E-Health Family Interventions for Parents of Children With Autism Aged 0–6 Years: A Scoping Review

Chuang Shang; Wei Xie; Jinpeng Zeng; Nour Osman; Caihong Sun; Mingyang Zou; Jianli Wang; Lijie Wu

doi:10.30773/pi.2023.0399

Psychiatry Investig > Volume 21(9); 2024 > Article

Shang, Xie, Zeng, Osman, Sun, Zou, Wang, and Wu: E-Health Family Interventions for Parents of Children With Autism Aged 0-6 Years: A Scoping Review

Review Article

Psychiatry Investigation 2024;21(9):925-937.

Published online: August 20, 2024

DOI: https://doi.org/10.30773/pi.2023.0399

E-Health Family Interventions for Parents of Children With Autism Aged 0-6 Years: A Scoping Review

Chuang Shang^1,^*

, Wei Xie^1,^*

, Jinpeng Zeng¹

, Nour Osman¹

, Caihong Sun¹

, Mingyang Zou¹

, Jianli Wang²

, Lijie Wu¹

¹Department of Children’s and Adolescent Health, Public Health College, Harbin Medical University, Harbin, China

²Department of Community Health and Epidemiology, Centre for Clinical Research, Halifax, NS, Canada

Correspondence: Lijie Wu, MD, PhD Department of Children’s and Adolescent Health, Public Health College, Harbin Medical University, Harbin 150081, China Tel: +86-451-87502867, Fax: +86-451-87502867, E-mail: wulijiehyd@126.com

^* These authors contributed equally to this work.

Received November 16, 2023 Revised February 8, 2024 Accepted June 2, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with onset in infancy. Early intervention is critical to improve the prognosis for these children. E-health interventions have tremendous potential. This review aimed to determine the status and effectiveness of family interventions for parents of children aged 0-6 years with ASD in the context of e-health.

Methods

The review methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Web of Science, and China National Knowledge Infrastructure were searched from inception to June 2022. The searches were limited to children with ASD of the age range between 0 and 6 years. We collated the available information and used descriptive statistics to analyze the synthesized data.

Results

Our initial search identified 3,672 articles, of which 30 studies met the inclusion criteria. The 30 articles selected were released between 2012 and 2022. All articles are in English. Most articles reviewed were from high-income countries (27/30, 90.0%), especially from the United States (16/30, 53.3%). Four major themes emerged from the 30 studies that matched the inclusion criteria, as follows: 1) type of e-health interventions, 2) duration of interventions, 3) clinical aspects of e-health interventions, and 4) evidence for intervention effectiveness, looking into the positive, negative, and mixed findings of previous studies.

Conclusion

These findings suggest that a wide variety of e-health interventions may actually help support both children with ASD aged 0-6 years and their parents.

Keywords: Autism spectrum disorder, eHealth, Parents, Family, Internet-based intervention

INTRODUCTION

A neurodevelopmental illness known as autism spectrum disorder (ASD) is characterized by limitations in interests and repetitive activities, as well as difficulty in social communication [1]. About 1 in 36 children have been identified with ASD according to estimates from the American Centers for Disease Control and Preventions’ Autism and Developmental Disabilities Monitoring (ADDM) Network [2]. The average age of the first clinical diagnosis of ASD in the United States currently is 4.2 years [3]. Early intervention in the first years of life is critical, as the great brain plasticity at this stage allows the establishment and reorganization of neural networks in response to environmental stimulation [4]. The most crucial time for brain development is thought to be the first six years of life, during which time perceptual and motor skills, cognition, language and communication skills, and socioemotional skills are developed [5,6]. However, nearly half of children with the disease are not diagnosed until they are older than 6 years [3]. The aims of early intervention are to reduce ASD symptom severity, to prevent secondary (behavioral) problems, and to support family functioning to facilitate the acquisition of critical developmental skills and allow children to achieve independence across different environments [6,7]. Early intervention is beneficial to autistic children in various regards, including social functioning, adaptive behaviors, and behavioral regulation [8].

With the rapid development in information technology and telecommunication, medicine has been benefited immensely, and a new term “electronic health (e-health)” has emerged [9]. It is an emerging and rapidly growing field of medical research that involves the application of digital technologies (i.e. those delivered via digital means, such as computers and smart phones) to support or deliver health interventions. E-health interventions can take a variety of forms, from reasonably simple, primarily text-based programs (such as websites offering information) to multimedia and interactive programs that can incorporate emails or text messages, all the way up to sophisticated applications such as virtual reality systems [10]. The worldwide impact of the coronavirus disease-2019 (COVID-19) pandemic can be seen in healthcare delivery [11]. The pandemic has sped up the transition from conventional care to e-health [12]. During the epidemic, traditional physical consultations had to be minimized [13], and e-health has been intensively used to reduce the risk of cross-contamination caused by close contact [14].

The field of e‐health is a relatively new one [10], but the worldwide spread of COVID-19 unexpectedly stimulated the development of e-health [15]. It is therefore important to understand the effectiveness of e‐health family interventions, especially for parents of children aged 0-6 years with autism. The purpose of this review is to determine the current status and effectiveness of family-based interventions for parents of children aged 0-6 years with ASD in an e-health context.

METHODS

This scoping review was based on the paradigm developed by Arksey and O’Malley [16]. We adhered to the rules and guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMAScR) [17]. The PRISMA-ScR checklist was provided in the supplementary material (Supplementary Table 1). The protocol was registered in the Open Science Framework (https://osf.io/n8esh).

