Tele-rehabilitation Program: An Innovative and Sustainable Early Intervention Service for Children With Autism Spectrum Disorders
Phase: NA
Conditions: Autism Spectrum Disorder
Sponsor: National University Hospital, Singapore

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
 
Tele-rehabilitation Program: An innovative and sustainable Early Intervention service for 
children with Autism Spectrum Disorders 
19/08/2022 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
HSDP Telerehabilitation Program Protocol 
Contents 
Administrative information ......................................................................................................................................... 4 
Introduction ................................................................................................................................................................. 5 
Background & Rationale .......................................................................................................................................... 5 
Objectives and Trial Design ..................................................................................................................................... 6 
Methods: Program Overview ...................................................................................................................................... 6 
Setting ...................................................................................................................................................................... 6 
Target population .................................................................................................................................................... 6 
Inclusion criteria .................................................................................................................................................. 6 
Exclusion criteria .................................................................................................................................................. 7 
Program Implementation ........................................................................................................................................ 7 
Implementation Strategies and Patient Flow ...................................................................................................... 7 
Baseline Assessments .......................................................................................................................................... 7 
Intervention: Standard Program .......................................................................................................................... 8 
Intervention: Telerehab Program ........................................................................................................................ 9 
Parent-delivered therapy (Home-based) ........................................................................................................... 10 
Program Timeline .............................................................................................................................................. 10 
Follow-up and Review (Standard Program and Telerehab Program) .................................................................... 10 
Midterm Progress Review: Visit 7 to Visit 11 .................................................................................................... 10 
Final Reviews and Assessments: Visit 12 to 14 .................................................................................................. 11 
Final Paediatrician review: Visit 15 .................................................................................................................... 11 
Transfer to Early Intervention Programs ............................................................................................................... 11 
Logic Model for Telerehab Program .......................................................................................................................... 12 
Evaluation Framework ............................................................................................................................................... 13 
Literature Review................................................................................................................................................... 13 
Evaluation Questions ............................................................................................................................................. 13 
Effectiveness Trial .............................................................................................................................................. 13 
Process Evaluation ............................................................................................................................................. 13 
Cost-Effectiveness .............................................................................................................................................. 13 
Indicators and Outcomes ....................................................................................................................................... 14 
Data Collection Plan ................................................................................................................................................... 19 
Recruitment ........................................................................................................................................................... 19 
Pilot ........................................................................................................................................................................ 19 
Sample Size Calculation ......................................................................................................................................... 19 
Randomisation Process and Blinding ..................................................................................................................... 19 
Data Collection Time Points ................................................................................................................................... 20 
Exit Review for Early Withdrawals ......................................................................................................................... 20 

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Qualitative Data Collection .................................................................................................................................... 20 
Data Analysis Plan ...................................................................................................................................................... 20 
Qualitative Data Analysis ....................................................................................................................................... 20 
Protocol Deviation and Per-protocol Analysis ....................................................................................................... 21 
Quantitative Outcomes ......................................................................................................................................... 21 
Cost-Effectiveness Analysis ........................................................................................................................................ 21 
Methodology ......................................................................................................................................................... 21 
Decision Problem ............................................................................................................................................... 21 
Objective ............................................................................................................................................................ 21 
Target Population .............................................................................................................................................. 22 
Study Perspective .............................................................................................................................................. 22 
Comparator – Standard Care ............................................................................................................................. 22 
Analysis Approach.............................................................................................................................................. 22 
Time Horizon ...................................................................................................................................................... 23 
Univariate sensitivity analysis ............................................................................................................................ 23 
Probabilistic sensitivity analysis ......................................................................................................................... 23 
Direct Healthcare Costs ......................................................................................................................................... 23 
Health sector cost .............................................................................................................................................. 23 
Direct Non-Healthcare Costs ................................................................................................................................. 23 
Transportation Costs ......................................................................................................................................... 23 
Caregiver and other care costs .......................................................................................................................... 23 
Indirect Costs ......................................................................................................................................................... 23 
Productivity Loss ................................................................................................................................................ 23 
Outcomes............................................................................................................................................................... 24 
Input Data for Outcomes and Cost Data for the Model ........................................................................................ 24 
Data Cleaning Methodology and Approach .......................................................................................................... 29 
Evaluation Management ........................................................................................................................................... 30 
Evaluation Time Frame .............................................................................................................................................. 30 
Dissemination of Findings .......................................................................................................................................... 33 
Quality Assurance and Ethics ..................................................................................................................................... 33 
Quality Review ....................................................................................................................................................... 33 
Research Ethics ...................................................................................................................................................... 33 
References ................................................................................................................................................................. 34 
 
 
 

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Administrative information 
1.Title 
Tele-rehabilitation Program: An innovative and sustainable Early Intervention service for 
children with Autism Spectrum Disorders 
2. Trial registration: 
3. Protocol version: 8 
4. Funding: 
MOH HSDP project to fund manpower, material costs, training and operational costs. 
5. Roles and responsibilities 
5a. Protocol contributors: 
Dr Isaac Sia, Senior Principal Speech Therapist, NUH, Principal investigator 
Dr Chong Shang Chee, Senior Consultant, NUH, Co-Investigator 
Dr Kang Ying Qi, Consultant, NUH, Co-investigator 
Dr Brent Joseph Gibbons, Senior Research Fellow, SSHSPH, Co-Investigator 
Dr Yoong Su-yin, Joanne, Associate Professor, Saw Swee Hock School of Public Health  
5b. Name and contact information for the trial sponsor 
Ministry of Health HSDP, Singapore 
Ms. Quek Boon Zhi, Senior Manager, Health Services Group, Hospital Services Division, Ministry of 
Health, Singapore  
5c. Role of study sponsor and funders 
5d. Composition, roles, and responsibilities of the program evaluator 
 
 
 
 
 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Introduction 
Background & Rationale 
This proposal supports the evaluation of a pilot project focusing on a telerehabilitation (telerehab) 
model for early intervention (EI) in children with Autism Spectrum Disorder (ASD) to improve access 
to services and facilitate intervention in the natural environment of children and their families.  
In Singapore, ASD is ranked number one in disease burden for children 0-14 years of age. The Child 
Development Unit at the National University Hospital serves 3000 children annually, of which 25-30% 
of children have been diagnosed with ASD. Therapists provide interim therapy for these children 
before entry into a community-based Early Intervention Programme for Infants and Children (EIPIC). 
EIPICs currently have waiting times of 6-9 months. Current limitations with our interim care includes 
long wait times, high cost for families, lack of manpower and space to serve the patients, poor parental 
involvement due to their work commitments, parental difficulties attending frequent, but necessary, 
in-hospital therapy and difficulty generalizing patient treatment to the home/community setting, 
thereby decreasing treatment effectiveness.  
The proposed telerehab initiative involves the use of video conferencing technology to help address 
the aforementioned deficits. Offering therapy through telerehab will allow us previously unattainable 
benefits such as seeing the child in their home environment, allowing multiple caregivers to have 
access to the therapeutic training, more frequent contact with families and the ability to trouble shoot 
real life difficulties in real time. The important advantages to the caregivers include less financial 
burden arising from time off from work and travel, more access to treatment over a longer period of 
time and ability to access a multidisciplinary team frequently. An additional benefit for the children is 
they need not travel to unfamiliar environments, which is frequently distressing for children with ASD. 
Lastly, telerehab is a sustainable initiative allowing for less manpower to cover the growing number 
of patients, and the possibility to be implemented in other government run hospitals and clinics facing 
similar challenges.  
Key benefits of this program are: 
1) Enabling parent and caregiver empowerment. Early Intervention in the current model has been 
predominantly centre-based with initiatives to increase caregiver education. A large body of literature 
suggests that early intervention is highly successful when provided at the age of diagnosis, with 
younger children yielding better outcomes. Caregiver involvement is vital to long-term success, as 
they spend a significant amount of time with their child; they can support the generalizations of new 
skills. The National Research Council identifies parent training to be the key component for successful 
intervention for children with autism (NRC 2001), improving quality of life by reducing parental stress 
and increasing optimism. 
2) Addressing nationally identified gaps. The Enabling Master Plan recommendations for 2012-
2016 (under Ministry of Family and Social Development) identifies gaps in family involvement and 
support in acquiring necessary skills and knowledge to be competent in helping their children make 
developmental gains. CDU envisions that telerehab is a viable avenue for supporting parents in 
learning EI skills. 
 
