Parent-implemented intervention has been one of the evidence-based practices for children with autism spectrum disorders. Previous studies have suggested tiered approaches to enhance the effectiveness and efficiency of parent training. This study incorporated a three-tier model into ImPACT curriculum. The program is a widely-researched parent-implemented intervention designed to train parents as instructors for children with autism spectrum disorders, specifically focusing on parenting skills of social engagement, language, social imitation, and play. We adapted the ImPACT curriculum in Taiwan and developed three tiers of training to deliver the curriculum, including self-administered online learning, small group sessions, and individualized coaching. We conducted the research to evaluate training impacts by utilizing a single-subject changing conditions design across three tiers. The percentage of using target parenting strategies was assessed through video analysis, with progression to higher tiers for those not meeting the intervention criteria. The goal was to increase the use of target strategies to 90%. Of the ten mother-child dyads, nine mothers completed the program with one withdrawal due to COVID-19. Three mothers achieved the goal at Tier 1, five at Tier 2, and one at Tier 3. The findings suggest that the three-tier parent education model can support parenting skills by tailoring their learning needs. The study highlighted the adaptation of a Western parent training curriculum in an Eastern context and the implications of the three-tier parent education model. More research is recommended to further validate and explore this novel approach.
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Introduction
Parent-implemented intervention (PII) is an evidence-based practice (EBP) for children with autism spectrum disorder (ASD) (Wong et al., 2015). According to the National Professional Development Center on Autism Spectrum Disorder (NPDC) and National Clearinghouse on Autism Evidence-based Practices (NCAEP), PII for children with ASD involves training parents in communication skills, play, self-help, and behavior management in either group or individualized parent-training settings, typically within the home or community (Wong et al., 2015; Steinbrenner et al., 2022). Previous studies reveal that PII can lead to improvements in communication and challenging behaviors among toddlers with ASD. These studies also show that the results can be maintained and generalized (Aldred et al., 2004; Kasari et al., 2010; Lang et al., 2009; Wallisch et al., 2024).
PII is a crucial aspect of effective intervention programs for young children with ASD since autism is a lifelong condition. The diverse needs of families often present a barrier to the successful implementation of PII. For instance, while some parents require group learning which may lead to deeper didactic learning due to the absence of children with autism, others prefer self-paced learning (Lundahl et al., 2006; Steiner et al., 2012). Additionally, parent involvement may be limited by the presence of younger siblings or the structure of the program (Ingersoll et al., 2017; Koegel et al., 2002). Given that each family and participant has distinct characteristics and needs, Multi-Tiered Systems of Support (MTSS) may be the optimal solution. MTSS is distinguished by three core features: data-based decision-making, evidence-based instructional interventions, and supportive systems to maximize implementation fidelity (Freeman et al., 2017). MTSS is often applied in school-wide or classroom-level research and requires decision points to determine which participants are suitable for further instructional adjustments. For example, Greenwood et al. (2019) found that kindergarten teachers naturally provided more intensive instruction (i.e., longer duration and higher frequency) to children at high risk for literacy and language difficulties. Therefore, to determine who should receive more intensive instruction and when MTSS is frequently complemented by Response to Intervention (RTI) as a decision-making tool (Greenwood et al., 2019). The Response to Intervention (RTI) approach offers a pyramid model for delivering and organizing intervention resources based on learners’ needs and their responses to instruction. Some studies focus on school-wide implementation (Walker & Shinn, 2002), while others target individual students within classroom settings (Greenwood et al., 2019). Several studies were conducting multitiered interventions for parenting education of children with developmental delays, for example, research aimed at improving behavioral issues in children with disabilities (Phaneuf & McIntyre, 2007; Whittingham et al., 2009). These interventions were conducted in family and community settings and embedded in daily routines. Some multi-tiered parent intervention programs aim to reduce behavioral problems in children with developmental disabilities (Phaneuf & McIntyre, 2011; Tellegen & Sanders, 2013), while others focus specifically on enhancing communication in children with autism (Ingersoll et al., 2017b; Ingersoll & Wainer, 2013).
Three-Tier Parent Education Model
The three-tier parent education model proposed by McIntyre and Phaneuf (2008), consists of a stepped approach to address the diverse needs of families. The first tier, Tier 1, involves self-administration through various means such as reading materials, watching parenting videos, or accessing resources on the Internet (Brookman-Frazee & Koegel, 2004; Nefdt et al., 2010; Wang, 2017). The self-administration format provides flexibility for parents to complete the training at their convenience, despite schedule conflicts, cost, traffic, or limited time (Phaneuf & McIntyre, 2011). If families require additional support beyond Tier 1 or do not respond well, Tier 2 is implemented. Tier 2 involves group training sessions that provide social support and group discussion with therapists and other families (Drew et al., 2002; Ingersoll & Wainer, 2013; Tonge et al., 2014). Literature has suggested that group discussion can guide the self-learning process of acquiring new strategies (Knowles, 1980; Mukhalalati & Taylor, 2019). For families that require more individualized support, the tertiary tier, Tier 3, should be considered. Tier 3 parent training is implemented within a more individualized format, such as one-on-one sessions, culturally, sensitive approaches, and individualized feedback and modifications (Casenhiser et al., 2013; Kaiser & Hancock, 2003).
