In recent years, telehealth, the delivery of healthcare services using telecommunication technologies, has emerged as a promising modality for delivering early autism intervention services; however, questions remain about how these services are experienced by caregivers and service providers. The COVID-19 pandemic and resulting social distancing measures prevented many families with young children on the autism spectrum from accessing in-person early intervention services (Bellomo et al., 2020; Crockett et al., 2020; Kronberg et al., 2021; Manning et al., 2021). The preschool years represent a critical developmental period in which children who receive evidenced-based intervention can make significant gains in language, cognitive, and adaptive functioning (Fuller & Kaiser, 2020; Schreibman et al., 2015). As an alternative way to maintain intensive intervention during COVID-19 restrictions, many autism service providers (such as behavioral consultants, therapists, educators, and psychologists) switched from providing in-person early intervention to offering sessions via videoconference (Crockett et al., 2020; Ellison et al., 2021; Kronberg et al., 2021). This created a unique opportunity to study telehealth services in autism on a larger scale than ever before.

Telehealth had been identified as an emerging practice for autism service delivery prior to the COVID-19 pandemic, particularly for its potential to increase access to specialist expertise for families living in remote areas; however, little was known about caregiver and service provider satisfaction with remote service delivery, especially in community settings (Brian et al., 2022; Ellison et al., 2021; Hume et al., 2021; Ingersoll & Berger, 2015; Mirenda et al., 2022). A systematic review examining the use of telehealth for autism services supported the feasibility and effectiveness of providing remote services and found that caregivers reported high levels of satisfaction with the remote consultations, similar to caregivers receiving in-person services (Knutsen et al., 2016). Many telehealth studies on autism services to date have focused on parent-mediated intervention (PMI; also referred to as parent-implemented intervention or caregiver-mediated intervention), where a parent or caregiver is coached by a service provider to use techniques that promote learning and engagement with their child. PMI is widely considered a valid and essential part of early intervention in autism, with studies showing decreases in caregiver stress, improvement in caregiver intervention skill, increased caregiver–child interactions, as well as high overall caregiver satisfaction (Green et al., 2010; Kasari et al., 2014; Oono et al., 2013; Rogers, Dawson, & Vismara, 2012a). Although child improvements related to PMI have been more challenging to demonstrate, recent studies have found gains in communication skills, language comprehension, social interaction, and behavioral regulation, as well as a reduction in the severity of autism symptoms (Brian et al., 2022; Green et al., 2010; Oono et al., 2013; Rogers et al., 2019).

Research on in-person and telehealth-delivered PMI suggests that a caregiver’s satisfaction with services may influence their participation and engagement in their child’s program (Estes et al., 2019; Haine-Schlagel et al., 2020; Leadbitter et al., 2020; Popp & You, 2016; Rojas-Torres et al., 2020). Vismara et al. (2018) found that caregivers who received PMI via telehealth reported high levels of satisfaction, with caregivers noting that the videoconferencing meetings were helpful and productive and made them feel supported. However, other studies on telehealth delivered PMI have identified variables such as access to technology and child symptom severity as influencing parent satisfaction and participation in treatment (de Nocker & Toolan, 2021; Ellison et al., 2021; Lindgren et al., 2016).

Despite relatively promising results, most studies on providing PMI via telehealth prior to the COVID-19 pandemic relied on volunteer participants who were motivated and available to participate in research, with many living in rural areas where access to services was limited. Participants were typically white, college-educated mothers, and not employed outside the home (Bravo et al., 2022; Ellison et al., 2021; Knutsen et al., 2016). Indeed, less is known about how families in urban communities, working parents, fathers, families with lower socioeconomic status, and families from diverse cultural backgrounds experience these autism services (Mirenda et al., 2022; Rogers et al., 2022; Stahmer et al., 2019, 2020). This has meant that the majority of caregivers who could potentially benefit from these services have not been well represented in the literature (Ingersoll & Berger, 2015; Rogers et al., 2022).

Similarly, very few studies have looked at the satisfaction of the service providers delivering autism intervention via telehealth. The existing literature suggests that service providers generally appreciate the option to work remotely, with many reporting an increase in job satisfaction as well as reduced stress, despite reported barriers such as technical difficulties and unreliable internet access (Bravo et al., 2022; Iacono et al., 2016; Lindgren et al., 2016; Reisinger et al., 2022). Studies have also found that service providers report difficulties in building rapport with families via telehealth and a perception that families prefer face-to-face services. Bravo et al. (2022) surveyed service providers and caregivers as they experienced the rapid shift to telehealth early intervention services during COVID-19. Service providers reported that remote delivery allowed for an increase in caregiver support, with many noting that they had improved their communication style with caregivers while working remotely. However, both caregivers and service providers described difficulty in maintaining child engagement during the remote sessions, with half of the caregivers reporting a decrease in service satisfaction following the switch to telehealth (Bravo et al., 2022).