Search strategy

A systematic electronic search for articles was conducted on three databases (PubMed, Web of Science, and China National Knowledge Infrastructure [CNKI]) in June 2022. Search strategies were developed according to the principal concepts of the topic. Initial literature research based on different databases was conducted to create a list of alternative terms related to the concepts, including subject terms and free-text terms. Search strategies were designed separately for each data source and modified through team discussion. The titles and abstracts were searched using both subjective and free-text terms. Search terms within a concept were joined with “OR”. There were no year limits in the search strategy. The results of these searches were imported into EndNote 20 (Clarivate Analytics, Philadelphia, PA, USA), and duplicates were removed. The search strategies were reviewed by a supervisor. The complete search strategy can be found in the Supplementary Table 2.

Inclusion criteria

We established the following inclusion criteria: 1) intervention targeting parents of autistic children aged 0-6 years, 2) articles in English or Chinese, 3) abstract and full-text articles available, and 4) programs designed for family intervention for children with autism. It is worth noting that we excluded all studies that were not randomized controlled trials.

Study selection

We imported all article titles and abstracts from each database into EndNote 20. Once duplicates were removed, we screened the remaining studies in two stages: by title and abstract, and by full text. We used Rayyan (http://rayyan.qcri.org), a freely available web tool, to conduct the review. Uncertainties were resolved by discussion and consensus among the three researchers.

Data abstraction and charting

Two reviewers (WX and JZ) reviewed the titles and abstracts of studies identified by the search strategy and full texts obtained from the studies potentially meeting the inclusion criteria. The two reviewers resolved uncertainty or disagreement through discussion or, if necessary, by referral to a third researcher (CS). During the full-text review process, the following information was recorded in the data extraction table: year of publication, country, target population, age of children, sample capacity, form of intervention, duration of intervention, and so on. All the relevant data and information were charted.

Data analysis and presentation

The data were analyzed based on the themes associated with research articles using simple descriptive studies. All findings were presented with regard to the research objectives of the study. Finally, the content extracted from each study was summarized into four themes: types of intervention, duration of intervention, clinical aspects of e-health interventions, and effectiveness of the intervention.

RESULTS

Literature search

The database search produced 3,672 results, including 1,084 in PubMed, 2,078 in Web of Science, and 510 in CNKI. We reviewed 2,791 articles by title and abstract after removing duplicates, leaving 212 for full-text screening; 30 of these 212 publications matched the requirements for inclusion and were therefore included in this scoping review (Figure 1).

Characteristics of articles

Table 1 summarizes the characteristics of the selected studies. The 30 articles selected were published between 2012 and 2022 (Figure 2). We observed that the number of papers sharply increased in 2020: 12 of the 30 studies (40.0%) were published before 2020, and 18 studies (60.0%) were published in 2020, 2021, and 2022.

Figure 3 shows the region of publication of the included studies, which were published in different parts of the world. In North America, 16 studies (53.3%) were conducted in the United States. Six studies (20.0%) were conducted in Europe, in the Netherlands, France, Spain, Italy, and the United Kingdom. In Oceania, three studies (10.0%) were concluded in Australia. In South America, three studies (10.0%) were conducted in Brazil. In Asia, two studies (6.7%) were conducted, in South Korea and in Saudi Arabia. The majority (27/30, 90.0%) of the publications featured research that was primarily done in high-income countries, and 10.0% (3/30) of the papers concentrated on non-high-income nations (all from Brazil).

We conducted the analysis based on four themes derived from the primary results and objectives of each study. The four major themes were: 1) type of interventions, 2) duration of the intervention, 3) clinical aspects of e-health interventions, and 4) evidence for the effectiveness of the intervention.

Theme 1: type of interventions (n=30)

In terms of interventions, articles included video conferencing, online websites, video feedback, e-Learning programs, video modeling, Apps, web-based tutorials, and online platforms. Video conferencing was the most commonly used ehealth technology, used in 26.7% (8/30) of the interventions. The objectives are usually achieved through dedicated remote training with the support of educational videos, web-based programs, and weekly video conferencing coaching sessions with an operator [18]. An online website was used in 13.3% (4/30) of the interventions. An online website named ImPACT Online is an interactive website that teaches parents to promote their child’s social communication within the context of play and daily routines [19]. Video feedback was used in 10.0% (3/30) of the interventions. It provides the parent with an opportunity to reflect on his or her interactions with the child and the responses of the child to the interaction, with an emphasis on positive, successful interaction sequences. The intervener videotapes actual parent-child interactions at home, and in a following session watches and discusses with the parent carefully selected video-recorded episodes of parent-child interactions [20]. Other e-health interventions that were used less frequently were e-Learning programs, video modeling, Apps, web-based tutorials, and online platforms. The e-Learning program is a self-paced, interactive, web-based training system consisting of visual notes, vocal instruction, and video clips demonstrating implementation of procedures [21]. Video modeling is a mode of teaching that uses video recording to provide a visual model of the target behavior or skill [22]. An application named WhatsApp, which is a free mobile messaging application in which people can exchange private or group messages as well as visual and audio media, was used for one intervention [23]. One web-based tutorial was developed using adult learning principles designed to foster engagement, participation, and interest. The tutorial is highly interactive, making full use of the technology and principles of instructional design to enhance the learning experience [24]. Notably, eight of the interventions combined the use of two e-health technologies.

Theme 2: duration of interventions (n=30)

The total time for each intervention was between 6 hours and 12 months in all trials employing e-health interventions. Total intervention months were as follows: less than 2 months (5 articles), 2 to 5 months (12 articles), 6 to 9 months (6 articles), 1 article for more than 9 months, and the other 6 articles did not state the duration. As seen in Figure 4, the duration of a single session was different for each intervention. The most common intervention time for a single session per intervention is more than 1 hour. The shortest intervention time was 30 minutes while the longest was 2 hours. Ten studies did not describe the duration of a single session.