A meta-analysis encompassing 12 studies evaluated the Stepping Stones Triple P (SSTP) program, a positive family intervention aimed at enhancing positive parenting practices and reducing behavioral problems in children with disabilities. SSTP is a component of the Triple P-Positive Parenting Program, which is structured into five levels: Level 1 involves media and communication strategies; Level 2 includes brief, selective interventions such as one or two large group seminars; Level 3 offers targeted individual teaching; Level 4 provides extensive training through individual, group, or self-directed formats; and Level 5 consists of intensive additional modules for families experiencing extra challenges. Based on the family’s characteristics and the child’s needs, parents are recommended to participate in different levels of the program. Since its development in 2004 (Sanders et al., 2004), Triple P has been implemented in various countries, effectively supporting numerous families in need. Participating parents reported increased self-efficacy in parenting, reduced feelings of frustration and stress, fewer family conflicts, improved parental adjustment, and enhanced quality of parent-child interactions. Furthermore, children exhibited decreased behavioral problems. Parents expressed high satisfaction with the outcomes of SSTP (Tellegen & Sanders, 2013).
Whittingham et al., (2009) applied the SSTP program to 59 families, each with a child aged 2–9 years with autism spectrum disorder (ASD). The results indicated significant reductions in parent-reported child behavior problems and dysfunctional parenting styles (laxness, verbosity, and over-reactivity). These effects were maintained at a 6-month follow-up. Thus, the data suggest that the Stepping Stones program is an effective intervention for addressing child behavior problems and parenting difficulties in the ASD population. In addition to the SSTP adaptation, an adaptive intervention refers to the modification of the dosage (duration, frequency, or amount), type, or delivery mode of an intervention based on the unique and changing needs of the individual. Adaptive interventions are prespecified and clearly defined through explicit decision rules (Nahum-Shani & Almirall, 2019).
Another adaptation suggests that the three-tier parent education model may improve the coverage and efficiency of parent training without compromising intervention efficacy or fidelity (McIntyre & Phaneuf, 2008; Phaneuf & McIntyre, 2011). McIntyre and Phaneuf (2008) also discussed incorporating the three-tier model into an existing PII, Incredible Years Parent Training Program (IYPT) (Webster-Stratton et al., 2001), for children with developmental delay (DD). The authors later examined the utility of the three-tier parent training model incorporated with IYPT for eight parents of children with DD and indicated the effects in increasing positive parenting strategies and reducing children’s challenging behaviors, with a moderate effect size (Cohen’s d = 0.42). The findings also suggest that it was more cost-effective because the model minimized the need for time-intensive interventions (Phaneuf & McIntyre, 2011). Tiered parent interventions have been shown in some studies to effectively address the diverse strengths and challenges of families. Participating families can be connected to different levels of support according to their needs. The tiered concept allows families to receive services at various community sites, such as family doctor clinics, which can serve as places for warm handoff services (Canfield et al., 2023). This approach may provide much-needed relief for families experiencing high levels of stress due to ASD and can be incorporated into existing parenting training programs.
The ImPACT Program
The ImPACT program (Improving Parents as Communication Teachers) is a well-researched PII designed to improve social communication for young children with ASD (Ingersoll & Dvortcsak, 2019) designed for improving social communication for young children with ASD from birth to six years of age in natural settings (Rojas-Torres et al., 2020). The ImPACT project focuses on training parents to use a series of integrated strategies that integrate naturalistic, developmental, and applied behavioral approaches (Ingersoll & Wainer, 2013). Studies have shown its effectiveness in social engagement and communication skills (Ingersoll et al., 2017b; Stadnick et al., 2015). Although ImPACT has not yet been employed within a tiered approach, researchers conducted trials and compared self-administration lessons to therapist-assisted group sessions via video conferences (Ingersoll et al., 2016), which indicated that some parents responded well to self-administration lessons while some might need additional support, such as group sessions. The findings show the possibility and importance of incorporating a tiered approach with ImPACT. To date, ImPACT has demonstrated substantial effectiveness through studies involving remote self-directed learning (Ingersoll et al., 2017a), small parent groups, and individualized teaching (Ingersoll & Wainer, 2013; Stadnick et al., 2015). However, it has not yet been integrated into an MTSS-RTI three-tiered parent intervention model based on data and participant information. Therefore, this study aims to integrate the self-directed, small group, and one-on-one coaching instructional modes into a three-tiered MTSS-RTI parent intervention model using the ImPACT curriculum. The goal is to apply an adaptive intervention that accurately addresses the unique strengths and challenges of families.