Service provider and caregiver satisfaction in telehealth-delivered early autism services may also be related to how often they interact together. Studies indicate that caregivers appreciate frequent contact with service providers and that service providers feel more satisfied with their work when they are able to meet more regularly with the families (Bravo et al., 2022; Brian et al., 2022; Brookman-Frazee et al., 2012; Iacono et al., 2016; Leadbitter et al., 2020; Popp & You, 2016). The benefits of remote PMI have usually been studied at a frequency of one to 3 h of contact per week, which appears to be arbitrarily determined, based perhaps on the funding available, or on an estimation of how often caregivers would agree to participate in sessions, or of how much time they required between sessions to consolidate their learning (de Nocker & Toolan, 2021; Oono et al., 2013; Parsons et al., 2017; Rogers et al., 2019). The idea of more frequent sessions of PMI was explored in a study by Rogers et al. (2019) where they compared weekly PMI with an enhanced program that involved bi-weekly sessions, demonstrating that caregivers who received more frequent support made significantly greater gains in interaction skills with their child. More research is needed in order to define how often service providers and caregivers should meet and to better understand what variables influence optimal frequency of contact (Oono et al., 2013; Rogers et al., 2019; Wetherby et al., 2014). The rapid adoption of telehealth service delivery during COVID-19 eliminated travel time and cost, allowing many service providers more frequent, albeit virtual, “in-home” visits with families, creating an opportunity to measure how service providers and caregivers experience more frequent meetings.

In the present study, we report on 45 families and 45 early intervention therapists from community-based autism intervention programs in Geneva, Switzerland, as they replaced in-person intensive intervention programs with telehealth sessions provided via videoconference over a 2-month period. The majority of sessions provided were PMI. The primary objective of this study was to measure the engagement and satisfaction of both caregivers and service providers as they experienced telehealth service provision for the first time. The second objective was to gain an understanding of how caregivers and service providers experienced a significant increase in frequency of contact. Thirdly, we aimed to investigate whether the socio-economic status, level of education, country of origin, and language of the caregivers were related to program engagement and satisfaction. Lastly, we measured child progress prior to and during home confinement in an effort to monitor child learning during the switch to telehealth services.

Methods

Participants

Children

All 48 children enrolled in one of three intensive intervention programs (the Centre d’Intervention Précoce en Autisme (CIPA), the Boussole program, or the CIPA Inclusion program (CIPA-I)) at the time of the home confinement were offered remote services (see Table 1 for child and family profiles). These participants were part of an already established longitudinal study on the developmental trajectories of young autistic children (Franchini et al., 2016; Robain et al., 2020). Forty-three children had a diagnosis of autism spectrum disorder (ASD), according to the DSM-5, confirmed using a full-battery evaluation (American Psychiatric Association, 2013). Five toddlers were suspected of having autism but did not yet have a confirmed diagnosis.

Table 1 Description of the sample of children (n = 48)
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Caregivers

All 45 families (three families had siblings enrolled) were invited to participate in the study. They had varying socioeconomic status levels, with 38% considered low income, 31% mid income, and 31% high income as indexed by the cost-of-living standards in Switzerland (Table 1). Educational attainment also varied, with 13% having completed no more than elementary school; 48% having only completed secondary school, and 40% with post-secondary education. Five children came from single-parent households. Parents came from 29 different countries of origin and spoke 15 different languages at home, representative of Geneva’s multicultural demographic (see Table 2 for list of countries and languages). All families provided their written consent for the study, in accordance with protocols approved by the institutional review board of the University of Geneva.

Table 2 List of parent’s countries of origin and languages spoken to children at home
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Service Providers

All 45 early intervention service providers (referred to in French as “Thérapeutes” and translated to “therapists” in this article) working in the CIPA, Boussole, and CIPA-I programs at the time of the home confinement participated in the study. They were all female, aged between 25 and 38 years old.

Procedure

Context of COVID-19 Home Confinement in Switzerland

On the 16th of March 2020, in response to the initial outbreak of the COVID-19 pandemic, the Swiss Federal Office of Public Health ordered a nationwide closure of all non-medical services, including schools and childcare centers. Our intervention centers re-opened gradually starting April 27th, 2020, with schools re-opening May 11th, 2020. Families were given the option to continue sessions online through to the end of May, and despite subsequent social distancing measures, schools and intervention centers have remained open to date.

Design

The present study was conceived with only a few days’ notice, with the intention of monitoring the experience and satisfaction of the parents and therapists as we switched from in-person to telehealth services, for what was then an unknown duration of time. Our data was primarily collected through survey questionnaires during and following home confinement. In addition to the surveys, we also measured child progress before and during the home confinement period using the Early Start Denver Model Curriculum Checklist for Young Children with Autism, which had already been used every 3 months with the preschool-aged children (Rogers & Dawson, 2010a).

Intervention Received Prior to Home Confinement: Three Programs

Prior to the home-confinement period, the 48 children were enrolled in one of three programs: the CIPA, the Boussole, or the CIPA-I. The amount (duration) of intervention received prior to home confinement depended on the age at which they entered one of the three programs and their current age (see Table 1 for detail).