3) Improving existing parent training programmes. CDU has successfully piloted a parent-training 
program for children with ASD called SPEECCH. In our study of the impact of this parent-training 
program (2011), children made measurable progress in all four skill areas assessed (p<0.001). Focus 
on achievable and observable family-centred developmental goals showed evidence for increased 
parental understanding of children’s learning and behaviour & effective use of strategies for facilitating 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
communication and interactions to support their child’s development (p<0.001). However, this 
intervention service could not be sustained due to high caseload demands and insufficient manpower. 
Parent interviews during review visits identified having sustained contact with therapists and parent 
coaching to be key areas of need. 
Currently the service provides intervention for 24 children with ASD weekly for one hour across 12 
weeks, and continued support for up to 20 weeks (maximum of 16 hours of intervention). Of the new 
referrals of 300 children with ASD, if a sustained service is to be provided, only 50% of children will 
receive intervention. In order to address the demand, the frequency and intensity of intervention has 
had to be sacrificed to be able to provide some service to all patients. Hence to maximize the impact 
of early intervention, a sustainable model of service delivery using technology through video 
conferencing is being proposed. 
Objectives and Trial Design 
We propose to evaluate the implementation and effectiveness of delivering telerehabilitation using a 
randomised, controlled, parallel group non-inferiority trial, supplemented by qualitative analysis. 
Participants willing to participate in the proposed research study and providing informed consent will 
be randomized to either the experimental (telerehab program) or control (standard program) arm of 
the intervention. In addition, we will evaluate the service model objectives of increased efficiency and 
sustainability, compared to current standard of care (clinic-based delivery).   
Methods: Program Overview 
Setting 
Child Development Unit, NUH  
Target population 
The target population for the program consists of children referred to the Child development Unit at 
National University Hospital, a tertiary care hospital. Children in the target population meeting all the 
inclusion criteria will be eligible to enrol in the evaluation study. They will be excluded if they meet any 
of the exclusion criteria. We will not be advertising this study to the public. 
Recruitment: Children found to be at risk for Autism Spectrum Disorders (ASD) on clinical evaluation 
by Developmental Paediatrician based on Diagnostic and Statistical Manual of Mental Disorders, 5th 
Edition (DSM-5) criteria will be considered for the study. DSM-5 is the handbook used by healthcare 
professionals as the guide to the diagnosis of mental disorders including ASD. 
Inclusion criteria 
1. Children aged 15-48 months 
2. Children meet cut off score for Autism Spectrum Disorders (ASD) on Autism Diagnostic 
Observation Schedule-2 (ADOS): The Autism Diagnostic Observation Schedule (ADOS) is a 
semi-structured assessment of communication, social interaction, and play (or imaginative use 
of materials) for individuals suspected of having autism or other pervasive developmental 
disorders. The ADOS consists of a toddler module and four other modules, each of which is 
appropriate for children and adults of differing developmental and language levels, ranging 
from nonverbal to verbally-fluent. The ADOS consists of standardized activities that allow the 
examiner to observe the occurrence or non-occurrence of behaviours that have been identified 
as important to the diagnosis of autism and other pervasive developmental disorders across 
developmental levels and chronological ages. 
3. Parent(s) is/are willing and able to give informed consent 

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4. Families with at least one parent who is digitally literate with the home use of the internet and 
access to Wi-Fi 
5. The same parent(s) or caregiver(s) in attendance for most intervention sessions and all review 
sessions in order to monitor performance across outcome measures  
Exclusion criteria 
1. Participants not having access to the internet will be excluded 
2. Received or receiving other treatment or interventions (Note: this is an exclusion criterion but 
not a withdrawal criterion) 
3. Children with genetic and other associated auditory or visual impairment and/or seizure 
disorders 
Program Implementation  
The current standard program for early intervention treatment is in-clinic therapy based on the 
Foundational Skills Curriculum (FSC): a framework for early intervention developed from outcomes 
of an Autism research project conducted in the UK. This framework provides a clear and systematic 
approach to understanding the child’s functioning in 3 core areas of development (across 141 items): 
Play, Social Interaction, and Communication. 
The telerehab program will provide parent coaching on EI through video conferencing using the FSC.  
The telerehab program aims to improve access to services and facilitate intervention in the natural 
environment of children and their families by developing video conferencing (VC) as a feasible and 
acceptable medium to build parent capabilities in EI. The specific service model objectives are to 
realize positive gains in service efficiency (i.e. reducing the total time and resource utilization per 
completed intervention course relative to current practice); reduce total costs and non-financial 
barriers for patients (i.e. access) as well as the total cost to the health system per completed course 
(i.e. sustainability) and realize positive gains in provider productivity and hence cost-effectiveness (i.e. 
reduced cost per unit outcome achieved). 
Implementation Strategies and Patient Flow 
CDU receives referrals from polyclinics for children at risk of ASD. These referrals will be scheduled 
for a developmental assessment by the developmental paediatrician. Baseline assessments will be 
conducted under the program as well as under standard care. Children who are enrolled into the 
evaluation study will then continue with either the standard program (clinic-based therapy) or the 
telerehab program. The program schedule for the patient in terms of type of visits and intervention 
blocks for both the standard program and telerehab is shown in Annex 1: Program Schedule. The 
duration of clinic-based intervention sessions will be 60 min while the duration of VC based 
intervention sessions will be 45 min.1 
Baseline Assessments  
Visit 0/1: Child found to be at risk for ASD on clinical evaluation by the developmental paediatrician 
based on the DSM-5 criteria will be referred for this study. The informed consent will be obtained prior 
to undergoing any research-related activities.     
Visit 2 to 3: Upon parent consent in Visit 0 or 1, the child will be assessed on the MSEL and ADOS. 
However, MSEL assessment may be conducted before informed consent as part of clinical routine 
practice. They will also be assessed on the Vineland Adaptive Behaviour Scales (VABS) and 
                                                             
1 Clinic-based intervention sessions are 60 minutes while VC based intervention sessions are 45 
minutes. This includes an additional 15 minutes for therapists’ administrative and documentation 
time. 

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Parenting Stress Index (PSI). Children who meet the criteria for Autism on the ADOS and do not have 
any of the exclusion criteria will be offered to be part of the study.  
Visit 4: On completion of the above assessments, the paediatrician will share the MSEL and ADOS 
report with parents and confirm enrolment into the study if the child meets the inclusion criteria. If the 
child does not, they will be referred to standard care outside the study. Children whose parents 
consent to be on the study will be randomly assigned to either the telerehab program (experimental 
arm) or standard program (control arm) using block randomisation. The paediatrician will inform 
parents of the study arm that they are assigned to.  
Visit 5a: Initial assessments based on the FSC, Joint Engagement Rating Inventory (JERI), child’s 
routines (parent interview) and Family Early Intervention Quality of life (FEIQoL) will be completed for 
all. Parents will also participate in a short demographic and cost survey. If parents are unable to 
complete the surveys during their clinic-based session, they will be sent the surveys through email or 
asked to answer the questions over a phone call. Parents may also be invited to participate in an 
(semi structured,  in–depth) interview for evaluating the perceived effectiveness of standard care. 
Visit 5b: For the telerehab group, initial assessments and observations will be collected through 2 
settings, one clinic-based, as well as one using VC. The latter is done in order to observe parent-child 
interactions and skills demonstrated by the child in the context of the natural home environment. The 
VC assessment and intervention will be conducted using a MOHH commissioned VC platform. This 
platform will allow the therapist and parents to see, hear, and communicate with one another live in 
real-time. The therapist will access the program from an office computer with a web-camera in the 
clinic, whereas parents will access the program from their home. Parents who do not have the 
necessary equipment for VC will be provided with notebook computers and needed accessories. An 
orientation to the use and care of VC equipment will be provided. 
Visit 6: Parents of children in both programs will attend a parent education workshop. The workshop 
will discuss the role of parents and therapists in early intervention, the key areas that children have 
difficulties with during development, the use of routines to facilitate the child’s learning and strategies 
that can be embedded in routines. If parents choose to not attend the workshop or are unable to 
attend their scheduled workshop, parents can still proceed with the intervention phase. Parents who 
are unable to attend the workshop will be reminded to reschedule the workshop to the next available 
date and will have training slides and materials sent to them through email for their reading. Parents 
will have also have opportunities to seek further clarification during subsequent visits with their 
therapist. 
Intervention: Standard Program  
The profile of the child in terms of their developmental status based on initial evaluation results and 
an individualised intervention plan (IIP) will be discussed by the therapist with parents. The therapist 
will coach parents in the context of clinic-based play activities and help parents identify contexts and 
activities at home where the parents could follow up on the program at home. Children and their 
parents will receive the standard program which consists of 16 clinic-based intervention sessions of 
60 min each, separated into 3 intervention blocks, with breaks in between so that parents will have 
opportunities to practise at home. This arrangement also allows parents who had missed their 
scheduled sessions to have make-up sessions during the breaks. Intervention sessions empower and 
equip parents with skills and strategies to engage with their child at home. Since the program involves 
behavioural intervention and parent coaching, active participation of parent and child are key to each 
session. However, realistic challenges in terms of child/parent or therapist being unwell, or when the 