Cultures and Contexts Matter
Although Project ImPACT offers promising PII, it is rarely adapted in Asian countries. To adapt this Western-based intervention in Asian countries, modifications are necessary to improve the fit for the target populations or contexts, as this can lead to better child-parent outcomes or engagement among parents (Wiltsey Stirman et al., 2019). A recent study in India adapted ImPACT to serve families in a low-resource and culturally diverse region. The researchers made some adaptations, for example, by including extended family members as the communication partners, due to the significant roles extended families play in Indian culture. Findings indicate that participants reported high acceptability and feasibility, attendance, and perceived improvement in children’s social communication (Sengupta et al., 2020). It is also suggested that future research should explore the use of ImPACT and improve its fit across varied settings. Although Project ImPACT provided workshops for practitioners in Taiwan and the parent manual (Ingersoll & Dvortcsak, 2010) has been translated into Mandarin Chinese by Ingersoll & Dvortcsak (2020), the effectiveness of the adapted version has not been examined in the context of Taiwan.
In addition to the cultural adaptations that target a population or overall cultural setting, each family is unique and has different strengths and needs. The three-tier model could potentially function as a systematic way to guide modifications and tailor families’ needs. Therefore, to address the varied needs of families of children with ASD in Taiwan, this study aims to implement a three-tier PII approach, which integrates the three-tier model with a culturally adapted the ImPACT curriculum. We conducted pilot research to examine the effectiveness of this novel three-tier PII (see Fig. 1) in improving parents’ use of strategies selected from the ImPACT curriculum. Two specific research questions were: (a) Do parents learn and increase the use of the ImPACT strategies through the three-tier PII approach? (b) What is the proportion of parents who responded to the intervention within each tier?
Fig. 1
The illustration of the three-tier PII
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Method
Participants and Recruitment Procedures
Ten mother-child dyads were recruited from child development agencies in the northern region of Taiwan. The recruitment of participating children with ASD and their mothers was conducted by distributing flyers at autism-related organizations in Taipei and New Taipei City. These areas were selected because the in-person training sessions were implemented in National Taiwan Normal University in Taipei.
The inclusion criteria for participating mothers were as follows: the mothers (a) were primary caregivers and had lived with their children for a minimum of six months before the research, (b) possessed basic Mandarin Chinese language skills including reading, writing, listening, and speaking because the materials and homework were written in Mandarin, (c) were able to operate a video recording device at home, and (d) were able to commute to the university and participate the in-person sessions. The mother is not eligible for this study if she had mental health disorders, such as depression. The inclusion criteria for children were aligned with the ImPACT program. Children were eligible if they were (a) between two to six years of age, (b) medically diagnosed with ASD or developmentally delay (DD), and (c) ambulant. The child is not eligible for this study if she/he had severe behavioral problems, such as self-injury, or any other medical diagnoses, such as cerebral palsy.
The researchers provided informed consent and obtained consent from all mother participants before the research. One mother-child dyad withdrew from the study during Tier 2 training due to concerns over the COVID-19 pandemic outbreak. The demographic information of the participants including the dropout is provided in Table 1. This three-tiered parent-implemented intervention (PII) study received approval from the Ethics Board of the National Taiwan Normal University in Taipei, Taiwan. Before the commencement of the study, written informed consent was obtained from the mothers of all participants under the Declaration of Helsinki Association (2013).
The setting of the Tier 1 training program included participants’ homes and online. Tier 2 training groups were held in a university discussion room equipped with video-playing and recording devices. Tier 3 individualized training sessions were conducted in participants’ homes, equipped with video playing and recording devices. Researchers administered all follow-up evaluations in participants’ homes.
Research Design
This study replicated Phaneuf and McIntyre’s (2011) research design. Researchers employed a single-subject changing conditions design in accordance with Alberto & Troutman’s (2016) guidelines. The intervention consisted of a three-tier PII approach using the ImPACT curriculum with selected strategies. All participants received Tier 1 parent training materials at the same time point. Based on their responses to the intervention, participants either progressed to the next tier or entered the maintenance period. The selected strategies and the three-tier model are described below.
The ImPACT Curriculum and Adaptations
The original ImPACT project is a 12-week program with weekly one-hour sessions. All session formats are either one-on-one or small-group settings. The sessions usually include instruction, modeling, role-play, and discussion. All demonstration videos and paper materials were in English. To adapt this curriculum in Taiwan and incorporate it with the three-tier model, we made the following adaptions and reported the modifications according to an expanded framework for reporting adaptations and modifications expanded framework for reporting adaptations and modifications (FRAME) (Wiltsey Stirman et al., 2019).