Theme 3: clinical aspects of e-health interventions (n=30)

These studies looked at a range of clinical aspects in children with ASD and their parents. Of the 30 articles, 27 interventions targeted only parents of children with ASD and three involved both children and parents. Of the 30 studies that made up this part, 8 findings focused on clinical aspects in ASD children, 6 findings focused on clinical aspects in their parents, 12 findings included clinical aspects in both parents and children, and the remaining studies did not show clinical results. The most studied clinical aspect concentrated in parents of ASD children was stress (n=5) and in ASD children was social communication (n=17).

Theme 4: evidence of effectiveness (n=28)

Based on the results of each trial, the effectiveness of the intervention was evaluated and categorized as either positive, negative, or mixed. The research findings were rated favorable or positive if they had a positive impact or led to advancements. Negative results, on the other hand, were labeled as such when they represented a subpar result or no change. Studies that produced both positive and negative results were referred to as having mixed findings. Efficacy was categorized based on the type of intervention.

Positive findings

Positive results were produced from 23 of the 28 studies, which demonstrated that e-health interventions are effective. This includes seven studies of video conferencing, three studies of online websites, two each for e-Learning program research, video feedback, and video modeling, one study involving an App and web-based tutorial, and five studies combining two types of intervention. These studies not only found improvements in behavior, communication, social competence, motor skills, and language among children with ASD, but also demonstrated improved parenting efficacy, reduced parental stress, and intrusiveness, etc.

Negative findings

Negative outcomes were reported in only one study, conducted using an online website [25]. The study found that online intervention did not improve sleep in parents of children with ASD.

Mixed findings

Four studies produced mixed findings, including video feedback, online website, video conferencing, and video modeling [20,26-28]. The results showed positive effects in reducing parental intrusion, enhancing self-efficacy, improving dyadic social communication, and so on. However, changes in other aspects of parent-child interaction, children’s play behavior, and children’s developmental scores failed to achieve significance.

DISCUSSION

This scoping review aimed to provide a general overview of the use of e-health as an ASD intervention, especially focused on families of children aged 0-6 years with ASD. Most of the included articles were from high-income countries. More than half of the articles reported positive findings in a variety of areas spanning all forms of e-health intervention. For children with autism, it can improve their social communication, abnormal behaviors, motor skills, language ability, cognition, eating behaviors, and sleep duration. For parents of children with ASD, it can improve their parenting effectiveness, intervention fidelity, self-efficacy, and positive perception of their child and reduce stress, depression, and intrusiveness. This suggests that e-health family interventions based on children with autism aged 0-6 years have a beneficial effect on both children with ASD and their parents.

Regarding the study characteristics, we noticed that the number of published papers has increased since 2020. This may be because more attention to e-health might have resulted from the response to the COVID-19 pandemic. It was evident that the eagerness of healthcare providers and expert researchers to share their opinions and research findings on the application and future potential of telehealth has increased. The increase in the number of e-health interventions published during the pandemic indicates the increasing recognition and use of this intervention, due not only to its flexibility and convenience, but also to its innovative and transformative role in healthcare [29,30]. In addition, the increase in the number of articles published may also be partially due to researchers working from home in the long term, caused by pandemic-related lockdowns.

Our analysis of the first authors’ affiliations and the study’s geographic focus showed that the vast majority of the publications originated from high-income countries, mainly in the Americas and Europe. This review identified a gap in such technology support for parents in lower- and middle-income countries. The highest number of publications was from the United States, which is commensurate with the recent rapid surge in e-health use seen in that country. This can be attributed to the flexibility provided by the Health Insurance Portability and Accountability Act of 1996 and the willingness of insurance companies to reimburse for the services provided via e-health [31]. E-health offers unprecedented opportunities for health interventions. However, the transition to e-health in some low- and middle-income countries faces several challenges: high adult illiteracy rates, low enrollment in primary, secondary, and higher education institutions, lack of information and communications technology (ICT) literacy, low per capita income, lack of ICT infrastructure, and limited Internet connectivity [32]. E-health is a new form of healthcare intervention that offers a low-cost, high-return alternative to traditional healthcare. Take China as an example: there are regional and rural-urban disparities in access to services and resource allocation in China, access to e-health intervention programs is often a challenge for families living in rural or remote areas, with low socioeconomic status, or experiencing other life hardships [33]. Only big cities such as provincial capitals allow families with ASD to receive an intervention, which will generate many additional costs, such as transportation, accommodation, and lost work. Future e-health research should take into account that the use of e-health in low- and middle-income countries appears to be influenced by the accessibility and affordability of technology, based on each country’s specific socioeconomic circumstances [34].

Among the types of e-health family interventions, video conferencing is the most common form. These findings demonstrate that videoconference-delivered coaching is feasible and acceptable to families, in line with shifts in recent years to this mode of intervention delivery [35]. Video conferencing provided patients with the opportunity to communicate face-to-face anytime, anywhere, effectively removing barriers in terms of time and place. It should be noted that video conferencing as a form of intervention also presented some challenges and limitations. For example, the trust relationship and communication between family members and healthcare workers may take time to establish and optimize [36]. In addition, the technical equipment and network conditions for video conferencing also have certain requirements, which may vary for families in different regions with different economic levels. Although video conferencing interventions were the most frequently used in the included articles, it is difficult to conclude which type of intervention provides the best response among the wide variety of e-health interventions. Therefore, more research is needed to answer this question.

