**3. Results**

### **3.1 Quantitative results**

#### *3.1.1 Caregiving centers' key persons' findings*

There were 30 active daycare centers in this study located in 19 (61%) provinces out of 31 provinces across the country. Each center introduced a key person as the main person who supervises parents' daily activities and collects information. The key persons' demographic information is presented in **Table 1**.

Twenty-one (70%) participants of the daycare centers who were acting as the key person already participated in the professional training courses that ISWO had for its under supervision ASD centers [26, 30], while nine (30%) centers key persons did not participate in these courses previously. A significant statistical relationship was reported between the parental fidelity score and the key persons' previous participation in ASD professional training course presented by ISWO (df = 2, N = 336) = 8.32, p = .016. While a similar level of significance was not reported between parental fidelity level and key persons' participation in the professional training courses on ASD.

#### *3.1.2 Parents' findings*

Out of 417 parents, data of 336 who finishes 8 weeks of the online training course were considered for the final analysis. A dropout rate of 19% (81 parents) was reported. The demographic information of this group is cited in **Table 2**.

Parents before and after the course were requested to rate their ideas regarding the online training course in choosing one of the three choices of having no ideas, negative, and positive. A comparison of the parents' attitudes toward the online course using the Pearson product-moment correlations test yield r = −0.261. p < .00. This indicates a low negative correlation, which might impact parental mainly negative attitudes at the beginning of the course changed to a positive. Meanwhile, there were changes in attitudes of parents who had no ideas or showed negative attitudes toward online courses.


#### **Table 1.**

*The key persons' demographic data.*

*Online Training for Parents of Individuals with Autism Spectrum Disorders during COVID-19… DOI: http://dx.doi.org/10.5772/intechopen.102949*


#### **Table 2.**

*Demographic data of parents.*

There was a statistically significant relationship between the child's age and level of satisfaction with the online course and younger children's parents were more satisfied with the online support X2 (df = 2, N = 336) = 1.17, p < .00. Similar statistically significant relationship found between parental age and their satisfaction with the online course before course X2 (df = 2, N = 336) = 10.53, p = .005 and after the course X2 (df = 2, N = 336) = 10.61, p < .00. Younger parents were more satisfied with the course compared with the older ones.

Parents of children with double-diagnosis attitudes toward the online course before (X2 "df = 2 N = 336" =8.43 p = .015) and after the course (X2 "df = 2 N = 336" =9.72 p = .007) were significantly different, and parents of children who had another accompanying diagnosis along with ASD were less satisfied with the online support.

Parents who speculate to have a family member as the assistant were statistically more satisfied with the online course before X2 (df = 2, N = 336) = 1.07, p < .00 and after the course X2 (df = 2, N = 336) = 23.57, p < .00.

The key persons' and parents' fidelity in applying the recommended practices was observed using two different rubrics. A comparison of the Chi-square test showed that there is a significant relationship between the two variables of the level of fidelity of key persons and parents. Key persons who gained higher scores in the fidelity rubric are more likely to supervise parents with higher scores of fidelities in the implementation of the suggested items in a different session with their children, X2 (df = 6, N = 336) = 32.46, p < .00.

Regarding parents' fidelity level and their final attitudes toward the online course (having a positive or negative attitude), the finding indicated a statistically significant relationship (X2 "df =6, N= 336" = 74.18, p < .00). This means that parents who received a higher score for their fidelity in the program administration were more satisfied with the online support. While parents who were less considered the presented information (received a lower score of fidelity) were less satisfied with the program.

**Figure 1** shows the parents' attitudes regarding the course after 8 weeks of the online training course that was in a range from 25 (7.4%) positive to 205 (61%).

**Figure 1.**

*Parents attitude regarding the online course before and after the course.*

A comparison of the parents' attitudes toward the online course yield r = −0.261. p < .00. This indicates a low negative correlation, which might impact parental mainly negative attitudes at the beginning of the course changed to a positive. Meanwhile, there were changes in attitudes of parents who had no ideas or showed negative attitudes toward online courses.

