Telehealth as a Model for Providing Behaviour Analytic Interventions … · 2019-09-06 · Current reviews have not focused specifically on ABA-based interventions and have instead

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Journal of Autism and Developmental Disorders (2019) 49:582–616https://doi.org/10.1007/s10803-018-3724-5

1 3

ORIGINAL PAPER

Telehealth as a Model for Providing Behaviour Analytic Interventions to Individuals with Autism Spectrum Disorder: A Systematic Review

Jenny Ferguson1 · Emma A. Craig1 · Katerina Dounavi1

Published online: 28 August 2018 © The Author(s) 2018

AbstractInterventions based on applied behaviour analysis are considered evidence based practice for autism spectrum disorders. Due to the shortage of highly qualified professionals required for their delivery, innovative models should be explored, such as telehealth. Telehealth utilises technology for remote training and supervision. The purpose of our study was to sys-tematically review the literature researching telehealth and ABA. We analysed intervention characteristics, outcomes and research quality in 28 studies and identified gaps. Intervention characteristics were: (1) research design (2) participants (3) technology (4) dependent variables (5) aims. Outcomes were favourable with all studies reporting improvements in at least one variable. Quality ratings were significantly low. Implications for future research and practice are discussed in light of identified methodological downfalls.

Keywords Applied behaviour analysis · Telehealth · Autism spectrum disorder

Autism spectrum disorder (ASD) is a neuro-developmental disorder categorised by impairments in social-communi-cation and restrictions in behaviours or thought patterns (American Psychiatric Association 2013). Recent esti-mates have suggested 1 in every 59 individuals now have a diagnosis of ASD (Centres for Disease Control and Pre-vention 2018). The high prevalence and lifelong nature of the condition mean a large demand on services to support individuals spanning across health, social care and educa-tion sectors. In the UK, the cost of these services have been estimated at £1.5 ($2.2) million across a lifetime (Buescher et al. 2014), making ASD the costliest medical condition to support (Knapp et al. 2009). More importantly, when com-pared to neuro-typical individuals, individuals with ASD have been shown to score considerably lower on indicators of life-quality and are less likely to be in paid employment,

have rewarding social lives or achieve full independence from their families (Howlin et al. 2004). This highlights the significance of providing successful yet cost effective inter-ventions, which should be based solely upon sound empiri-cal evidence and guided by current evidence based practice (EBP).

Research has indicated that best practice in autism inter-ventions should involve strategies based upon the princi-ples of applied behaviour analysis (ABA) (Makrygianni and Reed 2010; Reichow 2012; Reichow et al. 2018). ABA is an applied science aiming to determine environmental variables that shape socially significant behaviour and design inter-ventions accordingly. Teaching strategies derived from these principles have been identified as EBP (e.g., early intensive behavioural intervention, discrete trial training, functional communication training, functional behavioural assessment, extinction, naturalistic intervention, pivotal response train-ing and task analysis) (Wong et al. 2014).

However, the vast majority of European governments do not fund ABA-based provision; estimates suggest only a third of children with ASD currently access behavioural interventions across Europe (Salomone et al. 2014). In the UK, where an ‘eclectic’ and often ill-defined selec-tion of services is available, access to funded ABA can often be either a postcode lottery or a testament of parental

* Katerina Dounavi [email protected]

Jenny Ferguson [email protected]

Emma A. Craig [email protected]

1 School of Social Sciences, Education and Social Work, Queen’s University Belfast, 69-71 University Street, Belfast, Northern Ireland BT7 1HL, UK

http://orcid.org/0000-0003-1491-9301

http://crossmark.crossref.org/dialog/?doi=10.1007/s10803-018-3724-5&domain=pdf

583Journal of Autism and Developmental Disorders (2019) 49:582–616

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willingness to fight for services at tribunal (Dillenburger 2011; Keenan et al. 2015).

Another barrier to successful ABA treatment is a lack of appropriately trained professionals. To qualify as a Board Certified Behaviour Analyst (BCBA©) individuals must complete Master’s level training in behaviour analy-sis, undertake an extensive period of supervised practice and pass an exam (BACB 2014). Working under an appro-priately qualified supervisor has been shown to correlate with implementation fidelity, therapist job satisfaction and positive child outcomes (Plantiveau et al. 2018; Whiteford et al. 2012; Eikeseth et al. 2008). Difficulties in accessing this expertise is very problematic. In the UK there are cur-rently 314 BCBAs (BACB 2018); considering the number of individuals diagnosed with ASD is estimated to be 695,000 (National Autistic Society 2017), the ratio of 1 BCBA per 2213 individuals with ASD is worryingly small. These shortages are magnified in remote areas of the country, where the lack of local services results in parents travelling long distances to avail of the expertise of qualified profes-sionals. Parents of children with ASD living in rural areas have shown lower levels of service satisfaction and greater difficulties in accessing professional expertise when com-pared with their urban counterparts (Bulgren 2002; Mur-phy and Ruble 2012), highlighting the need to update the existing service dissemination model. Whilst it is clear that ABA-based services present best outcomes for individuals with ASD, it is not clear how best to resolve the gap between needs and service access. Alternative models of intervention and training should be explored which may extend the reach beyond a traditional face-to-face model; telehealth has the potential to do this.

