groups war-
rant additional research to solidify this foundation. When
evaluating against standard criteria for evidence-based
practices (PracticeWise, 2021), needs include RCT designs
tested against a placebo or established treatment control.
Studies that employed coaching as part of their design
also found promising effects, building a promising founda-
tion for the use of a stepped-care approach for service pro-
vision (McIntyre & Phaneuf, 2008). Seven of nine studies
that employed therapist delivered coaching did so remotely,
13
Review Journal of Autism and Developmental Disorders
through videoconferencing technology. For studies including
coaching, common needs to improve the level of evidence-
base (PracticeWise, 2021) included RCTs utilizing an estab-
lished treatment group or attention control group. Remote
coaching can help to broaden access to both parents who are
not in driving distance of a service provider, and to parents
whose schedule or caregiving demands may preclude in-
person appointments. Although there was variability in the
dosage of the parent coaching sessions, many (n = 5) studies
supported families with an hour or less a week of clinician
assistance.
Interventions ranged in the specificity and number of
intervention targets, with some targeting a few behaviors
in a specific context, and others covering a wide range of
behaviors across contexts. A key consideration related to
measurement of outcomes across contexts is the divergence
between parent report and observational measures (Cotter
& Brestan-Knight, 2020; Federico et al., 2021; Miller et al.,
2017). Parent report may be particularly appropriate for ran-
domized designs, where expectancy effects can be controlled
for (Whalley & Hyland, 2013) for larger samples where
observational data collection is less feasible (Anagnostou
et al., 2015), and to collect information on distal outcomes,
or across contexts. Observational methods may be more
appropriate for single-case designs or for greater specificity
on intervention targets and mechanisms of change (Yoder
& Stone, 2006). For two of the four studies employing both
types of methodology, positive effects were seen in both
parent-report and observation. Future research may consider
employing observational methods with smaller studies, and
utilizing parent-report data concurrently, or during a later
RCT to establish generalizability of intervention effects to
general domains (Fuller & Kaiser, 2020).
Another key consideration includes measurement systems
that are sensitive to change and consider developmental tra-
jectories (Schreibman et al., 2015). Social-communication
and adaptive behaviors, which encompassed outcomes for
eleven studies reviewed, are both acquired skills that follow
a developmental trajectory. For example, many operation-
alizations of child communication collapsed spontaneous
and prompted communication behaviors into one construct,
imposing limitations on interpreting if interventions were
successful in scaffolding development of communication
across levels of acquisition, or if intervention effects were
limited to prompted (i.e., adult driven) communicative
behaviors. One group design study used language targets as
a measure for communication, which is one way to account
for the developmental level of the child’s existing commu-
nication skills and provides sensitivity to growth across time
(Tager-Flusberg et al., 2009). Several SCD studies looked
at more specific instances of communication, such as spon-
taneous communication. For adaptive behaviors, a common
measurement tool (Vineland Adaptive Behavior Scales)
Review Journal of Autism and Developmental Disorders
excludes prompted behaviors and thus may show less sen-
sitivity to change relative to researcher created tools, which
may explain differences in outcomes for this domain. As
measurement may constrain interpretations of intervention
efficacy, this underscores the need for careful consideration
in operationalization of target behaviors with sensitivity to
development (Anagnostou et al., 2015; Lord et al., 2005).
Of the studies included in this review, eight studies
included interventions targeted toward children under the
age of 5, reflecting the role of this modality in early interven-
tion, as well as the developmental and naturalistic emphasis
of many parent-mediated interventions (Nevill et al., 2018).
A recent meta-analysis has also shown the effectiveness
of parent-mediated intervention for older autistic youth,
particularly for adaptive behavior, thus remaining a valid
modality as children age (Ratliff-Black & Therrien, 2020).
In this review, studies with older youth found preliminary
evidence for reduction of anxiety and challenging behav-
iors, and null results for increasing physical activity. As one
study also included child-directed content, this may reflect
a developmental need for transfer of support to other eco-
logically valid sources, such as peers, educators, or direct
support workers, to maximize independent living (Płatos &
Wojaczek, 2018).