Parents' main complaint about caregiving during the lockdown before and after the online course changed, and the percentage of the items they pointed to as the main problem in continuous caregiving was altered. There was a significant difference between parents' main complaints about caregiving during the lockdown before and after the online course based on the results of the Pearson productmoment correlations test (r = .36, p = .00).

Each caregiver's biweekly objectives were considered for the child under the observation and guidance of the key person from the center in which he/she was registered. They also followed the number of attained objectives on a biweekly time interval (this number was in a range between 0 and a maximum of 7). **Table 3** shows the objective considered through parents' suggestion in all for each round of biweekly reporting (the maximum and minimum in each domain are mentioned). Meanwhile, unattained objectives, which were less considered in each round of reporting, are shown in **Table 4**.

Analysis indicated that attaining cognitive (learning about color, shape, numbers, and other academic items) objectives were more possible to attain for parents, and the number of unattained cognitive objectives was lower than 15%


**Table 3.**

*Number and range of parents' considered objectives in each domain based on biweekly reports (N = 336).*

*Online Training for Parents of Individuals with Autism Spectrum Disorders during COVID-19… DOI: http://dx.doi.org/10.5772/intechopen.102949*


#### **Table 4.**

*Number of parents' unattained objectives in each domain based on biweekly reports (N = 336).*

each biweekly. While attaining communicational objectives through exercises, play, and activities was the most challenging item to attain. Tasks with a sensory-motor nature were at a mid-level of difficulty to attain for parents.

To assess parents' impression of children's symptoms severity before and after the online course, they were asked to score the child's basic ASD features using the screening scale. The correlation between two scorings was r = 0.919, p < .00. Similar comparisons have been done regarding parental impression on their child's behavioral (r = 0.931, p < .00), communication (r = 0.975, p < .00), and social (r = 0.813, p < .00) aspects using GARS2 scale. Parents were asked to score their satisfaction with caregiving before and after the online course, and the results from the pretest (M = 27.18, SD = 9.05) and posttest (M = 42.72, SD = 14.27) PSCS indicate that caregiving under the supervision of the daycare center for a child with ASD resulted in an improvement in satisfaction with caregiving (t = 21.87, df = 335, p < .000).

Finally, to assess parents' effectiveness in their children's engagement in the daily caregiving, their final videos (provided for the final biweekly reporting) were sore by the centers' key person using a fidelity scale. Ten videos were rescored by the author and the number of agreements/number of agreements plus disagreements were considered and inter-rater reliability was reported as 85%.

Findings indicated that there is a significant and strong correlation between parental satisfaction with caregiving at time two and after the online course and their fidelity score (r = 0.85, p < .00) while this correlation for time 1 was very low (r = 27).

#### **3.2 Qualitative results**

This part of the chapter is a descriptive qualitative approach that utilized semistructured online interviews and in-depth content analysis. This is done to assess parents' attitudes and perceptions of the effectiveness of the online course and using social media and telecommunication technology, after the study they were requested to give feedback. Both groups of parents who participated completely and parents who dropout invited and 50 (eight from parents who dropped out and 42 from parents who finished the online course) responses were sent (20 voice messages and 30 written comments). In a closed question regarding the parental ideas all parents give admitted (ticked yes as their answer) to the question regarding their agreement with parental engagement in the daily caregiving for children with ASD. Parents found the telecommunication application easy and user-friendly. Hence, among 41 parents who continued online course, only three parents (7%) did not want to continue online support; because of the additional financial demands, which this newly developing service forced them to pay for; or the technical issues such as the wideness of the internet band and limitation of the data transferring speed, the rest 38 (93%) parents thought that because they found the online support, they continue to stay tuned for similar opportunities, recommend it to other parents, and consider as a useful service choice.

Nevertheless, all eight dropout parents who agreed to give feedback regarding the online services said that they do not persuade those online services are a sufficient service for children with ASD and their parents. Based on the topics presented in the current literature on online parental training courses, specific but open-ended online interview questions were devised that met the project aim of understanding the entire course participants' perspective. These were categorized into three main themes: (a) interfering with the duties, (b) extra demands, and (c) lack of understanding parenting (**Table 5**).