The CIPA program had thirty children aged 24 to 54 months who, prior to home confinement, were receiving 20 h a week of in-center, therapist-delivered Early Start Denver Model (ESDM) intervention (Rogers & Dawson, 2010b). ESDM is an evidenced-based Naturalistic Developmental Behavioral Intervention (NDBI) for young children on the autism spectrum (Schreibman et al., 2015). In addition, parents initially received 12 sessions of once-a-week, in-person parent-mediated intervention (PMI) based on the Parent-Early Start Denver Model (P-ESDM), an effective intervention aimed at coaching caregivers as they learn to embed social-communicative learning opportunities for their child into daily routines (Rogers et al., 2021; Rogers, Estes, et al., 2012b). Parents met with their child’s lead therapist one to two times a month to continue PMI sessions as needed once they had completed the initial 12 P-ESDM PMI sessions. The CIPA program is subsidized by Geneva’s Department of Public Education for seven children and by a private foundation (Fondation Pôle Autisme) for 23 children, along with funds from the federal disability insurance. The CIPA program is only available to children living in the Canton of Geneva. Children typically remain in the CIPA for 2 years (see Table 1 for intervention duration prior to the confinement period).

The Boussole program had five children suspected of having autism, aged 8 to 24 months, who, prior to home confinement, were receiving 8 h a week of in-home and in-center, therapist-delivered ESDM intervention and two 1-hour sessions per week of PMI based on the P-ESDM approach. The Boussole is specifically intended for children with an increased likelihood of having autism, who do not yet have a formal diagnosis; if and when an autism diagnosis is confirmed, children at the Boussole can continue at the CIPA with a more intensive program. The Boussole is subsidized by private foundation and insurance funds.

The CIPA-I program had thirteen children aged 4.7 to 6.6 years who were receiving 13 to 24 h of one-to-one in-school intervention services per week prior to home confinement. Seven were in their first year of school and six in their second year. These children had also received early intervention services at the CIPA before they had entered the CIPA-I program. The CIPA-I program is provided for 2 years and is funded by Geneva’s Department of Public Education.

Telehealth Intervention During COVID-19 Home Confinement

When the home confinement orders were first announced, each child’s lead therapist contacted the parents and discussed how best to maintain services through remote delivery, taking into account parameters such as the parents’ availability, their level of access to technology, and the child’s likelihood of engaging with a therapist via videoconference. Intervention offered to families during the home confinement period consisted of remote direct intervention (Remote DI) and remote parent-mediated intervention (Remote PMI).

In Remote DI, the therapist met with the child via videoconference and worked on the child’s learning objectives, proposing interactive activities such as singing songs, drawing, discussing topics, and playing turn-taking games using the screen sharing function. In these sessions, a parent was present in the home to set up the videoconference and materials for the child and would usually check in briefly with the therapist at the beginning and end of the session, but did not participate actively in the session.

In Remote PMI, the therapist coached the parent to use ESDM strategies via videoconferencing while the parent actively interacted with their child. In the context of the sudden shift to telehealth services, the therapists managed to implement most of the P-ESDM framework; however they did not consistently collect data on parent acquisition of skills, a key component of the P-ESDM (Rogers, Dawson, & Vismara, 2012a).

No formal criteria were used to assess the child’s readiness to engage directly with a therapist via videoconference, nor was the choice of service delivery program-specific. Therapists used their clinical judgment and parental input to assess which type of service delivery would be most appropriate, taking into account the child’s age and the likelihood that the child would be able to sit and attend to another person, while following basic instructions without much redirection or support. Children who were likely to attend via videoconference were offered two 1-h sessions a day, from Monday to Friday, of Remote DI. Families of children deemed not able to attend to a therapist on their own via videoconference were offered two 1-h sessions a day, Monday to Friday, of Remote PMI. In some situations where the child was deemed ready for Remote DI and the parents’ requested sessions of PMI, both types of delivery were provided, again offered at a rate of two-1-h sessions a day (of either type), from Monday to Friday (see Supplementary Figure 1 for details).

Materials

Zoom software (Zoom Video Communications, Inc, Version 4.4; https://zoom.us/) was used for videoconferencing sessions. Parents were asked to set up their computer, smartphone, or tablet in a place where the therapist would be able to have a clear view of a play area or of the child’s work area. Prior to starting, lead therapists contacted the parents to explain how to install the Zoom software and to discuss materials needed, such as toys, felt markers, and paper. A toy-lending program was arranged for families in need. The book An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn (Rogers, Estes, et al., 2012b) was recommended to families. When appropriate, the therapists also suggested videos, website links, and ideas for activities in line with each child’s intervention objectives.

Service Provider Training

All service providers were licensed psychologists with a minimum of a master’s degree and had been trained in the ESDM approach prior to the home-confinement period (Rogers & Dawson, 2010b). Within the team, 15 certified ESDM therapists and one ESDM certified trainer and certified P-ESDM parent coach supervised the children’s programs, ensuring that the ESDM was implemented as intended. The ESDM certification trains service providers on the use of the ESDM techniques and ensures that they meet peer-rated treatment fidelity on the ESDM Fidelity Checklist (Rogers & Dawson, 2010b). ESDM certification criteria can be found on the website https://www.esdm.co/certification. Therapists had no prior experience in telehealth service provision and were provided with a one-day basic “emergency” training prior to their first session by the clinical director of the centers. The majority of sessions were recorded for supervisory purposes and reviewed during remote weekly team clinic meetings.