First, the primary adaptation is the language. We obtained approval from the author and developer of Project ImPACT. With Dr. Ingersoll’s permission, the primary researcher translated the materials including the parent manual and fidelity checklists from English to Mandarin Chinese. The primary researcher had completed the ImPACT instructor training program with Dr. Ingersoll. Then, a research assistant who is a Taiwanese-Canadian with a Master’s degree in special education, reviewed the translated materials.
Second, the primary researcher and the second author, the faculty of the Department of Special Education, modified the format by incorporating the three-tier model. The original ImPACT training sessions are delivered through in-person sessions. Considering that most families in Taiwan are dual-income households with limited time for parent education, there was a need to emphasize the accessibility and flexibility of training sessions. We developed three tiers of training to deliver the curriculum, including online learning, small group sessions, and individualized coaching. In Tier 1, parents engaged in online self-learning by watching original ImPACT videos with captions in Mandarin Chinese and reading translated parent learning manuals. Parents were also able to share their experiences and questions on a social media group with each other and the researcher. In Tier 2, we provided small group training sessions as designed in the original ImPACT program. Then, we provided one-on-one coaching sessions in Tier 3. The one-on-one sessions would specifically focus on one mother-child dyad and their needs to provide individualized suggestions.
Third, some modifications were made at a content level to adapt to parents’ time and commitment. The original ImPACT program involves teaching 12 strategies over a 12-week in-person group course, with teaching one strategy per week. This study specifically focused on the first four strategies which are: follow the child’s lead, imitate your child, animation, and modeling and expanding language. Table 2 presents the definitions of the four selected strategies. These strategies are foundational interactive parenting skills for the subsequent strategies (Ingersoll & Dvortcsak, 2010, p. 60) and are easy to implement in daily routines. Additionally, findings from the pilot study indicate that this “light touch” ImPACT approach is compatible with the busy schedules of most families.
Table 2
Definition of the selected ImPACT strategies
Strategy
Description of skills
Follow the child’s lead
1. Let young children choose activities. When young children pay attention to an item or are interested in the activities, parents follow the child’s interest during play. Keep an eye out for young children who have the lead. For example, when the child plays with building blocks, parents would also play with a block with closer proximity to the child.
2. Observe how the child plays and participate in the games that children are playing, giving them meaning.
3. Waiting for children to interact or communicate. When a parent responds to a child’s last reaction, wait 3–5 s for the response to be repeated.
Imitate your child
1. Imitates the child’s words or vocalization.
2. Imitates how the child plays with toys.
3. Mimics gestures and body movements.
Animation
1. Excited about the event. Parents show cartoonish sounds, exaggerated movements, and expressions. Focus on the interests of young children.
2. Gesture movements, facial expressions, and sound quality hyperbole.
3. Use strategies to get attention. Make interesting sounds that describe what young children are doing.
4. Wait expectedly. When a child actively opens an interaction, the parent responds immediately within 3 s. Parents keep a positive facial expression and look at the child.
Modeling and expanding language
1. Give meaning to the behavior of young children. Parents give instructions and meaning when children are playing.
2. Adjust the language to the appropriate early childhood development stage. You can simplify the language, say monotone or duplicated words, or short sentences. Speak slowly and repeatedly.
3. Demonstrate the language with the focus of the child’s interest. For example, when young children take out a toy corn, parents say: eat corn, yellow corn, corn, and so on.
4. Extended language and elaborate the conversation. For example, if the child says water, parents would say drink water, pour water, boil water, a lot of water, and so on, according to the action of the child.
5. Provides a focused stimulus. The target language to be taught today can be said repeatedly. For example, boil water and turn it on.
6. Avoid asking questions. Synchronize narrator action, narrator language equals to early childhood development, and give meaning, do not ask questions. For example, toddlers knock on toys, parents say beats, drums, etc.
Fourth, we recognized the cultural differences between Western and Eastern societies and made modifications by adding elements, such as providing parents with additional explanations of the rationale and benefits of the strategies and using examples that were more relevant to Taiwanese cultures during the sessions. For example, we used common Taiwanese child songs when demonstrating some strategies. This adaptation can help mother participants understand the importance of using these strategies and how they look like in everyday activities.
Fifth, in addition to the planned adaptations described above, researchers also made a contingency adaptation by adding respite care to Tier 2 group training because some mothers had difficulties finding someone to take care of their children with ASD or younger siblings while they were attending Tier 2 sessions. This adaptation helped increase participants’ motivation to attend group sessions. The detailed training procedures of each tier are described below.