They raised different issues such as putting extra pressure on parents, advantageous for the center because regardless of being closed, using online services caused them to receive governmental financial aid while the responsibilities of child caregiving will remain on parents.

Parents in both satisfied and dissatisfied groups indicated some negative aspects of an online prenatal training program such as videos and pictures sharing of their child although they are guaranteed that documents will be protected and used for this study will not be used or seen by the others.

Parents who did not finish the course were asked about any proposals about the other desired training opportunities for them. They generally requested for centers reopening, or some of them asked for private home teaching services for their children.

Those parents stayed with the online course and finished 8 weeks of support invited to answer an online questionnaire consisting of six open questions: 1. Leading advantages of the online training support, 2. The main shortcoming of the program, 3. Your suggestions for improving the online training opportunity, 4. What part was the most useful for you? 5. What part was less useful for you? 6. Any further comments and suggestions.

Parents mostly said that the greatest advantage of the course was assisting them while they were under pressure for continuous caregiving. A mother said: [No.12] "We got the opportunity of testing our abilities in managing our child and acting as the trainers for the first time."

Nearly all of them considered entire parts of the online support useful, and some of them mentioned special functional ideas for fine and gross motor improvement or parts of the behavioral suggestions for educating children as the most appropriate part for them. They suggested various issues for improving the online support but mostly recommended receiving hard copies and different video audio resources in the form of training packages. A father said: [No.27] "I do recommend the preparation of parents for similar situations. To supply us with some special packages


*Online Training for Parents of Individuals with Autism Spectrum Disorders during COVID-19… DOI: http://dx.doi.org/10.5772/intechopen.102949*

#### **Table 5.**

*Parents who dropped out of the program and their interview extracted themes.*

such as internet access multipurpose training and educational tools." Similar suggestions and recommendations were repeated in response to the final question. A mother said: [No. 34] "Since most of our children are fascinated by the gadgets it's better to have some apps and computer software to help us. I recommend the preparation of parents for similar situations. To supply us with some special packages such as internet access multipurpose training and educational tools. It was a perfect opportunity. Thank you very much, but it can be improved."

### **4. Discussion**

In recent years, the availability of online training courses and usage of technologies in service provision and also its impacts on consumers and the level of the acceptance of its application by regulatory agencies alike received attention from the developed societies. It has rarely been studied and developed in developing countries. At present with the forceful lockdown due to the pandemic COVID-19, the only available services seem to be the application of accessible technology to address the growing needs of children with ASD and their families. In addition to reviewing the experience of the developed countries and adopting the research summaries, policymakers in the developing countries are encouraged to understand and to determine what may be useful to them in practice. Results indicate that online training courses for parents training supervised by daycare centers for parents of individuals with ASD could be listed as applicable support for parents of children with ASD as assistance for facilitating continuous caregiving due to conditions such as the imposed lockdown due to pandemic.

Regarding the first question of this study and asking about the feasibility of the online training course, finding indicating that online training course might be a feasible approach and worth developing in developing countries with the lack of professional and restriction of accessible services and supports in distant geographical areas especially the rural parts [31] and for ASD in particular [32]. Findings indicated that prepared and qualified daycare centers' staff through utilizing telecommunication facilities can enter the parents' living places virtually and assist them while caring for their offspring in their natural setting. The practice environment is under professional observation without any extra time and expenses. The presented finding indicated that the imposed new online training course-based treatment models in which parents are acting as the main program administrators under the supervisor of the daycare centers might be considered as a feasible approach to consider [33].