Measures

Caregiver and Service Provider Satisfaction Questionnaires

Satisfaction questionnaires were developed by the principal investigator, with the help of members of our research team and intervention centers, in the day following the home confinement order, prior to the first telehealth session. Given the time constraints, we were unable to formally validate or test the questionnaires. The aim of the questionnaires was to measure caregivers’ and service providers’ perception of and satisfaction with the telehealth format. Survey questions covered four main areas: (1) ease and comfort in using the videoconferencing technology; (2) perception of quality of interaction and engagement between caregivers and service providers via telehealth; (3) perception of caregiver and child learning and acquisition of skills during the telehealth sessions, compared to in-person sessions; and (4) experience of increased frequency of contact between caregivers and service providers.

The questionnaires also gathered information about the type of devices participants used for telehealth consultations, the number of caregivers working from home during home confinement, and who (mother/father/both) attended the sessions. Questionnaires were created using Google Forms at https://workspace.google.com and sent via email to parents and therapists at three time points to measure adaptation to the telehealth intervention: (1) right after the first remote intervention session, (2) after 3 weeks of remote intervention, and (3) after their final telehealth session. Participants responded to between 9 and 12 items (depending on the questionnaire time point) of multiple choice and Likert seven-point scale questions, ranging from strongly disagree to strongly agree, and were given the opportunity to add written comments pertaining to their experience with the services.

The Early Start Denver Model Curriculum Checklist for Young Children with Autism

To measure the magnitude of progress of children in the CIPA and Boussole programs, we considered three time points (T1: pre-pre-confinement; T2: pre-confinement, and T3: post-confinement) using the Early Start Denver Model Curriculum Checklist for Young Children with Autism (Rogers & Dawson, 2010b). The ESDM-CC is a comprehensive checklist assessment of developmental skills across multiple domains used with young children on the autism spectrum. It is administered by the child’s lead therapist in a play-based, unstructured setting, with the child’s caregivers present. It was initially developed as a tool to be used for treatment planning in early intervention, helping caregivers and service providers decide which learning targets to prioritize over a 3-month period. Given that the present study was set up overnight, we did not have a way to evaluate the children with formal standardized testing prior to the home confinement period. However, all children in the CIPA and Boussole programs were regularly evaluated with the ESDM-CC approximately every 3 months for treatment planning. Following recent publications that have provided psychometric validity for the use of the ESDM-CC to analyze child progress (Rogers et al., 2019; Talbott et al., 2020), we decided to use the ESDM-CC to monitor developmental progress during the service provision change from in-person to telehealth sessions.

First, we wanted to establish child progress in the period prior to home confinement, when sessions were in-person. For this, we compared T1, the ESDM-CC administered three-months prior to the pre-confinement ESDM-CC, with T2, the ESDM-CC administered pre-confinement. Then, we looked at the progress made during the telehealth period by analyzing change between pre-confinement (T2) and T3, the ESDM-CC administered post-confinement.

The ESDM-CC evaluates areas of expected child development at 4 levels: 9–18 months, 18–24 months, 24–36 months, and 36–48 months, covering subdomains such as communication, social skills, motor skills, and cognition (Rogers & Dawson, 2010b). In the current study, we looked specifically at the ESDM-CC subdomains that span all four levels: receptive and expressive language, social skills (including joint attention in level 2), and play. At each of the four levels, skills are evaluated as being A (acquired, consistent, and generalized); P (partial or emerging); N (child is unable or unwilling to perform the skill); or X (no opportunity or not tested). We considered a child’s global developmental level to be where the majority (50% or more) of the skill items were rated as an A. We used their numerical equivalents (1–4) to analyze the global developmental levels. If the highest level had an equal number of acquired and not-yet acquired skills, the child was considered between two levels for that skill (i.e., 1/2) and the levels were converted into numerical levels for the purpose of the statistical analyses (1/2 = 1.5; 2/3 = 2.5, etc.).

Data Analysis

We used the Mann-Whitney test to examine group differences in program satisfaction as the measures did not follow a normal distribution (Shapiro-Wilk test). We compared the parents’ and service providers’ overall experience and satisfaction with the remote intervention, as well as the change in satisfaction between the first day and the third week of treatment. To illustrate child developmental progress, we used the Wilcoxon matched-pairs signed-ranks test to compare the global and subdomain scores of the ESDM-CC between the three time points, as the measures were not normally distributed. Statistical analyses were conducted using GraphPad Prism v.8 and SPSS v.25 software (https://www.graphpad.com/). All results in our study were considered significant at the p value of 0.05. The false discovery rate (FDR) was controlled using Benjamini-Hochberg procedure (Benjamini & Hochberg, 1995).

