Background Intervention during the first years of life for children with autism spectrum disorder (ASD) may have the strongest impact on long-term brain development and functioning. Yet, barriers such as a shortage of trained professionals contribute to significant delays in service. The goal of this proof-of-concept study was to explore strategies that support timely and equitable deployment of ASD-specific interventions. Methods This 15-week, randomized proof-of-concept study explored the acceptability of a digital parent mediated intervention online reciprocal imitation training (RIT; a naturalistic developmental behavioral intervention) and compared it to a treatment as usual (TAU) control on parent and child outcomes. Eligible children were between 18 and 60 months, met the cutoff for ASD on the Autism Diagnostic Observation Schedule-2nd Edition and demonstrate significant social imitation deficits. Primary outcomes include the acceptability of RIT (Scale of Treatment Perceptions) and the feasibility of the Online RIT digital intervention (online RIT attributes). Secondary outcomes included parent fidelity (RIT parent fidelity form) and parental self-efficacy (Early Intervention Parenting Self-Efficacy Scale). Exploratory outcome measures included child social communication (Social Communication Checklist), child imitation skills (Unstructured Imitation Assessment), and family quality of life (Beach Center Family Quality of Life Scale). Results Twenty participants were randomized in a 1:1 fashion. The acceptability and feasibility of RIT and the Online RIT digital intervention were rated highly. Among the secondary outcomes, there were significant group differences in parent fidelity (p < .001) and self-efficacy (p = .029). On exploratory outcomes, there were group differences in child social communication (p = .048). There were no significant group differences in imitation ability (p = .05) or family quality of life (p = .22). Limitations There are several limitations with this study, including the small sample size as well as lack of data on enactment and website engagement. This study was not able to address questions related to which variables predict program engagement and treatment response, which will be critical for determining which families may benefit from such a stepped-care delivery model. Conclusions Overall, the Online RIT program delivered in a stepped-care format shows strong acceptability and holds promise as an innovative delivery model. Trial registration ClinicalTrials.gov, NCT04467073. Registered 10 July 2020- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04467073

Background Intervention during the first years of life for children with autism spectrum disorder (ASD) may have the strongest impact on brain development, behavior and long-term functioning. Yet, barriers such as a shortage of trained professionals contribute to significant delays in service. The goal of this proof-of-concept study was to explore strategies that support timely and equitable deployment of ASD-specific interventions. Methods We conducted a 15-week, randomized control trial (RCT) comparing a stepped-care model (i.e. parents first used an interactive website, and then received parent coaching if warranted) of Online Reciprocal Imitation Training (RIT; a naturalistic developmental behavioral intervention) versus a waitlist control condition (WLC). To be eligible, children had to be between 18 to 60 months, meet the cutoff for ASD on the Autism Diagnostic Observation Schedule-2 Edition and demonstrate significant social imitation deficits. Primary outcome measures included child imitation skills (Unstructured Imitation Assessment (UIA)), parental self-efficacy (Early Intervention Parenting Self-Efficacy Scale (EIPSES)), and parent fidelity (RIT Parent Fidelity Form (RIT-PFF)) to the intervention. Secondary outcome measures included child social communication (Social Communication Checklist (SCC)) and family quality of life (Beach Center Family Quality of Life Scale (FQOL)). Results Twenty participants were randomized in a 1:1 fashion, after participant drop out, eight were in the WLC and seven were in Online RIT. Among the primary outcomes, there were significant group differences and improvements in parent fidelity (p= .000), self-efficacy (p=.029), and ratings of child social communication (p=.048) in Online RIT relative to wait-list controls. There was no significant difference of improvement in imitation ability (p=.05) or family quality of life (p=.220)Limitations There are several limitations with this study, including the small sample size, lack of enactment data, and a lack of website engagement data. The WLC design limits the strength of the conclusions that can be drawn.Conclusions Overall, the novel use of stepped-care telehealth shows strong acceptability and holds promise as an innovative delivery model.Trial Registration Trial Registration: ClinicalTrials.gov, NCT04467073. Registered 10 July 2020- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04467073