Procedures of Each Tier
Set-up and Baseline
Researchers first instructed participating mothers to set up a quiet free-play corner where children could access and play with their preferred toys or games alongside their mothers. Next, researchers conducted baseline assessments by evaluating mother-child interaction videos during free play, provided by the mothers. No intervention or feedback was provided during this stage.
Tier 1
Figure 1 illustrates the three-tiered model, and Table 3 presents the content and dosage of the three-tier PII. After baseline, all mothers participated in Tier 1 training. Tier 1 was a self-administered program that included reading materials and videos on selected strategies. All materials were adapted from the Mandarin Chinese version of the ImPACT manual for parents (Ingersoll & Dvortesak, 2020/2019). The Tier 1 training program instructed all participating mothers to complete one strategy per week by reviewing materials, watching videos, and practicing the strategy. The program was designed to be flexible, allowing participants to manage their schedules and learn at their own pace. Participants took a total of four weeks to complete Tier 1 training. Additionally, participating mothers could contact each other via a group chat on a social media platform (Line); however, researchers did not participate in discussions or provide feedback. At the end of Tier 1, researchers assessed mother-child interaction videos provided by participants to determine their response to the intervention and whether they met the criteria. Participants who met the criteria were followed for a month after the intervention. On the other hand, participants who did not respond to Tier 1 training were enrolled in Tier 2.
Table 3
Intervention table
Level
setting
dosage
materials
Tier 1
Self-administration
1 strategy / per week
Line group
Parent handbook
Video clips
homework
Tier 2
Group training
1 strategy / per week
2 h of group training
Line group
Parent handbook
Video clips
homework
Group discussing
Modeling
Role-play
feedback
Tier 3
One-on-one coaching
1 strategy / per week
50 min of one-on-one coaching
Parent handbook
Video clips
Homework
Tier 2
In this tier, researchers conducted three-hour in-person small group sessions each week for four weeks. Researchers provided structured instruction with a parent manual and videos. Researchers and mother participants practiced the strategies through role-playing and discussed their strengths and concerns. The group sessions provided social support for mother participants and opportunities to learn from each other. Researchers also provided feedback based on their discussion and practices. After each session, participants were required to complete a take-home activity by recording a 10-min mother-child interaction video. Additionally, Tier 2 participants could discuss their thoughts and questions with researchers via a separate group chat on a social media platform. At the end of Tier 2, researchers conducted another round of assessments by evaluating the mother-child interaction videos to determine participants’ responses to the intervention. Participants who met the criteria entered a one-month follow-up period. Participants who required additional support and did not respond to Tier 2 training would enter Tier 3 training.
Tier 3 and Follow up
In this tier, researchers provided one-on-one sessions that included consultation and coaching. Researchers first reviewed all videos from the previous tiers to identify each mother participant’s needs and strengths. Then, during the one-on-one sessions, the researcher discussed the strategies and practiced with the mother through modeling and rehearsal. Table 4 presents the structure of a one-on-one session. Each session lasted one hour per week for four weeks. The researcher conducted assessments at the participant’s home by recording mother-child interaction videos. Following Tier 3, the participants entered the follow-up phase. To evaluate the maintenance effect, researchers conducted follow-up assessments one month after the intervention by recording mother-child interaction videos in participants’ homes. Nine mother-child dyads participated in follow-up assessments.
Table 4
The structure of the individualized training session
Step
Description
Time
Review and discussion
The researcher and the discussed previous videos, strengths, and needs.
10 min
The researcher asked mothers questions about the designated strategy.
5 min
Instruction
The researcher explained the rationale, benefits, and procedure of the strategy.
5 min
The researcher described how the strategy is relevant to the child’s goals.
5 min
Practice
The mother practiced the strategy with her child while the researcher observed.
10 min
Performance feedback
The researcher provided positive and corrective feedback.
5 min
Wrap-up
The researcher and mother discussed home activities including setting and dosage.
5 min
The researcher and mother discussed potential difficulties and solutions.
5 min
Measures
Mothers’ Use of the Selected Strategies
To assess parental outcomes, a 10-min video of mother-child interaction during free play was recorded for each strategy. As a result, each mother-child dyad had four videos in each tier. Based on a parent check form from the ImPACT manual (Ingersoll & Lalonde, 2010), researchers used the translated Parental Intervention Fidelity Checklists of the ImPACT manual to measure parents’ use of the selected ImPACT strategies. The 5-min observation period for assessment started from the third minute and continued until the eighth minute of the videos. During this 5-min observation, researchers used a 30-s partial interval recording method to document whether mothers used the selected strategy during each interval. The percentage of mothers’ use of the selected strategies was calculated as follows: (the number of intervals using the selected strategy) / (the number of intervals recorded in one video) *100%. To assess the overall use of all strategies and determine the response to intervention, the average score was calculated as follows: (the total number of intervals using the four strategies) / (the total number of intervals recorded in four videos) *100%. The effect size of this single-case design research was calculated by percentage of non-overlapping data of the total scores (PND, Gevarter et al., 2016).