Results

Program Participation

All 48 children and their 45 families, as well the 45 therapists of the CIPA, Boussole, and CIPA-I programs, participated in the remote sessions during the confinement period (see Supplementary Figure 1 for remote intervention summary). Thirty-four of the 35 children from the CIPA and Boussole programs received Remote PMI of which 11 also had some sessions of Remote DI (see Supplementary Figure 1 for session detail). One older child in the CIPA (3 years, 9 months) and all 13 of the children in the CIPA-I program received only DI, although their parents were present in the background. Therapists adapted the length of sessions to the needs and availability of the families, with a session length lasting between 30 and 90 min, as illustrated in Supplementary Figure 1.

Remote sessions were offered over a period of 2 months, with a 7-workday break over the Easter holiday (Supplementary Figure 1). During the time when all families were in home confinement, services were provided for a total of 19 days for the families in the CIPA and Boussole and 29 days for the CIPA-I. Children in the CIPA and Boussole received an average of 8.75 sessions (7.3 (± 2.2) hours) of primarily Remote PMI intervention per week. The children in the CIPA-I received an average of 7.06 sessions (5.41 (±0.92) hours) of Remote DI per week (Table 3).

Table 3 Description of the remote intervention sessions
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Thirty-four of the families, including 56 individual parents, participated in the Remote PMI sessions. Twenty-seven percent of these sessions were done with fathers, 54% with mothers, 14% with both mother and father, and 2 % with a childcare provider (Table 3). Fifty-nine percent of the families used a computer, 24% a tablet, while 16% participated via smartphone. One family did not have access to a Wi-Fi connection and was coached via landline telephone.

Caregiver and Service Provider Satisfaction

Forty-two of the 45 families and all 45 therapists filled out all three time points of the satisfaction questionnaires. We divided the questionnaire responses into the following four areas of interest (detail in Figs. 1, 2, and S2).

Fig. 1
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Parents’ (A) and therapists’ (B) satisfaction with remote intervention delivery assessed at week 1

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Fig. 2
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Satisfaction questionnaire administered following the final remote session. A, B Multiple choice question answers for parents and therapists respectively; C responses of the parents and responses of the D therapists. The percentages of point responses in C and D are represented with the exception of the neutral point 4, neither agree nor disagree, on the 7-point Likert scale

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Experience and Satisfaction with Online Format

Both parents and therapists reported general satisfaction with the remote format, with 78% of parents and 79% of therapists saying they felt comfortable with the technology and their role in the telehealth intervention and only 12% of parents and 16 % of therapists reporting technical difficulties after the first telehealth session (Fig. 1). While 36% of parents and 42% of therapists found it was harder to understand each other via videoconference than in-person (Fig. 1), nearly all parents (90%) felt motivated to try and apply new techniques with their child following a remote session (Supplementary Figure 2), and 98% of parents and 85% of therapists felt it was important to continue the sessions remotely during the home confinement period (Fig. 1). Eighty-nine percent of parents and 81% of therapists felt the sessions helped the child to progress in their objectives (Supplementary Figure 2). At the end of the home confinement period, when asked what they found most challenging, 50% of parents said it was controlling the home environment around them during the sessions (i.e., siblings and other distractions), while 33% felt it was difficult to manage their own child’s behaviors. Only one parent found it difficult to play with their child while being observed remotely (Fig. 2, A1). Many parents added written comments about how the telehealth format was convenient, noting that they were able to join meetings from their place of work or participate in a PMI session with their older child while their younger child napped. Therapists also commented on how meeting via telehealth allowed them to observe “in the home” more regularly and target behaviors related to daily routines.

Caregiver and Service Provider Experience of Increased Frequency of Sessions

Prior to COVID-19, parents of children in the CIPA centers received, at most, one 60-min PMI session a week, with families at the Boussole having approximately two 60-min sessions per week. During home confinement, this increased to one to two Remote PMI sessions per day. Nearly all parents (93%) felt that checking in daily with their child’s therapist made them feel supported in their efforts (Supplementary Figure 2), and 86% felt that they learned more about ESDM techniques and were applying them more than before receiving the daily sessions (Fig. 2). Likewise, 84% of therapists found that they progressed in their ability to support the parents during the remote sessions, and 84% of parents felt that they made progress in their ability to use the intervention techniques. Following the period of remote delivery, 79% of parents felt that the weeks of online daily sessions helped them to have a better understanding of their child’s learning objectives and how to work on them, and 90% of therapists reported having a better understanding of the family’s needs and how the child functions at home than prior to home confinement (Fig. 2). We asked the parents and therapists what, for them, would be the ideal frequency of sessions, and 58% of parents and 60% of therapists felt that two sessions a day was ideal, while 28% of parents and 35% of therapists felt that one-session a day would have been better. None of the parents or therapists said they preferred the typical rate of one session a week; however, two families and three therapists said they would have preferred only 2–3 sessions per week (Fig. 2, A2 and B2).