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parent has work related commitments, may require rescheduling or cancellation of some visits. These 
are not anticipated to have any adverse impact on the child’s health or the study.   
Intervention: Telerehab Program  
The intervention will commence with 2 clinic-based intervention sessions of 60 min each to provide 
adequate opportunity to engage in relational family-centred practices, joint decision and planning of 
the IIP based on initial evaluations and explore effective strategies as foundation to the subsequent 
interactions and coaching through VC.  
Setting: Prior to intervention sessions, the therapist and parent will discuss and identify a suitable 
and feasible location to place the devices of their choice that would provide clear unobstructed views 
of parent-child interactions and activities. For 16 sessions, the therapist and parent will log onto the 
MOHH VC portal for the VC call.  
VC sessions are provided remotely by the child’s therapist from the clinic. Parents who do not have 
the necessary equipment for VC will be provided notebook computers and omnidirectional 
microphones. The MOHH commissioned VC platform will be used for observing the home session 
and coaching parents. Parents will orient the computer’s web cam to the selected activity area in the 
home while using the wireless headset for communication. An omnidirectional portable microphone 
will be placed in the vicinity of the routine home activity so that the therapist can look, listen and 
understand the dynamics of parent child interactions clearly during a given daily routine involving the 
child.  
Telerehab sessions will follow the ethical and practice guidelines of computer-mediated intervention 
including online communication, consent, confidentiality & privacy and security issues, verbal and 
nonverbal feedback. 
Strategies: Parents will be trained in using evidence-based strategies (e.g., follow your child’s lead, 
imitation & modelling, communicative temptations, playful obstructions) during playtime activities and 
daily routine. 
Approach: Intervention sessions will be provided by therapists trained in the FSC and the parent 
coaching protocol. Parent-child interactions during activities at home will be observed through the VC 
platform comissioned by MOHH. Parents will be encouraged to interact with their child using 
strategies aimed at increasing their child's attention and motivation, turn-taking routines, initiating and 
responding to joint attention, communication, etc. Sessions will follow the collaborative practice 
protocol. The protocol provides an outline for the session structure (i.e. checking in, reviewing, 
observation, reflection, explanation and coaching of new topics and strategies, setting goals and 
follow-up planning in the home context and closing).  
At the start of the session, the parents’ progress from the past topic and any other updates will be 
reviewed and discussed for 5–10 minutes. This is then followed by a 10-minute parent-child play 
activity. The activity allows the therapist to observe the parent’s competency in implementing 
intervention (i.e. the goals and effective use of strategies) from the previous session’s coaching. 
Based on observations made, the therapist will coach further to strengthen parent’s confidence and 
competency in using strategies to facilitate the attainment of specific learning objectives in the IIP. 
During the final 10–15 minutes of each session, the therapist will seek feedback from the parent to 
understand parent’s clarity, comfort and confidence in implementing the intervention plan and provide 
further input and information if required. The therapist will also address any challenges faced or 
anticipated in the context of implementing the intervention in the home context. The therapist will 
discuss with parents to implement the intervention plan using at least two play or daily routines 
(naturally occurring opportunities) identified by the parent. Adult learning principles will be adopted by 

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the therapist to facilitate active participation in planning and intervention implementation. For clinic-
based sessions, an additional 15 minutes is allocated to allow the child and parents to settle down 
and transit into and out of the therapist’s room.  
Data collection: For all subjects, video recordings of parent child interactions will be taken at 4 
specific time points, namely Baseline, two Midterm reviews and Final review. Specific to the children 
in the telerehab arm, an additional video recording of parent-child interaction will be done through VC 
for each on-site review session, totalling 8 video recording time points throughout the program’s 
duration. Recorded videos will be downloaded and transferred to a password encrypted hard drive 
authorized by the institution data protection and security teams. These recordings can only be 
accessed by authorized team members with institutional accounts and external raters. They will be 
used for evaluation on the JERI, NDBI-Fi and for inter-rater reliability assessment.  
Parent-delivered therapy (Home-based) 
At the end of each intervention session and at the end of each intervention block, a joint discussion 
will be held to craft a plan for parents to implement. This will include the functional goals to be 
embedded, specific strategies to be used that the parent has been coached in and the home routines 
that the parent plans to implement. Intervention related resources such as description of strategies 
and examples of embedding within routines and documents on the plan will be shared with parents 
for their reference.  
Program Timeline 
While set timeframes for assessments, intervention and reviews are important, this study will be 
implemented under routine operational conditions of the clinical service. The standard practice of 
having the same therapist for each session for continuity will be adopted. Scheduling challenges are 
an unavoidable field condition. This is compounded by the need for rescheduling of sessions at times, 
such as when a child/family member or therapist is unwell. For these reasons, the duration of time to 
complete each intervention block may vary slightly for each child. It may also vary between the 
intervention and control groups.  
In general, where delays from scheduling occur, each child will move to the next phase of the study 
(i.e. intervention and follow-up reviews) only when they have completed all planned sessions in the 
previous phase (e.g., intervention will only begin after all baseline assessments have been 
completed). These are recognised as limitations of the study design and will be considered when 
interpreting the study findings. 
Follow-up and Review (Standard Program and Telerehab Program) 
Midterm Progress Review: Visit 7 to Visit 11 
Paediatrician Review (two visits): The paediatrician will review the child’s general developmental 
profile, progress and child and family needs. The clinician will make appropriate recommendations 
and referrals as needed.  
Therapist Review (two visits): Therapists will review the child’s developmental profile on the FSC 
and JERI to track progress on the intervention plan and for program evaluation purposes. A cost 
survey will also be conducted with parents during these reviews by a member of the study team to 
identify any changes to household income and cost burden. If parents are unable to complete the 
survey during their session, they will be sent the survey through email or asked to answer the 
questions over a phone call. 
Midpoint IIP review: Therapists will review the child on the individualized intervention plan (IIP) 
developed after baseline assessment and plan for further intervention. 

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Final Reviews and Assessments: Visit 12 to 14 
The final reviews and assessments will be conducted across three sessions, which can take place in 
any order depending on the participant’s availability and therapist’s schedule.  
Final Review with Therapist: The child will be evaluated on the baseline assessment measures. 
Parents will also be given a parent satisfaction survey, cost survey and FEIQoL survey to complete. 
If parents are unable to complete the surveys during their clinic-based session, they will be sent the 
surveys through email or asked to answer the questions over a phone call. For children in the 
telerehab group, there will be a VC review in addition to the clinic-based assessment. 
Nurse Assessment: The child will be evaluated on MSEL. The Parental Stress Index will be 
administered as part of this assessment. 
Psychologist Assessment: VABS-III will be administered to the parent for this assessment. 
Final Paediatrician review: Visit 15 
This last paediatrician visit is for the paediatrician to share the reports on the evaluations, discuss 
progress and further needs of child and family. 
Transfer to Early Intervention Programs  
CDU provides interim therapy for children pending their enrolment into an EIPIC (or private early 
intervention service). Under normal circumstances, the child does not receive any intervention from 
EIPIC in the first 10 weeks on enrolment as the child is being assessed. In this transition period, the 
child continues to receive CDU intervention per standard clinical practice. As such, children in this 
study will continue to receive intervention for 10 weeks after EIPIC enrolment. Similarly, children who 
has been transferred to a private intervention service will continue to receive intervention per the study 
protocol as long as they have not started receiving intervention at the private service.  
Children also continue to remain as CDU patients under the care of their doctors until age 7, 
regardless of whether they have been enrolled to an EIPIC or private service. As such, study 
participants who have been transferred to an EIPIC will still be assessed per protocol for Midterm 
Progress Reviews and Final Reviews and Assessments. As far as possible, these assessments will 
be scheduled to coincide with their doctor’s follow-up at the CDU as part of standard care.  

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Logic Model for Telerehab Program 
 
 
 

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Evaluation Framework 
 
Literature Review 
There is a dearth of published research on the use of telehealth in coaching for parents of 
children with autism spectrum disorders. A literature search found only two representative 
studies (Vismara et al, 2013 and Maedan et al, 2016) both from the United States and with 
small sample size.   
One study followed eight families over a 12-week online video conference based intervention 
with three month follow up. Parents reported a better understanding of and appreciation for 
helping their children new skills, as well as increased confidence in addressing their child’s 
needs and sharing information with other caretakers. The other described a similar Internet-
Based Parent-Implemented Communication Strategies (i-PiCS) parental coaching program 
with 3 mother-child dyads and found positive changes in children’s communication skills with 
the implementation of the strategies taught in coaching. As illustrated by the sample size <10 
in each, neither previous study followed a rigorous RCT methodology but both studies 
highlighted the potential of telehealth as a feasible service-delivery option for parental 
coaching and called for further more robust studies of telehealth interventions with a greater 
diversity of participants. 
Evaluation Questions 
Effectiveness Trial 
Primary Research Question: Is the tele-health intervention as effective as standard care in 
improving short and long-term outcomes for children and parents?   
 
Process Evaluation 
 
How feasible and acceptable is the tele-health intervention? 
 
What features or conditions make the tele-health intervention more or less effective? 
 
What could be improved with acceptability, feasibility and scalability in mind? 
Cost-Effectiveness 
Is the tele-health intervention cost-effective (cost-saving) relative to standard care?

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Indicators and Outcomes 
Evaluation 
Question 
Primary 
indicator 
required 
Measurement & Reference 
Expected change 
a.  
Is the 
intervention as 
effective as the 
standard care 
model in 
improving the 
level of function 
among children 
with ASD? 
Mullen’s Scale 
of Early 
Learning 
(MSEL)  
MSEL is a standardized developmental assessment to examine developmental 
skills of children aged birth to 68 months on gross motor and cognitive scales 
using 5 subscales: Gross Motor, Visual Reception, Fine Motor, Expressive 
Language, and Receptive Language. T scores, percentile ranks, and age 
equivalents can be computed for the five scales separately. 
For each scale, the assessment derives a T-score with a mean of 50 and 
standard deviation of 10, a percentile score, and an age equivalent indicating at 
what developmental age the child is performing. An early learning composite 
(ELC) score is calculated from the total of scores on all scales (excepting the 
gross motor scale) with a mean of 100 and standard deviation of 15. T scores 
for subscales have a mean of 50 (SD: 10). (Bacon et al,2014) 
 
For children suspected of ASD, MSEL is often chosen because of its wide age 
range and 5 subscales that allow separate assessment of verbal and non-verbal 
abilities. 
 