The Number and Proportion of Participants Responding to Each Tier
To determine whether the participant responds to a tier or needs to move to the next tier, we set a criterion for mastery. In mastery learning, the standard for defining mastery of a unit is typically set between 80–90% (Block & Burns, 1976). Considering that the pass criterion in the literature on three-tier parent interventions is 85% (McIntyre & Phaneuf, 2008), this study defines the goal criterion for mastery as 90%, which suggests the mastery requirement of a learning topic. Thus, mothers who did not meet this criterion would move on to the next tier for further intervention. To report the proportion of participants responding to Tiers 1, 2, and 3, researchers recorded the number of mothers in each tier and converted it to a percentage.
Treatment Integrity and Inter-Observer Agreement
The researchers completed ImPACT workshops and training before conducting the research. The researchers also used the implementation fidelity checklist adapted from the Project ImPACT Guide to Coaching Parents (Ingersoll & Dvortcsak, 2019), to guide the implementation and enhance treatment integrity. To assess reliability through inter-observer agreement (IOA), a research assistant, trained with pilot parent-child interaction videos using the recording system and assessment tool, served as the second observer. The IOA during training ranged from 95 to 100% before the research began. In each tier, researchers randomly selected one of four videos (25%) for each mother-child dyad to calculate IOA. Five minutes from the 3rd to the 8th minute in each video were used as observation data. The average IOA was 97% (93–100%) in baseline, 97.6% (90–100%) in Tier 1, 97.1% (90–100%) in Tier 2, and 95% in Tier 3.
Social Validity
To evaluate social validity, researchers adapted a parent satisfaction questionnaire from the ImPACT manual (Ingersoll & Dvortcsak, 2019). The questionnaire contained 18 questions using a 5-point Likert scale, ranging from 5 points (totally agree) to 1 point (totally disagree). It also included two open-ended questions that allowed participants to write down their feedback and thoughts about the courses. Here are some examples of items: “I know how to apply the teaching techniques learned in everyday family life.” and “During the course, I appreciated the video examples that helped me learn how to implement the techniques.”
Results
Overall Parents’ Use of ImPACT Strategies
Figure 2 shows the numbers of mothers at all levels. Figures 3–5 present the percentage of ImPACT strategy used across the baseline, Tier 1, Tier 2, Tier 3, and maintenance phases. During the baseline, participants demonstrated an average of 79.15% (range: 30–100%) for “follow the child’s lead,” 31.30% (range: 0–75%) for “imitate your child,” 67.37% (range: 14–100%) for “animation,” and 69.44% (range: 6–100%) for “modeling and expanding language.” The overall average percentage of all strategies during the baseline was 65.29% (range: 18–90%). After the three-tier PII intervention, mother participants increased their strategy use to an average of 99.67% (range: 97–100%) for “follow the child’s lead,” 92.22% (range: 60–100%) for “imitate your child,” 97.22% (range: 85–100%) for “animation,” and 92.67% (range: 77–100%) for “modeling and expanding language.” The overall average percentage of all strategies increased to 95.56% (range: 90–99%) post-intervention. At the one-month follow-up, mother participants maintained a high level of strategy use, with an average of 95.89% (range: 90–100%). PND was calculated by total scores of four strategies. Among the nine mothers who completed the entire training and intervention, seven achieved a PND of 100% (Mothers A, B, C, D, E, F, G), while two demonstrated a PND of 50% (Mothers H, J).
Fig. 2
The number of mothers involved in each tier
Fig. 3
Tier 1 percentage of mothers’ use of selected ImPACT strategies
Fig. 4
Tier 2 percentage of mothers’ use of selected ImPACT strategies
Fig. 5
Tier 3 percentage of mothers’ use of selected ImPACT strategies
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Response to Tier 1
Figure 3 shows how each mother participant responded in tier 1. Ten mothers completed the baseline and participated in Tier 1. Three mothers (30%), mothers A, F, and G, responded to Tier 1 training by achieving the criterion. The three mothers increased their use of all strategies from 76.67 to 95.33% of intervals after Tier 1 training. They continued to rate between 94 to 99% of intervals at the follow-up.
Response to Tier 2
The remaining seven mother participants proceeded to Tier 2 training, with five of them responding positively to this tier (50%), as shown in Fig. 4. During baseline, mothers B, D, E, H, and J, rated low at 56.4% of intervals for the use of all strategies. Although they increased their use to 78.6% of intervals, they did not meet the criterion of response to intervention after Tier 1 training. The five mother participants reached an average of 95.2% of intervals and maintained their use of strategies at 94.2% of intervals at the follow-up.