Comparison of Caregiver and Service Provider Perceptions and Satisfaction

Overall, the therapists tended to be more hesitant about the telehealth format than the parents. In our assessment of parents’ comfort level with the new format, we found significant group differences between parents and therapists, with therapists perceiving the parents as less comfortable with the format than the parents actually were, both at week 1 (U = 649; p = 0.004, d = 0.6) and week 3 (U = 986; p = 0.001, d = 0.6) (see Fig. 3 for parent–therapist comparison). Similarly, parents tended to perceive the therapists as more comfortable with the telehealth format than the therapists actually reported feeling. We found group differences both at week 1 (U = 339; p < 0.001, d = 1.4) and week 3 (U = 963; p < 0.001, d = 0.6). However, therapists showed a significantly higher estimation of their own comfort with the service delivery format at week 3 compared to week 1 (U = 1023; p < 0.001, d = 0.7).

Fig. 3
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Comparison of parent and therapist response impressions of remote sessions. Note. Week 1 and week 3 comparison of change in parents’ and therapists’ impressions with regard to parental comfort with the remote intervention format (upper left), therapists’ comfort with the remote intervention format (upper right), perception of remote intervention usefulness (lower left), and family perception of importance to continue the online intervention (lower right). The effect size is expressed using Cohen’s d and significance level is defined as follows: *p < 0.05,**p < 0.01, ***p ≤ 0.001, and ****p ≤ 0.0001

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We also found group differences for how useful the parents and therapists felt the daily sessions were. Parents perceived the sessions as being more useful than the therapists did, both at week 1 (U = 687; p = 0.012, d = 0.5) and at week 3 (U = 1145; p = 0.029, d = 0.4). However, the difference at week 3 did not hold statistical significance after the Benjamini-Hochberg correction for multiple comparisons (Benjamini & Hochberg, 1995). When we asked parents and therapists whether they felt it was important to continue early intervention services remotely, we detected group differences at week 1, with therapists having a slightly lower estimation of the importance to continue intervention during home confinement (U = 778; p = 0·020, d = 0·4). However, by the third week, both groups strongly agreed that it was important to continue the services remotely.

In the final questionnaire, we asked parents which characteristic they liked most about the therapist working with them (Fig. 2, A3). Thirty-seven percent of parents reported that the therapists’ level of concern for my child was what they appreciated most, with the others appreciating the therapists’ patience (19%), level of knowledge (16%), encouragement (14%), and positivity (14%). Likewise, when the therapists were asked which qualities they most appreciated in the parents, 44% answered that it was their perseverance, while others felt it was the parents’ positivity (25%), punctuality (16%), appreciation of my work (11%), and flexibility (4%) that they liked most (Fig. 2, B3).

Relationship Between Caregiver Background and Their Participation and Satisfaction

All caregivers, regardless of country of origin and language, maintained high levels of participation and reported similar levels of satisfaction with the telehealth services. The multiplicity of languages and countries of origin in this community sample made it difficult to compare satisfaction and participation by cultural group. Questionnaire results were analyzed by three levels of family annual income, based on the Swiss Federal Office Statistics levels of standard of living (www.bfs.admin.ch/bfs/fr/home/statistiques/situation-economique-sociale-population/enquetes/silc.html) (Table 1). Overall, we did not find significant group differences in regard to participation or satisfaction of sessions, but noted a tendency for lower-income families to be more unanimously positive about the services. All three groups reported that the sessions were very useful and helped their child progress, with less variance in the low-income group (Supplementary Figure 3, B). All groups reported high motivation to apply intervention strategies and valued the daily check-ins with the therapist. Mid-income families reported less technical issues compared to both low-income (U = 70.5; p = 0.07) and high-income families (U = 48; p = 0.04); however, this last comparison did not withstand the Benjamini-Hochberg procedure for FDR control (Benjamini & Hochberg, 1995).

Monitoring Child Developmental Progress

We aimed to measure the magnitude of child developmental change across different developmental domains assessed by the ESDM-CC during a period of in-person sessions prior to home confinement (T1 to T2: baseline progress), compared to progress made during a period of telehealth sessions during home confinement (T2 to T3: home confinement progress) (Rogers & Dawson, 2010a). We compared the ESDM-CC global and subdomain scores between the three time points (T1: pre-pre-confinement, T2: pre-confinement, and T3: post-confinement) using Wilcoxon matched-pairs signed-ranks test. As depicted in Fig. 4, we observed a pattern of continued significant improvement between all ESDM-CC evaluations, without any stagnation of progress related to the confinement period (between T2 and T3) in all domains but expressive language. For expressive language, the improvement observed between T2 and T3 did not reach significance level (p = 0.06). Global scores showed significant change post (T3) compared to prior confinement (T2), with a slightly higher change observed in the period preceding the confinement (see Fig. 4 & Table S1). However, the change observed in three out of four assessed domains, namely, receptive communication, social skills, and play, was higher during the confinement period (T2–T3) compared to the pre-confinement change T1–T2 (Fig. 4 and Table S2). This global effect might be driven by a lesser change evidenced in the expressive communication domain during T2–T3 (r = 0.18) compared to the pre-confinement period (r = 0.47).