The samples included in these studies were not
entirely matched to respective populations on certain
demographic aspects such as income, parental education,
race, and ethnicity. Future studies should focus on equitable
recruitment practices, to ensure these treatment models
are accessible and generalizable across the full spectrum
of families needing ASD-specific support, especially due
to previous research on implementation barriers (Pickard
et  al., 2016; Safer-Lichtenstein et  al., 2019). To further
contextualize, the latest survey from the Pew Research
Center (2019) found that while having a smartphone does
not vary by race, it does vary by education and income,
and is lower for those in rural communities. Additionally,
access to home broadband internet and overall internet
use does vary by race, education, income, and location.
In general, more people have access to smartphones than
do home internet (81% versus 73%), and disparities across
demographic categories are particularly pronounced
for home internet. Furthermore, twelve of the fourteen
studies reviewed listed home internet access as a specific
inclusion criterion, and some studies specifically listed
technology skills as eligibility criteria. For the two
studies utilizing tablet technology, tablets were loaned to
parents. In future research, to broaden the reach of this
technology, studies should consider developing programs
that will be smartphone compatible or test deployment using
community resources (e.g., local libraries, school technology
partnerships, subsidized internet access) to provide parents
access to required technology.
Because this area of research is still emerging, the con-
clusions that can be made about the overall efficacy of these
intervention models are limited. For instance, there has yet
to be a clear comparison of how families who do not receive
any training compare to those who receive self-directed
training, versus those who receive self-directed training and
coaching. Additionally, design methodologies that include
a component analysis could help to identify the “active
ingredients” within these treatment models Ward-Horner
and Sturmey (2010). Testing findings against an “attention-
only”-type control group paradigm, where the control group
is given access to a website with non-specific strategies, is
also important to confirm intervention effects cannot be
attributed to the novelty of receiving a web-based interven-
tion and to establish a stronger evidence-base (PracticeWise,
2021). This control condition type was only employed in
Vismara et al., (2018). For the purposes of this review, we
limited our reporting to website elements reported in journal
articles; however, websites with similar elements could vary
widely in user experience (UX) and interface (UI) design
elements and evidence-based instructional design.
Despite the promising results for this modality of inter-
vention, more research is needed to address the limitations
of the current state of evidence. Any future research should
consider factors that may affect the efficacy and evidence-
base for these models such as: a) sample demographics, b)
family technology access and experience, c) parent famili-
arity with parent trainings and interventions, d) evidence-
based instructional design features embedded within the
website, e) the number and complexity of intervention
components, f) sequencing of intervention components, g)
dosage of the trainings, h) how and if coaching will be used,
i) measurement of outcomes using methods that maximize
sensitivity to change and clinical interpretability, j) social
validity, k) measurement of both parent and child behaviors.
Critical areas for future research include effectiveness trials
examining the incorporation of these models into commu-
nity settings, the combination of multiple training programs
into one centralized website, and the expansion to a broader
definition of caregiver training (e.g., foster care parents,
direct support workers in residential facilities).
This review builds upon the evidence accumulated by
previous reviews (Knutsen et al., 2016; Parsons et al., 2017)
investigating telehealth approaches for ASD intervention,
and suggests online, self-directed, parent-mediated inter-
ventions also are establishing a promising evidence-base
in the literature. This modality has the potential to triage
service delivery in a more efficient and accessible manner
for the autism community. While some families may require
a higher intensity of support, self-delivered, web-based
parent-mediated interventions can expand equitable access
to critical, evidence-based supports for families of autistic
children. Self-guided resources may help parents target a
13

specific behavior they need guidance with, allow parents to
try strategies on their own before consulting with profes-
sionals, and expand access to evidence-based strategies for
parents who are on a waitlist and likely in need of support.
Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 40489-0​ 22-0​ 0307-9.
Acknowledgements  A version of this paper was presented at the Inter-
national Society for Autism Research Conference in 2019.
Author Contributions  EG conceived/designed the study, conducted
database searches, oversaw data collection, conducted the literature
review, and drafted and edited the manuscript. AT, HR, and SA were
involved in data collection and drafting the manuscript. LLM partici-
pated in study design and revision of the final manuscript. All authors
read and approved the final manuscript.
Declarations  related health information on the web. Journal of Applied
Ethics Disclosure  On behalf of all authors, the corresponding author
states that there is no conflict of interest.
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