Response to Tier 3
Two mothers were classified as non-responders in Tier 2. However, one mother-child dyad (Mother I) withdrew from the study after Tier 2 training due to the concerns of the COVID-19 pandemic. Therefore, only one mother participant (10%) was in Tier 3 training. Another parent, Mother C, continued Tier 3 training and completed it in four weeks. Mother C showed an average of 75.67% of intervals during baseline, 83% in Tier 1, and 89% in Tier 2. After Tier 3 training, Mother C reached 98% of intervals and maintained 98% of intervals at the follow-up, as shown in Fig. 5.
Social Validity
Based on the information collected from our social validity questionnaire, the average satisfaction score was 4.7 for Tier 1 mothers (n = 3), 4.5 for Tier 2 mothers (n = 5), and 4.1 for Tier 3 mothers (n = 1), indicating overall good satisfaction. Mothers provided positive feedback about the training in which they found preferred learning formats.
Discussion
This study incorporated a three-tiered parent education model with the ImPACT curriculum: Tier 1 involved parent self-learning, Tier 2 comprised small parent groups, and Tier 3 includeds one-on-one coaching. A pilot was conducted to examine the effectiveness of this novel approach in improving parents’ use of interactive strategies for their children with ASD. Results indicated that among the ten participating dyads, nine dyads completed the training and achieved 90% of use of ImPACT strategies, with one dyad withdrew due to the pandemic. Three dyads responded to Tier 1 training, five responded to Tier 2, and one responded to Tier 3. This study expands the literature on the multi-tiered intervention model and the implementation of the culturally adapted ImPACT curriculum in Taiwan.
The three-tiered parent education model showed the potential to tailor parents’ learning needs and reduce the manpower required for traditional in-person sessions. This is particularly crucial during the pandemic, as it not only limits face-to-face interactions but also exacerbates professional staff shortages. Previous studies also suggest the adoption of remote online (Gerow et al., 2021) or hybrid instruction (Ferguson et al., 2022) as an alternative and effective solution. In this study, we support the use of self-administrative online learning as most participants showed improvement after the Tier 1 training.
In Tier 1, three mothers who met the mastery criterion shared some common characteristics, including holding a master’s degree and being fully employed in professional roles. Their children usually exhibited verbal abilities, ranging from single words to short phrases composed of 2–3 words. These mothers reported that they practiced an additional 20–30 min daily beyond the assigned activities. The ImPACT program utilizes existing household toys, items, and daily activities as intervention materials, rather than a fixed set of instructional toys. Parents need to be creative in designing teaching activities; for example, one mother developed a game using clothespins that their child enjoyed. This outcome may align with the previous study (Russell & Ingersoll, 2021) suggesting that successful parent interventions require a certain level of child ability, a positive child response to the intervention, compatibility between the parent’s interaction style and the intervention program, and environmental support. The shared mother-child characteristics might explain why these mothers responded to Tier 1 self-administrative online learning (Russell & Ingersoll, 2021). They were more likely to acquire skills through online materials, practice at home, and ask questions on the social media platform.
In Tier 2, seven mothers participated with five meeting the mastery criteria. We observed that the five mothers who succeeded were more active in in-person discussions, provided feedback, and engaged in informal conversations about parenting during breaks or early arrivals. This suggests that the parent group can offer social support and motivate parents to participate and practice learned skills. Our observation in Tier 2 is consistent with previous studies indicating that professional support is crucial for parents’ skill acquisition and attendance (Ingersoll et al., 2016). Only one mother-child dyad received Tier 3 individualized training. The mother actively asked questions and felt more comfortable sharing her thoughts during one-on-one sessions, suggesting that some parents can benefit more from the one-on-one coaching format. Coaching is crucial and effective for ensuring fidelity in parents’ implementation, as highlighted in the literature where parents demonstrated immediate and significant improvement in parenting skills, such as shared reading strategies (Akemoglu & Tomeny, 2021).
Cultural Adaptation and Considerations
As the first study to implement ImPACT parent training with the three-tier model in Taiwan, the researchers identified cultural differences and the need for adaptations. For example, two of the selected strategies, Follow the Child and Imitate Child, require mothers to be responsive, follow their children’s lead, and imitate their children during play (Ingersoll & Wainer, 2013b). However, during Tier 1 training, some mothers expressed doubt about these strategies and did not increase their use of these strategies. They thought that some of their children’s behaviors, such as playing with a light switch, were not appropriate. These mothers tended to instruct their children how to play with toys correctly and focus more on cognition. This aligns with research indicating that Taiwanese parents, particularly those from high socioeconomic backgrounds, value general developmental play for preschool children but prioritize academic achievement over play when compared directly (Lin & Yawkey, 2013). As a result, in Tier 2 and 3 training sessions, researchers provided more explanation and examples about the rationale and benefits of these strategies and worked with mothers to find ways to implement them while redirecting children from inappropriate play.