Fig. 4
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Change in ESDM-CC levels at three time points. Note. Bar plots depicting the change in ESDM-CC levels at 3 time points: T1, ESDM-CC completed 3 months prior to pre-confinement ESDM-CC; T2, pre-confinement ESDM-CC; T3, post-confinement ESDM-CC. The magnitude of change is expressed in effect size r = Z/√ N and significance level is denoted as follows: **p < 0.01, ***p ≤ 0.001, and ****p ≤ 0.0001

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Discussion

The COVID-19 pandemic disrupted our programs for children on the autism spectrum, forcing us to re-think our service delivery model. We aimed to measure the engagement and satisfaction of both caregivers and service providers as they experienced telehealth service provision for the first time and to gain a better understanding of how caregivers and service providers experienced a significant increase in parent-mediated intervention (PMI) session frequency. We also aimed to investigate whether caregiver background was related to program engagement and satisfaction. Finally, we measured child progress prior to and during home confinement in an effort to monitor child learning during the switch to telehealth services.

Caregiver and Service Provider Satisfaction with Telehealth Services

The current study supports previous research showing that remote provision of autism intervention for young children, including PMI, is generally well received by caregivers and service providers (Ellison et al., 2021; Ingersoll & Berger, 2015; Oono et al., 2013; Vismara et al., 2018). We expected participants to report more challenges in the use of technology, since most were just becoming familiar with the ZOOM software and the delivery of telehealth services; however, the majority of participants reported feeling comfortable connecting via videoconference. The widespread adoption of telecommunications in the wake of COVID-19 will undoubtedly facilitate further advances in user-friendly telehealth software, decreasing the technology-related barriers previously reported in the literature (Bellomo et al., 2020; de Nocker & Toolan, 2021; Ferguson et al., 2019; Kronberg et al., 2021). In the current study, participants reported occasional technical problems such as an unstable internet connection, with some parents and therapists reporting difficulty in understanding what the other person was trying to convey over videoconferencing. However, despite these challenges, most parents and therapists were motivated to continue the telehealth sessions and described them as useful. This, in addition to the high level of participation and engagement over the course of the telehealth period, suggests that satisfaction with these services may be determined by factors beyond ease of use (Bravo et al., 2022; Ingersoll & Berger, 2015; Knutsen et al., 2016).

The flexibility and accessibility of the telehealth modality, particularly in how it reduces travel time, may have also contributed to the high levels of participation and satisfaction among our participants. For example, parents who were required to go into the office during the home confinement period were able to join videoconferencing sessions during their lunch break at work. As a result, service providers were able to engage more with working parents, especially fathers who, prior to the COVID-19 pandemic, were sometimes unable to attend these meetings. Other parents, who would normally have had to schedule in-office sessions around a younger sibling’s nap time, appreciated the convenience of having remote PMI sessions with their child with autism at home, while their younger child was napping. We also noted that for separated parents, meeting on videoconference meant that they could hear the same information without being physically in the same room. These observations support findings from de Nocker and Toolan’s (2021) systematic review of telehealth autism services, which report high overall program satisfaction across all nine of the studies that used satisfaction or treatment acceptance ratings as outcome measures, and suggested that telehealth’s great advantage is its accessibility. Prior to COVID-19, remote delivery of autism services was mostly considered a solution for families living in rural areas, far from service providers (Ellison et al., 2021; Knutsen et al., 2016; Parsons et al., 2017). The current study found that the telehealth format is helpful to families and service providers, regardless of where they live, and lends support to the current argument that the delivery of early autism services will increasingly rely on telehealth, regardless of the availability of in-person services (Bravo et al., 2022; Brian et al., 2022; Ferguson et al., 2019; Pickard et al., 2016).

Importantly, many service providers reported appreciating how working via telehealth allowed them to work with the families in the natural context of the child’s home, albeit virtually. Our programs had always provided in-person home visits, however, due to commuting time, only at an average rate of once a month. Prior to COVID-19, many providers commented on how beneficial the in-home moments were and wished they could go more often. In the current study, both parents and therapists remarked on the benefits of having more frequent “in-home visits,” finding it helpful to have sessions in the environment in which the parent-child interaction typically takes place. Parents were able to show the therapists challenging behaviors as they occurred in the home or prop their computer on the lunch table while getting help with their child’s feeding skills. This finding supports previous studies that have emphasized the importance of working on real-life situations outside of the clinical setting (Marino et al., 2020; Rogers et al., 2019; Vivanti et al., 2018).

Comparison of Caregiver and Service Provider Experience

Responses to the questionnaires revealed significant differences between therapists and parents, indicating that the therapists perceived the parents as being less at ease with the telehealth format than the parents reported feeling. Conversely, the parents tended to perceive their therapists as being more comfortable than the therapists reported feeling. These findings suggest that service providers may underestimate the readiness of families to participate in remote PMI and may themselves come across as more confident than they actually feel. As with other studies looking at parent satisfaction with autism services, most of the parents in the current study reported that their therapist’s level of concern for their child was the characteristic they most appreciated, while therapists reported appreciating the parents’ perseverance and positivity (Bravo et al., 2022; Estes et al., 2019; Makino et al., 2021; Mirenda et al., 2022).