As different studies implemented different methodologies and parameters, the effective duration might differ. A study of a web-based tutorial intervention with a total intervention time of just 6 hours showed improvements in the use of evidence-based strategies, parenting effectiveness, and children’s exhibited behaviors [24]. Another study applied both an online website and a video conferencing intervention with a total intervention duration of 6 months, but child development scores did not differ significantly between control and experimental groups [26]. Best practice recommends at least 25 hours per week of comprehensive interventions for children with ASD [37]. Additional studies have shown that greater intervention intensity (hours and duration in months) is associated with greater child gains [38].

On the clinical aspect, social communication is the most commonly studied in children with ASD. Social communication characteristics discussed in these studies include receptive communication, expressive communication, social capacity, imitation, and cognition. In e-health intervention studies targeting the clinical manifestations of ASD parents, the clinical manifestations of stress are most commonly involved, and previous research has also shown that the severity of stress in parents of autistic children is higher than that of parents of non-autistic children [39]. The studies included in this review demonstrate that electronic interventions can be effective in relieving stressful situations for parents [19,23,40,41]. A study of a parent intervention program called COMPASS for Hope explored the effects on child problem behavior, parent competency, parent stress, group alliance and parent satisfaction variables by using the Modified Checklist for Autism in Toddlers, Parental Stress Index—Fourth Edition Short Form, Vineland Adaptive Behavior Scale, Second Edition, and other scales [41].

E-health represents an alternative for those who have difficulties accessing in-person interventions or when in-person visits are not possible (e.g., the situation during the COVID-19 pandemic) [42]. E-health intervention may be an effective strategy for ASD families, as growing evidence indicates a favorable outcome for parents and for children with ASD. In a randomized trial of an electronic program, all participants who provided feedback were generally satisfied with the program and reported that the training was a helpful tool which provided an overview of all major components of applied behavioral analysis therapy (ABA). Many also reported that they had a better understanding and appreciation of their child’s ABA treatment programs after participating in e-Learning [21]. However, a REDCap-based model for online interventional research showed a negative result, and the researchers did not find that access to multimedia materials improved sleep [25]. This may be accounted for by a variety of factors. First, the sample size was relatively small; second, the study sample was heterogeneous; finally, a significant percentage of parents did not choose to view the online material. In addition, the sustainability of effects is also mixed and cannot be ascertained, as most studies have short follow-up times.

Strengths, limitations and future direction

The strength of this review was in its comprehensive search strategy, intended to find all published studies. Furthermore, unlike other scoping reviews, all of the articles included here were randomized controlled trials. The scoping review was conducted according to the suggested methodology, however we acknowledge that our study has some limitations. Our search was limited to three databases and excluded grey literature and preprints, which may have affected the comprehensiveness of our findings. In addition, some research on this topic might not be published owing to null findings. This review only included papers that were published in English or Chinese; other languages were not included, which may have led to the exclusion of some studies conducted in other parts of the world. This is a nascent field of research and more large-size randomized controlled studies are needed in the future.

CONCLUSION

A variety of e-health family interventions have the potential to help autistic children aged 0-6 years and their parents in various ways. For children with ASD, e-health interventions can improve their core symptoms and accompanying symptoms; for parents of children with ASD, it can improve their emotional problems. In the future, more studies are needed to clarify the effects of e-health interventions.

Supplementary Materials

The Supplement is available with this article at https://doi.org/10.30773/pi.2023.0399.

Supplementary Table 1.

Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist

pi-2023-0399-Supplementary-Table-1.pdf

Supplementary Table 2.

Search strategy for each database

pi-2023-0399-Supplementary-Table-2.pdf

Notes

Availability of Data and Material

All data generated or analyzed during the study are included in this published article (and its supplementary information files).

Conflicts of Interest

The authors have no potential conflicts of interest to disclose.

Author Contributions

Conceptualization: Lijie Wu, Jianli Wang. Data curation: Chuang Shang, Wei Xie, Jinpeng Zeng. Formal analysis: Chuang Shang. Funding acquisition: Lijie Wu. Methodology: Lijie Wu, Jianli Wang. Project administration: Lijie Wu. Software: Chuang Shang, Wei Xie, Jinpeng Zeng. Supervision: Mingyang Zou. Validation: Mingyang Zou. Visualization: Chuang Shang. Writing—original draft: Chuang Shang, Wei Xie, Jinpeng Zeng, Nour Osman. Writing—review & editing: Caihong Sun, Mingyang Zou.

Funding Statement

This review was funded by National Foreign Experts Project (no. G2022011021L).

ACKNOWLEDGEMENTS

Sincere thanks to the reviewers for their diligent review and insightful comments on this study.

Figure 1.

Flowchart of study selection process. CNKI, China National Knowledge Infrastructure; ASD, autism spectrum disorder.

Figure 2.

Number of published papers by year.

Figure 3.

Number of published papers by region.

Figure 4.

Duration of e-health intervention.

Table 1.