Previous studies of intervention efficacy has used MSEL subscale scores for 
greater granularity of analysis, to understand the impact of intervention on 
specific functions of the child and separate assessment of verbal and non-verbal 
activities (Vismara et al, 2009). 
 
Differences in scores 
on the subscales of the 
MSEL from baseline to 
program conclusion  
will be calculated and 
compared between the 
two intervention groups  
 
 
Vineland 
Adaptive 
Behaviour 
Scales (VABS-
III)  
VABS-III is a standardised assessment tool that utilises a semi-structured 
interview format to measure adaptive behavior. The main domains are: 
Communication, Daily Living Skills and Socialization. The Vineland-III is used 
for measuring an individual’s daily functioning, progress planning and 
monitoring. 
 
Differences in scores 
on VABS-III in 
communication, 
socialisation and daily 
living from baseline to 
program conclusion will 

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VABS-III provides a measure of adaptive skills used to cope with challenges of 
daily living. A caregiver completes a questionnaire regarding the individual’s 
current level of functioning across three domains: communication, daily living 
skills and socialization. The Vineland Scales are applicable to children with and 
without delays from birth to 18 years, 11 months. All scales use standard scores 
with a mean of 100 and a standard deviation of 15, a percentile score, and an 
age equivalent indicating at what developmental age the individual is 
performing. Scores on the three domains are combined to obtain an overall 
adaptive behavior composite (ABC) with a mean of 100 and a standard deviation 
of 15. 
be calculated and 
compared between the 
two intervention groups 
b.  
Is the tele-
health 
intervention as 
effective as 
standard care in 
improving 
parent-child 
interaction? 
Joint 
Engagement 
Rating 
Inventory 
(JERI)  
JERI measures:  
- joint engagement, 
- communication dynamics and  
- shared topics in a caregiver-child interaction on a 7-point likert scale (Adamson 
& Bakeman, 2012). 
 
This is a structured assessment of joint attention and communication. It 
measures multiple aspects of caregiver-child interactions and identifies the 
specific triadic elements in engagement which are effected in Autism. This has 
the advantage of being a standardized assessment of social communication. It 
provides an insight into the dynamics of caregiver child interactions which will 
help in intervention planning to enhance the quality of caregiver-child 
engagement. 
Change on the JERI 
will be tracked by 
calculating the changes 
in: 
- nature of joint 
engagement,  
- child’s participation in 
joint engagement with 
caregiver, 
- caregiver behaviours 
during engagement 
and  
- the range and quality 
of the caregiver-child 
interactions  
 
from baseline to 
program conclusion 
and compared between 
the two intervention 
groups 
 
c.  
Parenting 
Stress Index-
PSI-SF (Abidin, 1995) is an abbreviated version of the PSI. It is a 36-item self-
report questionnaire assessing the level of relative stress in a parent-child 
Change on the PSI-SF 
across 3 domains: 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Is the tele-
health 
intervention as 
effective as 
standard care in 
improving 
parental stress? 
 
Short Form 
(PSI-SF)  
 
 
 
 
 
 
 
 
 
 
 
relationship. The questionnaire is meant for parents of young children, and can 
be used for the parents of children 0-12 years of age. Each item requires the 
parent/caregiver to rate the degree to which s/he agrees with a statement on a 
five-point Likert scale (1 = Strongly Agree, 2 = Agree, 3 = Not Sure, 4 = Disagree, 
and 5 = Strongly Disagree). The questionnaire’s 36 items are divided into three 
subscales: Parental Distress (PD), Parent-Child Dysfunctional Interaction (P-
CDI), and Difficult Child (DC). Items are scored and added together to establish 
a total score as well as three subscale scores. 
 
The PSI-SF produces subscale raw scores ranging from 12 to 60 and an overall 
Parenting Stress (PSI-PS) total score that ranges from 36 to 180; a higher score 
indicates a greater level of stress. A PSI-PS score above 85 (at the 90th 
percentile) indicates clinically significant parenting stress (Abidin, 1995). 
 
parental distress, 
parent-child 
dysfunctional 
interaction and difficult 
child will be tracked by 
calculating the change 
in raw scores on the 
PSI-SF from baseline 
to program conclusion 
and compared between 
the two intervention 
groups 
d.  
Is the tele-
health 
intervention as 
effective as 
standard care at 
improving child 
outcomes over 
the long term 
and various 
contexts? 
 
Mullen’s Scale 
of Early 
learning 
(MSEL) Early 
learning 
Composite 
(ELC) 
For each scale, the assessment derives a T-score with a mean of 50 and 
standard deviation of 10, a percentile score, and an age equivalent indicating 
at what developmental age the child is performing. An early learning composite 
(ELC) score is calculated from the total of scores on all scales (excluding the 
gross motor scale) with a mean of 100 and standard deviation of 15. T scores 
for subscales have a mean of 50 (SD: 10) (Bacon et al., 2014). 
 
Early learning composite score has also been widely used as a score to 
compare effectiveness of early intervention programs (Shank 2011, Bishop et 
al., 2011). 
 
 
Differences in ELC 
score from baseline to 
program conclusion will 
be calculated and 
compared between 
intervention groups 
e.  
Is the tele-
health 
intervention as 
acceptable as 
standard care? 
Parent 
Satisfaction 
Survey and 
Parent 
Interview 
 
Parent Satisfaction Survey: This 13-item survey uses a 5-point Likert scale to 
obtain parents’ feedback on the telerehab program at the end of the intervention. 
Each item requires the parent/caregiver to rate the degree to which s/he agrees 
with a statement on a five-point Likert scale (1 = Strongly Disagree, 2 = 
Disagree, 3 = Neutral, 4 = Agree, and 5 = Strongly Agree). 
 
Parent Satisfaction 
Survey will be collected 
at the end of the study 
and the responses will 
be compared between 
the two intervention 
groups 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Pre-Programme Parent Interview on the following prior to parents starting on 
telehealth intervention program: 
 
1. Demographics 
2. Current situation (Knowledge, Existing sources of support and coping 
mechanisms, perceived barriers) 
3. Telehealth Programme Intervention (Technology comfort, motivation, 
expectations, perceived barriers/challenges) 
 
Post-Programme Parent Interview on their experience with the telehealth 
intervention program. 
 
Interviews will only be conducted with participants who have indicated interest 
and consented to participate in the qualitative interviews. 
 
f.  
Is the tele-
health 
Intervention as 
effective as 
standard care in 
enhancing  the 
family’s 
perceived 
quality of life? 
Families in 
Early 
Intervention 
Quality of Life 
(FEIQoL) 
FEIQoL includes 40 items across 4 areas rated on a 5 point Likert scale:  
1. Family Relationships (Problem solving, communication, parenting, 
relationships with extended family, and family participation in social 
activities) 
2. Access to Information and Services Knowledge of their child's disability, 
child development, managing challenging behaviors and resources such 
as support services, medical assistance, and organizations in their 
community 
3. Child Functioning (Child's engagement, independence, and social 
relationships within family daily routines)  
4. Overall Life Situation (Fulfillment of family needs in health, financial 
resources, and employment.) 
 
Change on the FEIQoL  
will be tracked by 
calculating the changes 
on the 4 areas from 
baseline to program 
conclusion and 
compared between the 
two intervention groups 
g. 
Is the tele-
health 
intervention 
more cost-
effective than 
Total direct 
and indirect 
costs from 
health system 
and societal 
perspective  
Total direct and indirect costs from health system perspective: Total intervention 
costs, including development costs, cost of using the videoconference platform, 
labour and infrastructure as well as total medical costs and costs of other 
interventions incurred by parents as related to ASD. Costs related to the 
evaluation alone will be excluded. 
 
Compare total direct 
and indirect costs from 
baseline to program 
conclusion from health 
system and societal 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
the standard 
care? 
 