Experience of Increased Frequency of Caregiver-Service Provider Contact

The telehealth format and home confinement condition made possible an increased frequency of contact between the therapists and the parents, compared to the pre-pandemic intervention. For most of the families, this involved an unprecedented increase in the frequency of PMI sessions, a key goal of which is to help caregivers acquire strategies to increase their child’s engagement and learning and ultimately to improve the child’s developmental progress (Oono et al., 2013; Shire et al., 2016). Given the unique circumstances of the current study, we were not able to measure parent acquisition of skill; however, the majority of caregivers reported that the more frequent sessions helped them feel more confident in their ability to use and apply the intervention techniques. Caregivers also reported they learned more with the daily Remote PMI format than they had with the weekly, in-center PMI sessions received prior to the pandemic. We found it interesting that, despite the time and energy it took to participate in the frequent PMI sessions, most of the caregivers and therapists felt that the ideal frequency of contact for them would be at least once a day. This suggests that caregivers and service providers appreciate a higher frequency of PMI sessions, perhaps because it provides them with the necessary support and motivation to implement early intervention strategies with their child. It also implies that the frequency of contact may be a crucial factor to consider in ensuring participant satisfaction (Parsons et al., 2017; Rogers et al., 2019).

Remote Autism Intervention Services for a Diverse Community

The current study’s sample included comparable numbers of low-, mid-, and high-income families, as well as caregivers with lower educational attainment, working parents, fathers, single parents, and families representing many different languages and cultural groups. This provided us with a realistic picture of how telehealth autism services could be implemented in our community setting. We found that nearly all of the families, regardless of background, were highly motivated to acquire the intervention tools and appreciative of the regular support they received.

Income-based disparities, race, and ethnicity have been shown to impact an autistic child’s access to care, with some families more likely to face barriers to participation, such as less flexible work schedules or limited time and resources to transport children to and from intervention appointments (Stahmer et al., 2019). In the current study, home confinement reduced some of these barriers, but nevertheless, the families of lower socioeconomic status tended to face more challenges, such as having a smaller living space in which to conduct telehealth sessions, fewer toys and materials, or a lack of a computer and reliable internet connection. Despite facing potential barriers, these families were just as engaged and satisfied with the sessions as their higher-income counterparts. The high levels of participation by all the families suggest that families from diverse backgrounds regard their child’s programs very much as do those who, until recently, have been predominantly represented in the literature (Ingersoll & Berger, 2015; Knutsen et al., 2016; Stahmer et al., 2019). However, for telehealth intervention to be more inclusive of historically underserved children, programs should ensure access to a computer, internet connection, toys, and materials, and offer flexible scheduling to accommodate working parents (de Nocker & Toolan, 2021; Stahmer et al., 2019; Zuckerman et al., 2014).

Child Developmental Progress During Telehealth Delivery of Services

Our regular monitoring of child developmental progress using the ESDM-CC, administered every 3 months in the CIPA and Boussole, allowed us to highlight the pattern of continued significant improvement across developmental domains. This pattern was maintained during the telehealth period, where we saw significant improvements in all developmental domains except expressive language, where there was considerable but more modest improvement compared to the period immediately preceding the home confinement period, possibly suggesting a consolidation learning phase following important skill acquisition.

Limitations and Future Research

The main limitations of the current study stem from that which made it possible: the unexpected circumstance of providing autism intervention services during a sudden period of home confinement. We had no opportunity to randomize groups, complete formal measures of child outcome, track parent acquisition of skills, or control for ongoing service provider treatment fidelity. In the absence of existing validated questionnaires that we could use in this unique context, we created our own questionnaires, but we did not have time to test and validate the survey questions in advance.

Despite the lack of formal metrics, the current study does offer a rare glimpse into community implementation of telehealth autism services and demonstrates that the switch to telehealth was not just tolerated, but appreciated, despite limited preparation time. The beginning of the COVID-19 pandemic was, however, a period of great uncertainty, and this may have increased parents’ willingness to participate, in an effort to maintain continuity of their child’s program. It is also possible that the home confinement condition meant that families had more free time to participate in PMI; however, this is debatable, as the majority of parents in our study continued to work from home while also managing their children.

The level of satisfaction with the increased frequency of PMI sessions was high and pervasive. It may well have confounded the satisfaction reported with the telehealth format. This is somewhat of a moot point, however, since the increased frequency would not have been possible without the cost- and time-saving videoconference technology. Future studies should examine the question of optimal session frequency in remote PMI for participant satisfaction and outcomes. Likewise, the parents’ willingness to try remote intervention may have been influenced by the fact that they already knew the service providers they would be meeting with. This fact may also have impacted their level of engagement and satisfaction with the sessions (Haine-Schlagel et al., 2020; Kronberg et al., 2021). Further research examining telehealth delivery of autism services where caregivers have not met their service provider in person prior to remote delivery will be necessary to establish whether initial in-person interaction impacts telehealth service satisfaction and engagement.