Characteristics of included articles

Citations num	Title	Year	Country	Area	Intervention population	Age of children with ASD	Sample	Type of interventions	Interveners	Total duration of intervention	Duration of a single session	Symptom improvement
20	Video-feedback intervention to promote positive parenting adapted to autism (VIPP-AUTI): a randomized controlled trial	2015	Netherlands	Europe	Parents and children	16-61 months	78	Video feedback	Professionals	3 months	60-90 mins	Positive: reducing parental intrusiveness, increased feelings of self-efficacy in child rearing
20		2015	Netherlands	Europe	Parents and children	16-61 months	78	Video feedback	Professionals	3 months	60-90 mins	Negative: parent-child interaction or on child play behavior
23	The effectiveness of a psychoeducation intervention delivered via WhatsApp for mothers of children with autism spectrum disorder (ASD) in the Kingdom of Saudi Arabia: a randomized controlled trial	2017	Saudi Arabia	Asia	Parents	26-78 months	62	APP	Therapists	N/A	30 mins	Positive: reducing maternal stress, depression, parent reported ASD symptoms, child behaviour problems, and increasing maternal happiness in mothers of children with ASD
4	The effectiveness of early parental coaching in the autism spectrum disorder	2021	Brazil	South America	Parents	29-42 months	18	Video conferencing and video feedback	Professionals	12 weeks	2h	Positive: the learning rate for comprehensive development skills in the ESDM checklist, such as receptive communication, expressive communication, social capacity, imitation, cognition, games, fine motor skills, gross motor skills, behavior, and personal independence was significantly higher, as well as the strategies and the quality of interaction betweenparents and children.
43	Telehealth parent training in the early start denver model: results from a randomized controlled study	2018	The United States	North America	Parents	18-48 months	24	Video conferencing	Therapists	12 weeks	1.5h	Positive: higher parent fidelity gains and program satisfaction, improved children’s social communication skills
18	Tele-assisted behavioral intervention for families with children with autism spectrum disorders: a randomized control trial	2020	Italy	Europe	Parents	30 months-10 years	74	Video conferencing	Clinical psychologists	12 weeks	2h	Positive: substantial improvements in the perception and management of children’s behavior by parents, as well as in the influence of a reduction in parent stress levels on said children’s behavior
21	Randomized trial of an eLearning program for training family members of children with autism in the principles and procedures of applied behavior analysis	2012	The United States	North America	Parents	3.1 to 11.5 years	28	e-Learning program	N/A	30-40 h	N/A	Positive: a substantial increase in their knowledge of ABA
44	Protocol for a randomized pilot study (FIRST STEPS): implementation of the Incredible Years-ASLD® program in Spanish children with autism and preterm children with communication and/or socialization difficulties	2021	Spain	Europe	Parents	2-5 years	72	Video conferencing	Clinicians	6 months	N/A
22	Procedures and compliance of a video modeling applied behavior analysis intervention for Brazilian parents of children with autism spectrum disorders	2017	Brazil	South America	Parents	3-6 years	67	Video modeling	N/A	22 weeks	90 mins	Positive: the parents learned to use a teaching strategy with their children called discrete trial teaching—DTT
19	Self-directed telehealth parent-mediated intervention for children with autism spectrum disorder: examination of the potential reach and utilization in community settings	2017	The United States	North America	Parents	Open trial group (27 and 152 months) controlled trial group (19 and 73 months)	162	Online website and video conferencing	Therapists	N/A	75 mins	Positive: improve children’s social communication skills
45	Parent engagement with a telehealth-based parent-mediated intervention program for children with autism spectrum disorders: predictors of program use and parent outcomes	2015	The United States	North America	Parents	27-73 months	27	Online website and video conferencing	Therapists	Online website: 6 months video conferencing: 12 weeks	Online website: 80 minsvideo conferencing: 30 mins	Positive: improve parental depressive symptoms
46	Investigating the effectiveness of parent-implemented shared book reading intervention for preschoolers with ASD	2021	Austria	Oceania	Parents and children	0-6 years	16	Video feedback	Practising speech pathologists	8 weeks	45 mins	Positive: increase parents’ use of book-related vocabulary and their explicit teaching of story structure; increase children’s verbal participation (number of utterances and number of different words).
40	Impact of challenging behavior online modules on Korean parents of children with developmental disabilities: a randomized controlled trial	2022	South Korea	Asia	Parents	0-9 years	88	Online website	N/A	3 weeks	N/A	Positive: increasing parents’ knowledge of behavioral principles, increasing positive parenting practices, and decreasing parental stress.
26	Feasibility of delivering parent-implemented NDBI interventions in low-resource regions: a pilot randomized controlled study	2022	The United States	North America	Parents	12-30 months	23	Online website and video conferencing	C-ESDM providers	6 months	N/A	Positive: significant gains in fidelity to the intervention strategies of parentsNegative: no significant differences between groups in child developmental scores
24	Enhancing interactions during daily routines: a randomized controlled trial of a web-based tutorial for parents of young children with ASD	2018	The United States	North America	Parents	18-60 months	104	Web-based tutorial	N/A	6h	N/A	Positive: increased parental use of evidence-basedStrategies; decreased parenting stress and increasedparenting efficacy; improved child engagement
47	ENACT (ENvironmental enrichment for infants; parenting with Acceptance and Commitment Therapy): a randomised controlled trial of an innovative intervention for infants at risk of autism spectrum disorder	2020	Austria	Oceania	Parents	N/A	66	Online website and video conferencing	Clinicians	8h	30 mins	Positive: improved parent- infant interaction, with greater emotional availability and parental sensitivity, less parental intrusiveness and greater child responsiveness
48	Efficacy of parent-mediated communication-focused treatment in toddlers with autism (PACT) delivered via videoconferencing: a randomised controlled trial study protocol	2021	France	Europe	Parents	18-36 months	238	Video conferencing and video feedback	Therapists	12 months	1 h
7	Development of a Video-feedback Intervention to promote Positive Parenting for Children with Autism (VIPP-AUTI)	2014	Netherlands	Europe	Parents	46 months- 4 years	78	Video feedback	Professionals	3 months	N/A	Positive: may enhance the children’s attachmentsecurity
49	Development and acceptability of a new program for caregivers of children with autism spectrum disorder: online parent training in early behavioral intervention	2021	The United States	North America	Parents	16-48 months	63	Online website	N/A	6 months	N/A	Positive: useful in teaching parents’ interventions and in improving their children’s skills and behavior
50	Developing and enhancing adherence to a telehealth ABA parent training curriculum for caregivers of children with autism	2020	The United States	North America	Parents	3-16 years	13 families	Online platform and video conferencing	Clinicians	2 months	Video conferencing: 30 mins	Positive: effective to teach skills
41	COMPASS for hope: evaluating the effectiveness of a parent training and support program for children with ASD	2018	The United States	North America	Parents	3-12 years	33	Video conferencing	Therapists	8 weeks	3h	Positive: a reduction in parenting stress and an increase in competence, reductions in child behavior problems
51	Comparison of a self-directed and therapist-assisted telehealth parent-mediated intervention for children with ASD: a pilot RCT	2016	The United States	North America	Parents	19-73 months	28 families	Online website and video conferencing	Therapists	6 months	30 mins	Positive: improved parents’ intervention fidelity, self-efficacy, stress, and positive perceptions of their child; Children improved children’s language measures
35	Coaching while waiting for autism spectrum disorder assessment: a pilot feasibility study for a randomized controlled trial on occupational performance coaching and service navigation	2022	Austria	Oceania	Parents and children	Mean age of 3 years 7 months	16	Video conferencing	N/A	N/A	Between 35 mins and 1 h and 10 mins	Positive: indicating the potential to improve child and family outcomes prior
52	A virtual resiliency intervention for parents of children with autism: a randomized pilot trial	2020	The United States	North America	Parents	N/A	51	Video conferencing	Clinical psychologists	N/A	1.5h	Positive: promising feasibility, acceptability, and preliminary efficacy for improving resiliency-related outcomes for parents of children with ASD
25	A REDCap-based model for online interventional research: parent sleep education in autism	2021	The United States	North America	parents	2-10, 11 months	138	Online website	N/A	12 weeks	N/A	Negative: did not find that having access to multimedia materials improved sleep when compared to a pamphlet alone. Improvements in sleep habits, sleep patterns, and PSOC were not statistically significant.
53	A randomized clinical trial of a virtual-training program for teaching applied-behavior-analysis skills to parents of children with autism spectrum disorder	2020	The United States	North America	Parents	N/A	25	e-Learning program	Researchers	5.2 months	between 35 and 60 mins	Positive: improvement in correct skills
27	A randomised clinical pilot trial to test the effectiveness of parent training with video modelling to improve functioning and symptoms in children with autism spectrum disorders and intellectual disability	2020	Brazil	South America	Parents	3-6 years	67	Video modeling	Therapists	22 weeks	90 mins	Positive: improvement in the Vineland standardized communication scores in CACE and a significant increase in the non-verbal IQ Negative: a non-statistically significant decrease in autism symptomatology (Autism Behaviour Checklist total scores)
54	An exploration of health behaviors in a mind-body resilience intervention for parents of children with developmental disabilities	2020	The United States	North America	parents	N/A	47	Video conferencing	Clinical psychologists	8 weeks	1.5h	Positive: eating behaviors showed small effect size improvements; sleep duration improved only with small or medium effect sizes; ASD parents rated their fatigue lower
55	A mixed-method evaluation of the feasibility and acceptability of a telehealth-based parent-mediated intervention for children with autism spectrum disorder	2016	The United States	North America	Parents	19-73 months	28	Online website	Therapists	N/A	N/A	Positive: improvements in child’s social communication skills and their own competence
56	Acceptability of a virtual mind-body intervention for parents of children with autism or learning disabilities	2021	The United States	North America	Parents	N/A	37	Video conferencing	Clinicians	8 weeks	1.5h	Positive: found mind-body skills helpful
28	Combined social communication therapy at home and in education for young autistic children in England (PACT-G): a parallel, single-blind, randomized controlled trial	2022	Britain	Europe	Parents	2-11 years	248	Video feedback and video conferencing	Therapists	6 months	N/A	Positive: improve dyadic social communication between child and parent at home and between child and learning-support assistants (LSA) in education Negative: no effect on the blinded primary outcome of autism symptoms, secondary outcome of symptom change in treatment or research settings, parent report of language or parent or teacher reported adaptive behaviour outcomes

