Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder associated with lifelong impairment in communication, behaviour, and social skills that begins early in childhood. It is known as the most serious and complex disorder among developmental disorders [1]. There has been a rapid increase in the global prevalence of ASD [2]. For instance, in the United States, it is estimated that 1 in 44 children has been identified with ASD (2018) [3]. The prevalence of ASD in South Korea is 2.64% (2011) [4].
Despite the high prevalence, there has been limited available services and interventions for individuals with ASD and their families, especially early intervention, special education, care coordination in South Korea [5], with some educational programs remaining one-time and lecture-based. For instance, in early therapeutic intervention parts, there are very few institutes to provide hospital-based early intensive intervention programs and specialist education programs such as Applied Behavioural Analysis (ABA) [5, 6] and parent training programs. Therefore, a systematic and verified program is required.
The Early Start Denver Model (ESDM) is one of comprehensive early intervention programs for children with or at risk for ASD, aged under 48 months. ESDM is a naturalistic behavioral intervention that integrates ABA methods with developmental approaches and parent coaching designed to promote learning and developmental skills such as social skills, play skills, motor skills, cognition. ESDM specifically targets imitation, nonverbal communication, joint attention, verbal communication, social development, and play, which are considered key deficit areas in young children with ASD [7, 8]. ESDM intervention is usually delivered by parents or therapists within a child’s home environments or in group settings. Specifically, ESDM was delivered in several ways [7] included (1) training parents to implement the program, (2) training therapists to implement the program, (3) having already trained therapists provide intensive one-on-one intervention, while also training parents to intensively provide intervention, and (4) having already trained therapists provide group intervention.
When ESDM early intervention was performed, cognitive, language, and adaptive behaviours were significantly improved [9]. It was found that the effect of the intervention was maintained even after two years [10]. Other studies indicate that ESDM reduces children's maladaptive behaviours such as self-harm and aggression [11]. Moreover, it increases parental satisfaction and reduces parenting stress, as it allows parents to respond effectively to children's problems [12].
Parent-implemented ESDM (P-ESDM) has been developed as the extended ESDM version to educate parents, so that they may directly intervene in their children’s treatment through assistance and coaching from therapists [13]. P-ESDM operates on the same developmental, relationship-based principles as the therapist-implemented ESDM. It fits well with the importance ESDM places on the quality of social skill between children with ASD and their parents. P-ESDM interventions that attempt to improve social interactions in a natural environment have advantages for parents who spend the most time with their children in day-to-day life [14–16]. It also emphasizes the value of family interventions involving treatment of their children.
To determine efficacy of parent-implemented interventions for children’s outcomes, many studies have been carried out over the past decade. However, there has been contradictory results so far [7, 17]. In a 12-week P-ESDM intervention, significant improvement was observed among children’s spontaneous language, social initiation, imitation, and parental interaction and treatment skills, which were maintained even after termination [6, 18, 19]. In another study, there were no differences in child development, autism level, and parental interaction skills between the P-ESDM and community groups, as both groups of parents improved their interaction skills and demonstrated progress [18]. In a study of P-ESDM using internet telehealth, the level of improvement in interaction skills of parents who received P-ESDM was higher than that of parents in the community group. However, children’s outcome differed based on the group and the effects on child’s development are yet to be understood [16, 19].
This pilot study examines whether the expected functions appear in mobile-based P-ESDM implementation in a non-face-to-face format. The primary goal of this study is to determine whether P-ESDM is effective for parents and their toddler with ASD, using videoconferencing, with online feedback received using the Personal Health Record (PHR) system [23].
Hypotheses
In previous studies, the proper and expected effects of P-ESDM intervention were classified into four categories [14–22]. Since this study was conducted with low intensity for a relatively short period of 3 months, we hypothesized in anticipation of realizing the first three of the four effects.
Parents receiving 12 weeks of P-ESDM intervention will show more skilled use of interactive techniques measured by the P-ESDM fidelity measure.
Parents receiving P-ESDM intervention will demonstrate more positive emotional changes such as increasing parenting efficacy and reducing parenting stress.
Communication and relationship between parents receiving P-ESDM intervention and their toddlers will be improved.
Toddlers of parents receiving P-ESDM intervention will demonstrate greater gain in reducing autism symptoms and problem behaviour and increasing adaptive behaviour and interaction skills.