Total direct and indirect costs from societal perspective: As above and also 
including cost of travel and productivity losses incurred by parents. 
 
perspective between 
two intervention groups 
h. Is the tele-
health 
intervention 
effective 
in 
improving 
parents’ 
implementation 
of intervention 
strategies? 
NDBI 
(Naturalistic 
Developmental 
Behavioural 
Interventions)-
Fi 
NDBI-Fi is an 8-item observational rating scheme that evaluates caregiver 
implementation of common strategies from treatments classified as NDBI based 
on short videos of caregiver-child interactions.  
Change on the NDBI-Fi 
will be calculated by 
tracking the changes 
on individual items and 
average rating from 
baseline to program 
conclusion for 
participants in the 
telerehab arm 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Quantitative process indicators (the outputs indicated in the logic model) will be assessed in 
the intervention group as well as part of monitoring and process evaluation.  
The qualitative research questions will enhance our understanding of both the impact and 
process-related outcomes, using semi-structured interview guides. Parents will be asked 
about perceived effectiveness, engagement and stress, as well as their ability to cope 
financially with treatment.  At baseline, we will also investigate attitudes/perceptions towards 
telerehab, and factors that affect willingness to take up telerehab. At the end of the study, 
while the scope of the quantitative evaluation is limited, we will explore parent experiences, 
satisfaction and concerns, and perceptions of sustainability and future care plans.   
Data Collection Plan 
Recruitment 
Patients will be recruited for the program after obtaining a preliminary diagnosis of ASD from 
the developmental paediatrician. ADOS-2 will be administered to confirm the diagnosis and 
thus participation in the research study. We will not be advertising this study to the public. 
Pilot 
An initial pilot feasibility study with 6 children and families will be conducted at the start of the 
project to identify any practical issues or weaknesses in the program or protocol before full 
scale evaluation.  
Sample Size Calculation 
The randomized trial is designed as a non-inferiority study to compare the changes in MSEL 
between 2 interventions. We expect that the change in MSEL score for the subjects in the new 
intervention arm will be slightly better than that in the control arm by 1.5 units.  Assuming the 
SD of changes in MSEL score is 15 units, with 5 units as the non-inferiority margin, based on 
a one-sided test with 80% power and 5% significance level, it is sufficient to recruit 132 
subjects (66 in each arm).  We decided to recruit 200 subjects in total (100 in each arm) after 
considering withdrawals and lost to follow up. The computation was performed using a 
proprietary software programmed in R. 
Randomisation Process and Blinding 
Computer-generated randomisation will be used to randomly assign the participants to one of 
the intervention groups. Block randomisation will be used to allocate the recruited subjects 
into one of the interventions. A randomisation list will be generated by the study statistician 
and envelopes will be prepared. Although the allocation of intervention will be concealed and 
the study team will not know in advance which subject will receive which intervention, the 
blinding will not be possible once the intervention is assigned. Assessors of the initial and final 
MSEL were not told of the intervention status of the patient to avoid bias in outcome 
assessment. Blinding of the parents is not possible in the context of this study. Phone calls 
will be made if necessary to confirm appointments and/or before commencing consultation 
over video conference in the Telerehab group. Parents in both study arms will be encouraged 
to spend 2h per week in quality interactions with their children. 
Children who meet the inclusionary criteria will be randomly assigned to the standard or 
telerehab group of the study. Parents will be informed of the randomisation assignment and 
clinical diagnostic impression on ADOS. Baseline evaluation measures – Mullen’s Scales of 
Early Leaning (MSEL), Vineland Adaptive Behaviour Scales (VABS-III), Parenting Stress 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Index (PSI-SF), Joint Engagement Rating Inventory (JERI) and FEIQoL (Families in Early 
Intervention Quality of Life) - will be completed for all.  
Data Collection Time Points 
The child and parents’ skills will be recorded at 4 data points (baseline; 2 midterm reviews; 
final review) and progress tracked on the IIP, JERI and FSC. Parent questionnaires will be 
given at the end of the intervention to evaluate parents’ experience with the technology used 
in the sessions, using a Likert Scale, and to evaluate their experience as providers of 
intervention services to their child. Video analyses will be performed by external raters. Inter-
rater reliability will be calculated based on the assessments of raters (number of 
agreements/number of agreements plus disagreements). Hospital resource use pertaining to 
the intervention will be recorded at each point as well as healthcare expenditures and 
household resource use, travel expenses and caregiver time spent.  
All clinical data will be collected in the case record form designed for the collection of data for 
the study. For the various assessment tools that will be used, data will be collected on the 
assessment tool itself, which will serve as the source of that data.  
All data will be later transcribed to excel sheets or other relevant databases as soft data for 
statistical analysis. The data will be coded to remove any patient identifiers before sharing with 
the statistician for analysis. 
Exit Review for Early Withdrawals 
If the participant has completed their first block of intervention and requests to withdraw from 
the study before their final reviews and assessments (Visit 12 to 14), they will be presented 
with the option to come back to the clinic for an exit review before withdrawing. In the exit 
review, the child will be assessed on MSEL, parental stress index, parent satisfaction survey, 
cost survey, FEIQoL and VABS. Specific to the children in the telerehab arm, an additional 
video recording of parent-child interaction will be done through VC. However, participants can 
opt to not come back for the exit review and withdraw from the study immediately.  
Qualitative Data Collection 
In-depth interviews (IDIs) would be conducted twice: (i) before parents participate in the 
program and (ii) at the end of the program or before they withdraw from the program or when 
they are transiting out of the program to receive early intervention beyond CDU before the 
completion of the program.  
Recruitment strategy: To space the recruitment of participants for IDI, we will recruit every 3rd 
participant (caregiver of patient) enrolled into the study, have consented to participate in the 
IDI and will be able to undergo the interview in English. We estimate that we will recruit up to 
10 parents in each study arm (standard and telerehab group) i.e. 20 parents, 2 interviews each 
and 40 interviews in total. 
Data Analysis Plan 
Qualitative Data Analysis 
For the qualitative research component, applied thematic analysis would be used to analyse 
the qualitative data gathered to understand the concerns and experience of the programme 
from the perspectives of the parents.  

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
A professional transcriptionist will complete data transcription. A standard operating guideline 
and format of the verbatim will be established jointly by the principal researcher and the 
transcriptionist. Subsequently, the qualitative analysis research team will perform an iterative 
and inductive process of identifying new themes and sub-themes derived from participants’ 
narratives. A codebook that best describe the data would be developed and used through 
coding and constant comparison to establish inter-coder reliability by the team for the analysis 
of all transcripts. 
Protocol Deviation and Per-protocol Analysis 
Protocol deviation is defined as any divergence from what was pre-planned and approved by 
the institutional review board. As the study is conducted as part of routine care and operations, 
there are practical constraints that may cause protocol deviations to occur. Rescheduling of 
appointments by the parents (e.g. due to work constraints, child’s sickness, other events) or 
defaulting appointments is inevitable. Hence, for per-protocol analyses, we will only exclude 
participants with major protocol deviation, which will be defined as participants who do not 
complete 80% of the intended therapy sessions allocated for their study arm. This means that 
a control arm participant must attend at least 8 out of 10 clinic-based sessions. For the 
remaining 2 sessions, participants can either be attending it through video-conferencing (due 
to the COVID-19 pandemic) or miss the appointment.  
Quantitative Outcomes 
For the randomized trial, since the study is a non-inferiority study, statistical analysis will be 
carried out on a per-protocol basis. Subjects with any major protocol deviation as defined 
above will be excluded from the final analysis.  
All demographic, clinical and cost characteristics will be analysed descriptively. Mean (SD) or 
median (range), whichever is more appropriate will be reported for numerical variables, while 
N (%) will be reported for categorical variables.2-sample t-tests, or Mann-Whitney U tests will 
be used to compare the change of MSEL score between 2 arms. Mean difference and 95% 
CI will be estimated.  If the lower boundary of the 95% CI is more than -5, non-inferiority will 
be declared. Changes in the quality of parent-child engagement, parental stress index score, 
and adaptive score will be compared by using either a 2-sample t-test, or a Mann-Whitney U 
test, whichever is more appropriate. Linear regression will be used to adjust for any covariates. 
Cost-Effectiveness Analysis 
To examine cost-effectiveness, we will compare resource utilization between treatment and 
control groups to estimate resource and cost differences in absolute terms from the direct 
medical cost perspective as well as the societal perspective (inclusive of the direct costs of 
travel and the indirect cost of parental time). As the trial focuses on non-inferiority, the 
assessment of cost-effectiveness will rely on whether the intervention is cost-saving relative 
to the standard of care. We will also perform modelling estimates to quantify the uncertainty 
surrounding the incremental cost-effectiveness ratio.  
Methodology 
Decision Problem 
Objective 
To assess the cost-effectiveness, in terms of incremental cost effectiveness ratio (ICER) of 
the tele-health (telerehab) mode of delivering the early intervention (EI) in children with 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Autism Spectrum Disorder (ASD) relative to the standard care (clinic-based sessions only) in 
costs and outcomes as measured by Mullen Scales of Early Learning (MSEL), Vineland 
Adaptive Behavioural Composite score (VABS) and Joint Engagement Rating Inventory 
(JERI). 
 
Figure 1: Incremental cost-effectiveness ratio (ICER), calculated by the difference in cost 
between two possible interventions, divided by the difference in their effect. 
Target Population  
The study target population for these analyses will be the children assessed to fulfil the 
inclusion criteria of the Telerehab RCT from NUH CDU. The delivery of early intervention 
heavily involves a caregiver, often the biological parent(s) of the children receiving therapy for 
early intervention.  
Study Perspective 
The study will take on a societal perspective. This includes healthcare costs from the 
provider’s perspective, non-healthcare costs incurred by the patient from social care and child 
care, as well as productivity losses for the patient’s caregiver.  
The time horizon of the study includes the cost incurred and benefits from the entire program 
duration, from enrolment to the final review. 
Comparator – Standard Care 
The comparator for this study will be the standard model of delivery for EI which are clinic-
based (face-to-face) sessions with the patients and their primary caregiver. The variable 
treatment component between telerehab and the standard model of delivery is the number 
of video-conferencing vs clinic-based intervention sessions. The assumption is that all non-
therapy related costs such as paediatrician reviews will be the same for subjects in both study 
arms.  
Table 1: Variable components of care between standard and telerehab care model 
 
Standard Model 
Telerehab Model 
Clinic-based intervention 
(45mins + 15mins) 
16 sessions 
2 sessions 
Video-conferencing  
(30mins + 15mins) 
0 sessions 
16 sessions 
Total Therapy time 720mins + 240 mins (admin) 570mins + 270 mins (admin) 
 
Analysis Approach 
We will take on two approaches to calculate the ICER. First, is the use of patient-level data for 
cost-effectiveness analysis. Second, we will use estimates generated from analyses Monte 
Carlo simulation to estimate the cost-effectiveness through parameters (mean, standard 
errors) obtained from the study. This will be decided by the analyst with the justification for the 
approach documented.  