N/A, Not applicable; ASD, autism spectrum disorder; ESDM, Early Start Denver Model; ABA, applied behavior analysis; DTT, discrete trial teaching; PSOC, parenting sense of competence; CACE, complier-average causal effect; IQ, intelligence quotient

REFERENCES

1. Kong X, Zhu J, Tian R, Liu S, Sherman HT, Zhang X, et al. Early screening and risk factors of autism spectrum disorder in a large cohort of Chinese patients with Prader-Willi syndrome. Front Psychiatry 2020;11:594934

2. Maenner MJ, Warren Z, Williams AR, Amoakohene E, Bakian AV, Bilder DA, et al. Prevalence and characteristics of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2020. MMWR Surveill Summ 2023;72:1-14.

3. Wolff JJ, Piven J. Predicting autism in infancy. J Am Acad Child Adolesc Psychiatry 2021;60:958-967.

4. Malucelli ERS, Antoniuk SA, Carvalho NO. The effectiveness of early parental coaching in the autism spectrum disorder. J Pediatr (Rio J) 2021;97:453-458.

5. Sáiz-Manzanares MC, Marticorena-Sánchez R, Arnaiz-González Á. Improvements for therapeutic intervention from the use of web applications and machine learning techniques in different affectations in children aged 0-6 years. Int J Environ Res Public Health 2022;19:6558

6. Bharat R, Uzaina U, Yadav T, Niranjan S, Kurade P. mHealth apps delivering early intervention to support parents of children with autism: a scoping review protocol. BMJ Paediatr Open 2022;6:e001358.

7. Poslawsky IE, Naber FB, Bakermans-Kranenburg MJ, De Jonge MV, Van Engeland H, Van IJzendoorn MH. Development of a Video-feedback Intervention to promote Positive Parenting for Children with Autism (VIPP-AUTI). Attach Hum Dev 2014;16:343-355.