Parents are known to be the best and the easiest to access, influential factors in both human and animal child's development trajectory [34]. For children with an ASD, extensive weekly hours have been recommended for working in most of the approved and recommended approaches of early intervention services [35]. After the pandemic COVID-19 and the forceful shutdown of the daycare centers for children with ASD in most of the countries around the world and the necessity of continuous service provision and round-the-clock service provision from the parents, a new aspect of parents (parental)-based services emerged. The role of parents as the main base in intervention has already been stressed because the care providers are the ones who know the child best and know about his/her needs. On the other hand, children and parents were forcefully kept in the lockdown and parent skill updating and service providing for caregiving are essential in assisting children with ASD to continue their progress toward the highest level of potential functionality during the lockdown period. Parents' available mobile-based technology enables daycare service providers to continue their services via engaging them more effectively than

#### *Online Training for Parents of Individuals with Autism Spectrum Disorders during COVID-19… DOI: http://dx.doi.org/10.5772/intechopen.102949*

ever before through the facilities this system offered most of the time free of charge and to promote their child's development every day [35]. Parents' general approval of the online support and positive attitudes with the online course and having a low level of dropout might also indicate the viability of this service. They provided an opportunity for information provision boosted parental knowledge regarding the main challenges of caretaking for their children helped them to attribute their child most challenging features to the core symptoms of ASD (communication) and pointed to it as their main source of complaining, which might help them to focus on increasing their augmentative communication approaches and nonverbalcommunication skills [36].

The second question of this study regarding the contributing factors for developing successful online support, findings indicate that several factors might contribute to parents' satisfaction with online services. Factors such as the age of the child, when children with ASD are younger parents, are more optimistic about the course and its impact. This is a reason for the focusing of the present studies of online training and ASD on young children [37]. Younger parents also were more positive regarding the online course, which has been reported in other services for individuals with ASD in a comparable cultural situation to present sample such as Saudi Arabia [38]. It also found that receiving help at home is a powerful predictor of parental satisfaction with online support [26]. It was also found that parents were more successful in attaining academic objectives for their children with ASD, similar findings reported in other studies when regular training opportunities were offered to parents of children with ASD [39]. This is an indicator of the difficulty of gaining and training the communication aims and objectives for individuals with ASD. The online service providers should consider the bases of communication to motivate individuals with ASD to start the collective attention that is a basic skill for social attention and social interaction [40]. Techniques such as Picture Exchange Communication System (PECS) [41] could be a very applicable strategy to consider in developing similar online courses.

Finally, in answering the third question of this study regarding increasing the implication of online training course services and boosting their affectivity, some elements needed to be considered. Parental feedback indicated mostly positive findings regarding the level of comfort using the technology and the perceived benefits of this approach, with some reservations regarding preference for online training course sessions at home versus daycare sessions.

It is of interest to note that the parents differed regarding the perceived benefit of the online session as compared with the face-to-face daycare sessions, and that this difference was correlated with the parents' fidelity score in administering the suggested activities a finding, which is previously reported [42]. Follow-up study is needed to carefully monitor the level of fidelity of implementation of the strategies used by the parents at home after the round of the online course and data collection period. Regarding the increasing of the implication of online training courses although ISWO admitted that its daycare ASD centers survived and children received their needed services, there are some cost-benefit analyses of the present finding that are needed to conduct in terms of financial, time, and general health system to prove the applicability of this approach. The child with ASD educational setting extension is another benefit of this model. Internet technology has its limitations as well, and not all parents are likely candidates for this type of technology as some of them were seriously commented against and left the course and had their justifications about this. Besides providing a service provision system in the time of emergency remotely, daycare centers might be able to appoint children and parents who might be beneficial candidates to use online training courses.

There are some serious limitations with the present finding first of all the course was prepared in an emergency in which no other services or choices were available. Therefore, the lack of a control group to receive comparable services in a face-to-face setting was a problem that was out of control and could not be addressed. Although online training course applications hold promise as a way of addressing some of the parents' challenges during a time of continuous caregiving situation, hence, there is still a lack of enough evidence for understanding the probable shortcoming and limitations of the online training course and the way that various rehabilitation, other interventions, assessments, and training protocols may be used through the online training course. Further studies are needed to identify the parents and type of services in which the online training course delivery system is appropriate or is not. Such comparative studies will contribute service providers to selecting an online training course delivery model for the appropriate group who might get more benefit. The versatility of online training courses allows daycare centers and parents to survive during a difficult time, but there are some other interventions or practices that are not compatible with this newly developing modality.