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Time Horizon 
The time horizon considered will be the duration of the program (around 1 year), from 
enrolment till final review. The cost and outcomes data collected will be limited to the duration 
of the program. It will be hard to justify extrapolations and assumptions after the program after 
the patient has transited out of NUH CDU to EIPIC, where treatment frequency and intensity 
will be substantially variable.  
Univariate sensitivity analysis 
One-way sensitivity analysis will be performed to assess the impact of a change in parameters.  
Probabilistic sensitivity analysis2 
Probabilistic sensitivity analysis (PSA) will be performed by incorporating the degree of 
uncertainty for each parameter. This involves assigning a primary mean value for each model 
parameter (mean cost, number of visits, probabilities) and the distribution of possible values. 
Monte Carlo simulation was used to estimate mean expected costs and outcomes, and 
statistical measures of expected variance (SD) around the mean for 1,000 iterations drawn 
from the distributions defined. 
Direct Healthcare Costs  
Health sector cost 
Health sector cost will be primarily attributed to the cost of treatment delivered by the 
institution, NUH CDU. The gross charges for paediatrician review, IIP review and 
administering surveys and assessments for the children are consistent in both study arms. 
Only variable cost between both study arms will be included. The variable cost includes the 
clinic-based intervention charges and video-conferencing-based intervention charges across 
both arms. The assumption for health sector cost will be that participants from both arms 
attend all the review and assessment sessions as they are essential to the intervention plan. 
The only variability would be attributed to defaulted therapy sessions.  
Direct Non-Healthcare Costs  
Transportation Costs  
Transportation cost will be estimated using the responses from the baseline cost survey 
administered to caregivers. The total transport cost per study arm (standard vs telerehab) will 
be calculated by multiplying the observed number of clinic-based visits (accounting for missed 
appointments/therapy sessions) with the average cost of transportation indicated by the 
caregiver multiplied by two to account for round-trip travelling.  
Caregiver and other care costs 
Costs from other sectors include care cost from attending courses, hiring domestic helpers 
and/or other forms of care support for the child. This information is obtained from the cost 
survey administered to the parents.  
Indirect Costs  
Productivity Loss 
Productivity loss will be calculated using the human capital approach. The human-capital 
method takes the patient's perspective (in this case the parent’s time) and counts any hour 
not worked as an hour lost.  
                                                             
2 https://yhec.co.uk/glossary/probabilistic-stochastic-sensitivity-analysis/ 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Productivity loss in this study will be primarily attributed to the caregiver taking time off from 
work to attend treatment with the patient (their child) and applying intervention strategies with 
the child. The time spent by caregivers includes the following:  
i. 
time spent on travelling CDU for treatment (two-way trip);  
ii. 
time spent on therapy sessions (30mins for video-conference, 45mins for clinic-based); 
iii. 
employment charges 
Outcomes  
We will examine the primary outcome, Mullen’s Scale of Early Learning (MSEL) Early Learning 
Composite Score (ELC) as the key outcome of interest (i.e. the denominator for ICER). We 
will also examine the outcomes in VABS and JERI as outcomes of interest. Parameters for 
modelling for outcomes will be obtained from analyses specified in the previous section.  
Input Data for Outcomes and Cost Data for the Model 
The input data for the model from the survey administered is listed below in Table 2. 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Table 2: Data Source and Parameters Estimates and Distribution for Cost-effectiveness Analysis 
 
Standard  
Telerehab 
Parameters Estimated 
Distribution 
Outcomes 
Estimates from analysis from t-
test/regression for: 
MSEL-ELC, VABS composite 
score and/or JERI  
Estimates from analysis from t-
test/regression for: 
MSEL-ELC, VABS composite score 
and/or JERI 
Mean (SD) improvement in 
outcomes examined 
Normal 
Direct Healthcare Cost 
Attendance for 
therapy sessions 
Number of clinic-based 
therapy sessions attended 
Number of clinic-based and 
telerehab therapy sessions attended 
 
Telerehab consists of clinic-based 
sessions at the start of the program + 
telerehab sessions 
Mean (SD) of therapy session 
attended across each study arm 
Normal or 
gamma 
Healthcare cost 
Total cost of clinic-based 
therapy sessions  
Total cost of clinic-based + telerehab 
therapy sessions  
 
 
Number of visits * fixed cost per 
visit (standardized for FY2021/22) 
Fixed 
Direct Non-healthcare Cost 
Transport costs 
Survey questions 
 
What mode of transport did 
you use to get here today? 
 
How much did it cost? 
 
Do you usually use this 
mode of transport to get to 
the clinic/CDU? 
 
If no, what is your usual 
mode of transport? 
 
How much did it cost? 
Survey question 
 
What mode of transport did you 
use to get here today? 
 
How much did it cost? 
 
Do you usually use this mode of 
transport to get to the clinic/CDU? 
 
If no, what is your usual mode of 
transport? 
 
How much did it cost? 
The total transportation cost 
incurred by participants will differ 
between study arms by nature of 
the mode of delivery. 
 
The actual transportation cost will 
account for two-way (round trip) 
and the observed visits 
(accounting for missed 
appointments for example)  
 
Normal 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Transport Cost = Total no. of trips 
* Mean transport cost * 2  
Caregiver and 
other care cost 
 
[At review] Did you pay for 
help (courses, caregivers, 
domestic helpers) after 
learning about your child’s 
diagnosis? 
 
How much did you pay? 
 
[At review] Did you pay for help 
(courses, caregivers, domestic 
helpers) after learning about your 
child’s diagnosis? 
 
How much did you pay? 
Assuming that the rate of care 
engagement is different in both 
study arms, the cost of engaging 
additional care.   
 
Care cost =  Probability of 
engaging additional care by 
group * mean cost care by groups 
Probability 
of requiring 
additional 
care = Beta 
 
Cost of 
added care 
= Gamma 
Indirect Cost from Productivity Loss 
Baseline change in 
employment 
 
Have you or other family 
members changed work 
hours because of your 
child's medical or 
developmental condition? 
 
Have you or other family 
members changed work hours 
because of your child's medical or 
developmental condition? 
 
1 Yes, someone in the family 
stopped working 
2 Yes, someone decreased 
his/her work hours 
3 Yes, someone increased his/her 
work hours 
4 No 
 
We can base it off some 
assumption  
Assumption:  
1 = 1.0 FTE Reduction 
2 = 0.5 FTE Reduction 
3 = 0.5 FRE Increase 
 
Baseline  
anticipated change 
in employment 
 
[at baseline] Do you 
foresee the need to adjust 
your employment situation 
in light of this intervention?  
 
 
[at baseline] Do you foresee the 
need to adjust your employment 
situation in light of this 
intervention?  
 
1 Yes, reduce number of hours at 
work 
2 Yes, make arrangements to 
work remotely 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
3 Yes, find a different job which 
allows me to spend more time with 
my child 
4 Yes, taking unpaid leave 
5 Yes, take time off 
6 Yes, Others 
7 No 
Follow-up change 
in employment 
 
[at review] Have there 
been any changes to the 
employment arrangement 
at home due to the 
beginning of the 
intervention? 
 
What is your monthly 
income now? 
 
 
[at review] Have there been any 
changes to the employment 
arrangement at home due to the 
beginning of the intervention?  
 
What is your monthly income 
now? 
 
 
Same as above 
 
Follow-up time 
spent on 
intervention for 
caregivers 
 
In the past month, on 
average how much time (in 
hours) do you spend 
engaging (Speaking to, 
playing with, 
communicating with, doing 
activities) with your child 
per day? 
 
In the past month, on 
average how much time (in 
hours) do you spend 
applying strategies learnt 
through the intervention 
with your child per day? 
 
In the past month, on average 
how much time (in hours) do you 
spend engaging (Speaking to, 
playing with, communicating with, 
doing activities) with your child 
per day? 
 
In the past month, on average 
how much time (in hours) do you 
spend applying strategies learnt 
through the intervention with your 
child per day? 
Productivity loss in the time spend 
on delivering intervention to child 
 
Time (in hour) spent on 
engagement with child + apply 
strategies learnt with child * hourly 
income of parent surveyed 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Transport 
 
[baseline] How long did it 
take you to get to the 
clinic/CDU today? 
 
Does it normally take you 
this long? 
 
If no, how long do you 
usually take? 
 
[baseline] How long did it take 
you to get to the clinic/CDU 
today? 
 
Does it normally take you this 
long? 
 