8. Seng GJ, Chiu YN, Tsai WC, Lin HY, Li SC, Hsiao MN, et al. Promotion and implementation effectiveness of World Health Organization’s caregiver skills training program in Taiwan. Front Psychiatry 2022;13:904380

9. Tian M, Zhang X, Zhang J. mHealth as a health system strengthening tool in China. Int J Nurs Sci 2020;7(Suppl 1):S19-S22.

10. Thabrew H, Stasiak K, Hetrick SE, Wong S, Huss JH, Merry SN. Ehealth interventions for anxiety and depression in children and adolescents with long-term physical conditions. Cochrane Database Syst Rev 2018;8:CD012489

11. Huston P, Campbell J, Russell G, Goodyear-Smith F, Phillips RL Jr, van Weel C, et al. COVID-19 and primary care in six countries. BJGP Open 2020;4:bjgpopen20X101128

12. Garfan S, Alamoodi AH, Zaidan BB, Al-Zobbi M, Hamid RA, Alwan JK, et al. Telehealth utilization during the Covid-19 pandemic: a systematic review. Comput Biol Med 2021;138:104878

13. Keuper J, Batenburg R, Verheij R, van Tuyl L. Use of E-health in Dutch general practice during the COVID-19 pandemic. Int J Environ Res Public Health 2021;18:12479

14. Costa AM, Marchiò M, Bruni G, Bernabei SM, Cavalieri S, Bondi M, et al. Evaluation of E-health applications for paediatric patients with refractory epilepsy and maintained on ketogenic diet. Nutrients 2021;13:1240

15. Zhang J, Zhang J, Wang K, Yan W. Should doctors use or avoid medical terms? The influence of medical terms on service quality of E-health. Electron Commer Res 2023;23:1775-1805.

16. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005;8:19-32.

17. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018;169:467-473.

18. Marino F, Chilà P, Failla C, Crimi I, Minutoli R, Puglisi A, et al. Teleassisted behavioral intervention for families with children with autism spectrum disorders: a randomized control trial. Brain Sci 2020;10:649

19. Ingersoll B, Shannon K, Berger N, Pickard K, Holtz B. Self-directed telehealth parent-mediated intervention for children with autism spectrum disorder: examination of the potential reach and utilization in community settings. J Med Internet Res 2017;19:e248.

20. Poslawsky IE, Naber FB, Bakermans-Kranenburg MJ, van Daalen E, van Engeland H, van IJzendoorn MH. Video-feedback intervention to promote positive parenting adapted to autism (VIPP-AUTI): a randomized controlled trial. Autism 2015;19:588-603.

21. Jang J, Dixon DR, Tarbox J, Granpeesheh D, Kornack J, de Nocker Y. Randomized trial of an eLearning program for training family members of children with autism in the principles and procedures of applied behavior analysis. Res Autism Spectr Disord 2012;6:852-856.

22. Bagaiolo LF, Mari JJ, Bordini D, Ribeiro TC, Martone MCC, Caetano SC, et al. Procedures and compliance of a video modeling applied behavior analysis intervention for Brazilian parents of children with autism spectrum disorders. Autism 2017;21:603-610.

23. Hemdi A, Daley D. The effectiveness of a psychoeducation intervention delivered via WhatsApp for mothers of children with autism spectrum disorder (ASD) in the Kingdom of Saudi Arabia: a randomized controlled trial. Child Care Health Dev 2017;43:933-941.

24. Ibañez LV, Kobak K, Swanson A, Wallace L, Warren Z, Stone WL. Enhancing interactions during daily routines: a randomized controlled trial of a web-based tutorial for parents of young children with ASD. Autism Res 2018;11:667-678.

25. Malow BA, Galion A, Lu F, Kennedy N, Lawrence CE, Tassone A, et al. A REDCap-based model for online interventional research: parent sleep education in autism. J Clin Transl Sci 2021;5:e138.

26. Rogers SJ, Stahmer A, Talbott M, Young G, Fuller E, Pellecchia M, et al. Feasibility of delivering parent-implemented NDBI interventions in low-resource regions: a pilot randomized controlled study. J Neurodev Disord 2022;14:3

27. Bordini D, Paula CS, Cunha GR, Caetano SC, Bagaiolo LF, Ribeiro TC, et al. A randomised clinical pilot trial to test the effectiveness of parent training with video modelling to improve functioning and symptoms in children with autism spectrum disorders and intellectual disability. J Intellect Disabil Res 2020;64:629-643.

28. Green J, Leadbitter K, Ellis C, Taylor L, Moore HL, Carruthers S, et al. Combined social communication therapy at home and in education for young autistic children in England (PACT-G): a parallel, single-blind, randomised controlled trial. Lancet Psychiatry 2022;9:307-320.

29. Marcu G, Ondersma SJ, Spiller AN, Broderick BM, Kadri R, Buis LR. The perceived benefits of digital interventions for behavioral health: qualitative interview study. J Med Internet Res 2022;24:e34300.

30. Zuccotti G, Calcaterra V. Telemedicine and E-health: an innovative challenge in pediatric care. Int J Environ Res Public Health 2023;20:2091

31. Doraiswamy S, Abraham A, Mamtani R, Cheema S. Use of telehealth during the COVID-19 pandemic: scoping review. J Med Internet Res 2020;22:e24087.

32. Kirigia JM, Seddoh A, Gatwiri D, Muthuri LH, Seddoh J. E-health: determinants, opportunities, challenges and the way forward for countries in the WHO African region. BMC Public Health 2005;5:137

33. Wang L, Zhang H, Shang C, Liang H, Liu W, Han B, et al. Mental health issues in parents of children with autism spectrum disorder: a multitime-point study related to COVID-19 pandemic. Autism Res 2022;15:2346-2358.