Previous studies indicates that Eastern parents tend to be more authoritative and expect their children follow their directions (Xu et al., 2005). As Wang & Casillas (2013) suggested in a previous study, parents in this study valued the importance of teaching their children rather than playing games with them. Therefore, when implementing PIIs derived from Western cultures in some Eastern countries, such as Taiwan, practitioners should be mindful of the cultural differences, diverse beliefs, and contexts. In addition to translation, practitioners should consider making cultural adaptations, such as providing additional explanations, examples, demonstrations, or alternatives, to improve the fit of interventions while maintaining fidelity (Wiltsey Stirman et al., 2019).
In addition, researchers also recognized that most families are dual-income households and it is critical to support parental motivation and attendance (Ingersoll et al., 2016). Thus, we made a contingency modification by adding the respite care in Tier 2 training when noticing that some mothers had to participate in Tier 2 sessions with their children and younger siblings. To support parents and promote attendance, the inclusion of respite care is recommended for future application of parent training.
Limitations
Some limitations in this study should be considered. Firstly, most observation data were recorded by mothers and there was no blinding procedure, this present study could not rule out performance bias (Reichow et al., 2018). Mothers might perform better and respond more positively to their children than usual. This study could be enhanced by the using the experimental design that includes a blinding procedure and/or recording multiple mother-child interaction videos throughout the day. Secondly, although all mothers recorded their interaction videos during free play with their children in the quiet play corner, unlike Phaneuf and McIntyre (2011) study, this study did not standardize the procedures including the materials, such as using the set of toys and scheduling a period of time for clean-up. The data collection procedure in the present study was more feasible for clinical settings and appropriate for practitioners to evaluate response to intervention. However, more rigorous data collection should be considered in future studies in terms of determining intervention effectiveness. Finally, the participants in this study were mothers with higher educational levels. Future studies should consider including fathers and/or diverse families, such as families with low socioeconomic status, LGBTQ+ families, or immigrants.
Implications
This study highlights several implications for practices. First, the present study found that about 30 to 50% of mothers responded to Tier 1 training, indicating the importance and effectiveness of a primary and universal approach for supporting families with limited resources. As suggested in a previous study (Wang, 2017), such universal interventions should be addressed to maximize resource utilization, and the three-tier model is worth exploring with other evidence-based practices. Practitioners and future researchers could consider incorporating the three-tier model into other PIIs for their target populations. Second, parents who have high educational level and full employment can benefit from self-administrative online learning which has more flexibility and accessibility for parents to learn at their own pace. This training format can be a cost-effective solution to implement in Tier 1 parent training. Practitioners could also consider creating online group discussion on social media platforms so that parents can share experience and ask questions with each other to facilitate their self-learning process.
Third, in line with Phaneuf and McIntyre’s (2011) recommendations, we sought to enhance the utility of the three-tier model by assessing social validity. The present study provided online group discussion and administered a satisfaction questionnaire to gather their feedback and overall satisfaction with the training courses. For example, we noticed that some mothers had questions about “following the child’s lead”, researcher then provided more explanation and culturally relevant examples for this particular strategy in Tier 2 training. Practitioners could consider several ways to gather feedback to make appropriate modifications to training.
Future research could benefit from a more diverse range of participants to identify the characteristics of parents, children, and families that are best suited for each tier of parent-implemented interventions (PII). In addition, as suggested in the literature, tiered approach may save resources, such as time and cost, while maintain benefits and fidelity (McIntyre & Phaneuf, 2008; Wang & Koyama, 2014). More research is need for incorporating the tiered model into other existing PIIs and examining the cost-effectiveness.
Acknowledgements
We would like to thank the research participating families and research assistants and volunteers: Ms. Inge Chen, Ms. Min Peng, Ms. Chia Jung Lee, Ms. Vivian Yang, Ms. Ting Ting Chou, and Ms. Po Chin Shen. Special thanks to Dr. Huey-Jiuan Chen’s and Dr. Bih-Ching Shu’s comments to the manuscript.
Author Contributions
Yu-Shan Ding contributed to the literature review, conducted data collection and analysis, and was primarily responsible for drafting the original manuscript. Hui-Ting Wang conceptualized the study and methodology, provided supervision throughout the research process, and was involved in reviewing and editing the manuscript. Fang-Yu Lin contributed to the manuscript by reviewing, editing, and providing suggestions for revisions.
Compliance with Ethical Standards
Conflict of interest
The authors declare no competing interests.
Ethics Approval
This study was approved by the National Taiwan Normal University.
Informed Consent
Written informed consent was obtained from all participants. For participants under 16 years old, parental consent was secured.
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