If no, how long do you usually 
take? 
 
[At review] How long does it take 
for you to set up the computer 
before each telerehab session? 
Productivity loss in travelling time 
 
Time (in hour) required to travel to 
CDU today * 2 (two-way trip) * 
hourly income of parent surveyed 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Data Cleaning Methodology and Approach  
The surveys administered were open ended and the quality of the data obtained is variable. 
The approaches and steps to standardise the cleaning of data for analysis are listed in the 
table below.  
Data entry type 
Approach 
Example 
Range of data 
indicated  
 
“3000-5000” 
The average value between 
the maximum and the 
minimum data will be 
calculated 
“3000-5000” (3000+5000/2)  4000 
“4k to 6k”  (4000+6000/ 2)  5000 
Undefined 
boundaries 
 
“2000+” 
The operators (~, +, ++, 
“plus) will be removed and 
the numeric value will be 
referenced instead 
“2k+ to 3k+” (2000+3000/2)  2500 
“7+”  7 
“3k~ ”  3000  
Variable string 
responses 
 
“1hr on 
weekday, 5hr 
on weekends” 
Value will be taken in 
reference to the question  
Total time spent with child per week:  
“1hr on weekday, 5hr on weekends”  
(1*5) + (5*2) = 15 
 
Average time spent with child each day:  
“1hr on weekday, 5hr on weekends”  
[(1*5) + (5*2)]/7 = 2.14 
 
Missing / Not 
Applicable 
 
“-“, “N/A”, “0”, 
“Not 
Applicable”, 
“NA”, “None”, 
“Null”, or 
“INF”, 
Converted to missing/empty 
responses 
“-“, “N/A”, “0”, “Not Applicable”, “NA”, 
“None”, “Null”, or “INF”  NA 
Out of range 
values 
Values that are out of range  
 
e.g. 20-30 hours for time 
spent with the child daily 
Replace with NA, treat as missing 
variable 
 
 
 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Evaluation Management 
 
This evaluation will be conducted by the NUS Centre for Health Services and Policy Research 
(CHSPR) and the research team at CDU. 
Evaluation Time Frame 
 
Table 3: Evaluation Time Frame from Protocol Version 6.0 dated December 2019 
 
The expected duration of the HSDP project was 3 years, from 01 June 2018 to 31 May 2021. 
As of January 2021, the Principal Investigator (PI) of the study, Dr Isaac Sia has decided to 
extend the study to fulfil the targeted recruitment number. The study is expected to end on 31 
May 2023. See Table 4 for the updated evaluation time frame. 
Time from project 
start date 
Phase 
Activity 
Milestone 
Year 1 Q1  
Program preparatory 
phase 
Manpower recruitment 
Clinical training in FSC  
 
Year 1  Q2 
Program development 
& stabilization phase 
Adapt and finalize 
Telerehab service 
model for Singapore 
context. 
Conduct feasibility 
study with 6 children 
and families 
Feasibility study 
report and review  
Year 1  Q3-Q4 
Implementation 
Enrolment and data 
collection for Year 1   
 
Year 2  Q3-Q4 
Preliminary analysis of 
Year 1 data 
Analysis of Year 1 
data including Year 1 
follow-up 
Interim Report 
 
Year 2  Q1-Q4 
Implementation 
Enrolment and data 
collection for Year 2 
 
Year 3  Q1-Q4 
Implementation 
Enrolment and data 
collection for Year 3 
 
Year 4  Q2-Q3 
Final Analysis  
Consolidation and 
analysis of final data 
including all follow-up 
data 
Final Report 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Table 4: Updated evaluation time frame as of June 2021 
 
Program Year 
Year 1  
Year 2 
Year 3 
Year 4 
Year 5 
Year 6 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Quarter 
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 
 (‘YY) 
18 
18 
18 
19 
19 
19 
19 
20 
20 
20 20 21 
21 
21 
21 
22 
22 22 22 
23 23 
Month 
Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar May 
Phase 
Activity 
 
Program 
preparation 
Manpower, 
training 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Program 
development & 
stabilization  
Adapt and 
finalise, 
conduct 
feasibility study 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Implementation 
Enrolment and 
data collection 
for Year 1   
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Implementation 
Enrolment and 
data collection 
for Year 2 
 
 
 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preliminary data 
analysis  
Analysis of 
Year 1 data  
including  Year 
1 follow-up 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Implementation 
Enrolment and 
data collection 
for Year 3 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
Study-Progress 
Report 
For MOH 
Grant 
Extension 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
Implementation 
Enrolment and 
data collection 
for Year 4 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
 
 
 
 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
MOH Bi-Annual 
report 
Every March 
and Sep 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
 
 
 
 
Implementation 
Data collection 
for Year 5 (no 
more 
enrolment) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
 
MOH Bi-Annual 
report 
Every March 
and Sep 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
Final Analysis  
Consolidation 
and analysis of 
final data  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Dissemination of Findings 
We propose to disseminate results to three primary groups of internal and external 
stakeholders 
 
Group 
Aim 
Timing of 
dissemination 
Method 
NUHS management 
To make decisions 
about the program 
but also about the 
general policies 
related to “big 
data” 
Ongoing 
Briefing and 
research round 
presentations  
HSDP management / 
MOH stakeholders 
 
Periodic results per 
the HSDP contract.  
Reports, briefing; 
at discretion of 
HSDP/MOH 
Academics, 
researchers and 
clinicians 
To support  
After endline data 
collection  
Publications, 
presentations, 
seminars 
 
Quality Assurance and Ethics 
Quality Review 
To ensure quality for the evaluation, we will seek review of the final analysis and report by an 
independent senior faculty member affiliated with CHSPR. 
Research Ethics 
Approval will be sought from the National Healthcare Group Domain-Specific Review Board. 
Protocol amendments will be conveyed to the DSRB review panel for approval before changes 
are carried out in the trial. Any changes in documents used (e.g., informed consent form, case 
report forms, data collection forms) will also be sent to the DSRB for approval. 
The study will be conducted in accordance with the protocol, International Conference on 
Harmonization (ICH) GCP guidelines, applicable regulations and guidelines governing clinical 
study conduct and ethical principles that have their origin in the Declaration of Helsinki. The 
investigator will ensure that the study is conducted in accordance with the provisions as stated 
in the ICH regulations and complies with prevailing local laws and customs. Prior to the 
initiation of any screening or study-specific procedures, the investigator and/or his/her 
representative will explain the nature of the study to the child’s parents and answer all 
questions regarding this study. Each informed consent will be reviewed, signed and dated by 
the child’s parents and the person who administered the informed consent. A copy of each 
informed consent will be given to the child’s parents and each original will be placed in the 
Investigator Site Manual.  
Information collected for this study will be kept confidential. Patient records, to the extent of 
the applicable laws and regulations, will not be made publicly available. Data collected and 
entered into the Case Report Forms are the property of NUH. In the event of any publication 
regarding this study, patient identity will remain confidential. 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
References 
Abidin, R. (1995) Parenting Stress Index (PSI) Manual, 3rd ed. Odessa, FL: Psychological 
Assessment Resources. 
Bacon, E.C., Dufek S., Schreibman L., Stahmer A.C., Pierce K., and Courchesne E., 
“Measuring Outcome in an Early Intervention Program for Toddlers with Autism Spectrum 
Disorder: Use of a Curriculum-Based Assessment,” Autism Research and Treatment, vol. 
2014, Article ID 964704, 9 pages, 2014. doi:10.1155/2014/964704 
Guest G, MacQueen K, Namey E. Applied Thematic Analysis. Thousand Oaks, CA: SAGE 
Publications, Inc.: 2012 
Maedan, H., Snodgrass, M.R., Meyer, E.M., Fisher, K.W., Chung, M.Y., Halle, J.W. Internet-
Based Parent-Implemented Intervention for Young Children with Autism: A Pilot Study. 2016. 
Journal of Early Intervention. 38(1): 3-23 
McWilliams 
(2011) 
FAQOL. 
Retrieved 
on 
21rst 
June 
2017. 
http://inclusioninstitute.fpg.unc.edu/sites/inclusioninstitute.fpg.unc.edu/files/handouts/Family
%20Quality%20of%20Life%20-%20HCBEI.PDF 
Mullen, E. M. (1994). The Mullen Scales of Early Development. Circle Pines, MN: American 
Guidance Services. 
Namey E, Guest G, McKenna K, et al. Evaluating Bang for the Buck: A Cost-Effectiveness 
Comparison Between Individual Interviews and Focus Groups Based on Thematic Saturation 
Levels. American Journal of Evaluation 2016. 
Ozonoff, S., Rogers S.J., and Hendren R.L., eds. Autism spectrum disorders: A research 
review for practitioners. American Psychiatric Pub, 2008. 
 
Rogers, S.J. and Dawson, G. (2010). Early Start Denver Model for Young Children with 
Autism: Promoting Language, Learning, and Engagement. New York: The Guilford Press. 
Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). The Vineland Adaptive Behavior 
ScalesInterview Edition. Circle Pines, MN: American Guidance Service. 
Vismara, L. McCormick C., Young, G.S., Nadhan, A., Monlux, K. Preliminary Findings of a 
Telehealth Approach to Parental Training in Autism. Journal of autism Development Disorders 
2013.43:2953-2969. 
 