34. Cho YM, Lee S, Islam SMS, Kim SY. Theories applied to m-health interventions for behavior change in low- and middle-income countries: a systematic review. Telemed J E Health 2018;24:727-741.

35. Bernie C, Williams K, Graham F, May T. Coaching while waiting for autism spectrum disorder assessment: a pilot feasibility study for a randomized controlled trial on occupational performance coaching and service navigation. J Autism Dev Disord 2023;53:2905-2914.

36. Lodder A, Papadopoulos C, Randhawa G. Using a blended format (videoconference and face to face) to deliver a group psychosocial intervention to parents of autistic children. Internet Interv 2020;21:100336

37. Maglione MA, Gans D, Das L, Timbie J, Kasari C. Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Pediatrics 2012;130(Suppl 2):S169-S178.

38. Landa RJ. Efficacy of early interventions for infants and young children with, and at risk for, autism spectrum disorders. Int Rev Psychiatry 2018;30:25-39.

39. Sipowicz K, Pietras T, Podlecka M, Mokros Ł. The association between depression and perceived stress among parents of autistic and non-autistic children—the role of loneliness. Int J Environ Res Public Health 2022;19:3019

40. Lee JD, Meadan H, Xia Y. Impact of challenging behavior online modules on Korean parents of children with developmental disabilities: a randomized controlled trial. J Posit Behav Interv 2022;24:222-235.

41. Kuravackel GM, Ruble LA, Reese RJ, Ables AP, Rodgers AD, Toland MD. COMPASS for hope: evaluating the effectiveness of a parent training and support program for children with ASD. J Autism Dev Disord 2018;48:404-416.

42. Stavropoulos KK, Bolourian Y, Blacher J. A scoping review of telehealth diagnosis of autism spectrum disorder. PLoS One 2022;17:e0263062.

43. Vismara LA, McCormick CEB, Wagner AL, Monlux K, Nadhan A, Young GS. Telehealth parent training in the early start denver model: results from a randomized controlled study. Focus Autism Other Dev Disabl 2018;33:67-79.

44. Valencia F, Urbiola E, Romero-González M, Navas I, Elías M, Garriz A, et al. Protocol for a randomized pilot study (FIRST STEPS): implementation of the Incredible Years-ASLD® program in Spanish children with autism and preterm children with communication and/or socialization difficulties. Trials 2021;22:291

45. Ingersoll B, Berger NI. Parent engagement with a telehealth-based parent-mediated intervention program for children with autism spectrum disorders: predictors of program use and parent outcomes. J Med Internet Res 2015;17:e227.

46. Westerveld MF, Wicks R, Paynter J. Investigating the effectiveness of parent-implemented shared book reading intervention for preschoolers with ASD. Child Lang Teach Ther 2021;37:149-162.

47. Whittingham K, McGlade A, Kulasinghe K, Mitchell AE, Heussler H, Boyd RN. ENACT (ENvironmental enrichment for infants; parenting with Acceptance and Commitment Therapy): a randomised controlled trial of an innovative intervention for infants at risk of autism spectrum disorder. BMJ Open 2020;10:e034315.

48. Jurek L, Occelli P, Denis A, Amestoy A, Maffre T, Dauchez T, et al. Efficacy of parent-mediated communication-focused treatment in toddlers with autism (PACT) delivered via videoconferencing: a randomised con trolled trial study protocol. BMJ Open 2021;11:e044669.

49. Dai YG, Thomas RP, Brennan L, Helt MS, Barton ML, Dumont-Mathieu T, et al. Development and acceptability of a new program for caregivers of children with autism spectrum disorder: online parent training in early behavioral intervention. J Autism Dev Disord 2021;51:4166-4185.

50. Yi Z, Dixon MR. Developing and enhancing adherence to a telehealth ABA parent training curriculum for caregivers of children with autism. Behav Anal Pract 2020;14:58-74.

51. Ingersoll B, Wainer AL, Berger NI, Pickard KE, Bonter N. Comparison of a self-directed and therapist-assisted telehealth parent-mediated intervention for children with ASD: a pilot RCT. J Autism Dev Disord 2016;46:2275-2284.

52. Kuhlthau KA, Luberto CM, Traeger L, Millstein RA, Perez GK, Lindly OJ, et al. A virtual resiliency intervention for parents of children with autism: a randomized pilot trial. J Autism Dev Disord 2020;50:2513-2526.

53. Fisher WW, Luczynski KC, Blowers AP, Vosters ME, Pisman MD, Craig AR, et al. A randomized clinical trial of a virtual-training program for teaching applied-behavior-analysis skills to parents of children with autism spectrum disorder. J Appl Behav Anal 2020;53:1856-1875.

54. Millstein RA, Lindly OJ, Luberto CM, Perez GK, Schwartz GN, Kuhlthau K, et al. An exploration of health behaviors in a mind-body resilience intervention for parents of children with developmental disabilities. J Dev Behav Pediatr 2020;41:480-485.

55. Pickard KE, Wainer AL, Bailey KM, Ingersoll BR. A mixed-method evaluation of the feasibility and acceptability of a telehealth-based parent-mediated intervention for children with autism spectrum disorder. Autism 2016;20:845-855.

56. Luberto CM, Perez GK, Finkelstein-Fox L, Millstein RA, Fell L, Chad-Friedman E, et al. Acceptability of a virtual mind-body intervention for parents of children with autism or learning disabilities. Glob Adv Health Med 2021;10:21649561211047804