 
 
 
 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Annex 1: Program schedule 
Visit no.  
Standard program 
Telerehabilitation program 
Test/Intervention 
Time 
(min) 
Test/Intervention 
Time 
(min) 
ASSESSMENT PHASE 
Visit 0 
 
First Paediatrician visit 
Screening for ASD (DSM-5) 
Initiate informed consent taking for study (refer to consent form) – can be done at Visit 0 or 1  
 
30 
Visit 1 
Second Paediatrician visit 
Initiate informed consent taking for study (refer to consent form) – can be done at Visit 0 or 1  
Refer for ADOS and MSEL if consent is given 
Otherwise continue with standard care 
 
30 
Visit 2-3 
 
Nurse Assessment 
MSEL + PSI  
 
120 
 
Psychologist Assessment 
ADOS + VABS 
 
120 
Visit 4 
 
Third Paediatrician visit 
 
Paediatrician visit to share Mullen’s & ADOS-2 report and confirm enrolment into the study and to inform arm of 
study. If patient does not meet the inclusion criteria. They will be referred to standard care outside the trial.   
 
30 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Visit 5 
 
Therapist Assessment (clinic based) 
 Foundational Skills Curriculum (FSC) assessment 
 Parent interview on routines 
 Joint engagement rating inventory (JERI) 
 Family Early Intervention Quality of life survey (FEIQoL) 
 Demographic survey 
 Cost Survey 
 
90 
 
Preparation for video conferencing 
Video conferencing observation (FSC, NDBI-Fi)  
30 
Visit 6  
 
Parent Education Workshop (Can be conducted either in person or through electronic training slides) 
 
90 
For eligible and chosen participants, pre-interview will be conducted between visit 5 and before the Intervention Phase. 
45 
INTERVENTION PHASE 
1st block of 
intervention    
 
Clinic-based intervention (CBI) x 6 
(Commencement of Individualised intervention 
plan (IIP)) 
60 x 6 
Clinic-based intervention (CBI) x 2 (Commencement 
of Individualised intervention plan (IIP)) 
60 x 2 
Video conference-based intervention (VCBI) x 4 
45 x 4 
Parent-delivered therapy home-based) 
2nd block of 
intervention    
 
Clinic-based intervention (CBI) x 4 
60 x 4 
Video conference-based intervention (VCBI) x 4 
45 x 4 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Visit 7-8 
 
Fourth Paediatrician visit 
Midpoint Review by paediatrician (clinic based or teleconsultation) 
 Child’s profile, progress 
 Child and Family’s needs 
 Appropriate recommendations and referrals (if needed) 
 
30 
Midterm Progress Review with Therapist (clinic based) 
 Foundational skills curriculum – Child’s development profile 
 Joint Engagement Rating Inventory (JERI) 
 
Cost Survey 
60 
Parent-delivered therapy (home-based)  
Visit 9  
 
Midpoint IIP Review with Therapist 
(clinic based) 
60 
Midpoint IIP Review with Therapist (clinic 
based) 
60 
3rd block of 
intervention 
 
Clinic-based intervention x 6 
 
60 x 6 
Video conference-based intervention (VCBI) x 2  
45 x 2 
Parent-delivered therapy (home-based) 
Visit 10-11  
Fifth Paediatrician visit 
Midpoint Review by paediatrician (clinic based or teleconsultation) 
 Child’s profile, progress 
 Child and Family’s needs 
 Appropriate recommendations and referrals (if needed) 
 
30 
Review with Therapist (clinic based) 
 Foundational skills curriculum – Child’s development profile 
 Joint Engagement Rating Inventory (JERI) 
 
Cost Survey 
60 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
4th intervention 
block 
Parent-delivered therapy (home-based) 
Video conference-based intervention (VCBI) x 6 
45 x 6  
Parent-delivered therapy (home-based) 
 
Visit 12-14  
 
Final Review with Therapist (clinic based) 
 Foundational skills curriculum (FSC) assessment 
 Joint engagement rating inventory (JERI) 
 Family Early Intervention Quality of life survey (FEIQoL) 
 Cost Survey 
 
Additional Indicators to baseline: 
 
Parent Satisfaction Survey 
 
 
90 
 
 
Final Nurse Assessment (clinic based) 
 MSEL  & PSI 
120 
Final Psychologist Assessment (teleconsultation) 
 VABS-III 
60 
 
Video conferencing observation (FSC, NDBI-Fi)  
 
30 
Visit 15  
 
Sixth Paediatrician visit (final visit) 
Paediatrician to share reports and discuss progress and further needs of child and family 
30 
Post-interview will be conducted for eligible and chosen participants after intervention is completed, or after participant has 
transitioned to EIPIC.  
45 
End of study 
 
 
 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
Annex 2: Comparison of 2 programs (standard and telerehab) 
Standard & Telerehab  
The FSC framework is drawn with specific focus on Autism needs and impairments. 
The core areas of Autism are subsumed in the framework. 
 
Curriculum framework for autism early intervention developed as an outcome of Autism 
research project, UK 
 
FSC program Reference: From Val Cumine, Julia Dunlop and Gill Stevenson, Autism in the 
Early Years, 2nd ed., London: Routledge. © 2000, 2010 Val Cumine, Julia Dunlop and Gill 
Stevenson. 
 
This framework has been used in CDU since 2010 and is currently referred to as 
“Foundational Skills Curriculum“. 
 
Assessment includes an observational profile under 4 key areas of need in Autism: 
1. Social interaction (gaze, proximity, Imitation, Initiation, turn taking, Emotional 
expression & understanding & development of Self) 
2. Communication (understanding simple verbal and non verbal approaches, Strategies 
for meeting needs, Engaging in social interaction, Joint attention strategies, and  
3. Play skills (types of play and interaction during play) and  
4. Daily routines (Independent daily living skills and participation) 
 
Though Behaviour is not explicitly included in the observational profile, the book with this 
approach provides detailed information and guidelines for behaviour assessment and 
intervention. 
 
Uses a developmental framework with specific inclusions of skill sets relevant to autism 
 
Intervention-guiding principles: 
An eclectic approach which includes principles of: 
 
building relationships, 
 
use of structured teaching,  
 
interactive play strategies, 
 
use of visual supports,  
 
Functional behaviour analysis and positive behaviour support,  
 
SCERTS model and 
 
activity based intervention and embedding intervention into everyday routines 
 
use of natural environment 
 
Individualized learning plan 
 
family partnerships 
 
transdisciplinary practice 
 
HSDP research study (control arm/standard 
program): 
 
HSDP research study (experimental arm 
/telehealth program): 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
FSP is implemented purely as a clinic based 
intervention program (in the current 
standard service) 
 
Baseline assessments: 
Clinic based session 
 
 
 
 
 
Intervention:  
16 clinic based intervention sessions 
conducted in the context of play activities in 
the clinic. 
 
 
 
Approximate duration of intervention:  
40 to 60 weeks  
 
FSP is being piloted to implement as a 
telehealth service. The proposed 
implementation includes: 
 
Baseline assessments:  
Clinic based session + one observation 
conducted through video conferencing. 
(This observation will provide valuable insight 
into the quality of parent child interactions in a 
natural home context and routine.) 
 
Intervention:  
2 clinic based intervention sessions 
16 intervention sessions will be conducted 
through video conferencing in the context of 
naturally occurring parent-child interaction in a 
daily routine. 
 
Approximate duration of intervention:  
40 to 60 weeks 
 
Clinic based intervention format: 
 
 
 
Initial assessment  
 
IIP planning 
 
Group parent education workshop 
 
Total of 3 blocks of intervention (16 
sessions – 60 min / session) 
 
 
 
 
Session protocol: 
Clinic based intervention protocol: 
 
Observation of parent child 
interactions 
 
Exploration of potentially effective 
strategies and contexts to embed 
goals 
 
Demonstration of embedding goals 
and strategies 
 
Guided feedback: caregiver practice 
with guidance and support from 
Interventionist 
 
Reflection & problem solving of the 
whole exercise 
 
Video conference based intervention 
program format: 
 
 
Initial assessment  
 
IIP planning 
 
Group parent education workshop 
 
Total of 4 blocks of intervention (2 
clinic based intervention sessions 60 
min / session and 16 video conference 
based intervention sessions 45 min / 
session) 
  
Session protocol: 
Clinic based intervention protocol: 
 
Observation of parent child 
interactions 
 
Exploration of potentially effective 
strategies and contexts to embed 
goals 
 
Demonstration of embedding goals 
and strategies 
 
Guided feedback: caregiver practice 
with guidance and support from 
Interventionist 
 
Reflection & problem solving of the 
whole exercise 
 

TRAutism HSDP Protocol_Version 8_19/08/2022 
 
 
 
Coaching protocol structure in video 
conference based sessions: 
 
checking in with parent how the plan is 
going on at home 
 
observation of routine chosen by 
parent to implement the goals and 
strategies 
 
explanation & guided feedback on 
parents’ skills and child’s responses 
with suggestions of enhancements 
 
coaching of new topics if earlier 
targets for caregiver competency 
achieved 
 
setting goals as parent and child 
progress in their skills 
 
Closing: recap proceedings of the 
sessions and plan for next session