Telehealth is the use of communication technology to assist in education and treatment of health related condi-tions. The availability of internet connections has been grow-ing exponentially in recent years. Current estimates suggest that 88% of all people in the UK accessed the internet at some point in the last 3 months (Office of National Statistics 2016). Researchers have capitalised on these advancements and demonstrated their usefulness for the delivery of health related interventions. These interventions utilise technology to provide remote communication, advice and training using tele-communications software and technology based train-ing platforms. The application of telehealth has been inves-tigated across numerous conditions, such as haemophilia, diabetes, heart disease and depression (Kessler et al. 2009; Webb et al. 2010), proving to be a promising advancement in healthcare government initiatives across the UK (Depart-ment of Health 2011; Department of Health, Social Services and Public Safety, Department of Health Northern Ireland 2011; Scottish Government 2011).

An initial examination of the literature indicated that there has been an emergence of a body of research

investigating the use of telehealth to provide behaviour analytic provisions to individuals with ASD and the initial findings appear promising; telehealth was shown to reduce costs associated with providing behaviour analytic inter-ventions by up to half (Horn et al. 2016; Lindgren et al. 2015) and was viewed favourably by parents living in rural communities (Salomone et al. 2017). However, a more extensive review capable of identifying the scope, effec-tiveness and limitations of using telehealth was required. To date there have been five published reviews summa-rising the body of literature in this area, these reviews have either been too broad (Boisvert et al. 2010; Knutsen et al. 2016) or too narrow (Meadan and Daczewitz 2015; Neely et al. 2016; Parsons et al. 2017). The subsequent paragraphs will discuss the limitations of these reviews in more detail identifying why a specific systematic review in this area in warranted.

Current reviews have not focused specifically on ABA-based interventions and have instead involved overarching reviews including research from wider fields, such as, educa-tion, occupational therapy or speech and language therapy. Boisvert et al. (2010) included five ABA-based studies in an overarching review of telehealth based support for indi-viduals with ASD and more recently Knutsen et al. (2016) identified 17 studies that utilised ABA-based interventions amongst a broader review of literature. The selected research investigated Functional Analysis (FA) and associated Func-tional Communication Training (FCT) (e.g., Barretto et al. 2006; Wacker et al. 2013a, b) or naturalistic teaching strate-gies (e.g. Vismara et al 2009, 2012, 2013). Outcomes varied within and between studies and individual differences were apparent in interventionist implementation fidelity and child outcomes (e.g. Meadan et al. 2016; Vismara et al. 2013). Despite these reviews indicating that practical limitations can be overcome, an ABA specific review by trained behav-iour analysts will allow for a unique analysis of the method-ology and outcomes reported in selected research.

Past reviews have also been limited to research utilising a parent training approach only (Meadan and Daczewitz 2015; Parsons et al. 2017). Meadan and Daczewitz (2015) selected six studies for their review, five of which were ABA-based interventions. Outcomes indicated that telehealth was an effective platform for parent training, increasing both par-ent’s knowledge and implementation skills. Parsons et al. (2017). ) reviewed research in using telehealth to conduct parent training in rural communities. The authors reviewed nine studies, all of which were behaviour analytic in nature, and concluded that, whilst parent training should be consid-ered a crucial factor in intervention and has itself been iden-tified as an EPB in the treatment of individuals with ASD (Wong et al. 2014), a more comprehensive review would provide a better insight into wider applications of telehealth across interventionists and beyond the home environment.

584 Journal of Autism and Developmental Disorders (2019) 49:582–616

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The most recent review focused on procedural fidelity and only selected studies that contained this measure (Neely et al. 2017). The authors concluded that all studies showed increases in interventionist implementation fidelity, demonstrating tel-ehealth can be an effective platform. Admittedly, fidelity is an important factor for methodological rigor and high fidelity has been linked with optimal outcomes (Penn et al. 2007; Symes et al. 2006; Whiteford et al. 2012), however research focusing on outcomes for participants with ASD alone was overlooked.

Additionally, only one review to date investigated the qual-ity of the included research (Parsons et al. 2017). Measures of research quality are essential as they allow for the assessment of research validity and indicate ability to minimise research errors and bias. Although Parsons et al. (2017) utilised a measure capable of simultaneously assessing the quality of multiple study designs, questions were more geared towards group designs and were somewhat subjective in nature (Kmet et al. 2004). Overall assignments of level of evidence were conducted using a separate grading system where single-sub-ject research was automatically scored as the lowest level of evidence (National Health Medical Research Council 1999). ABA-based interventions are highly heterogeneous in nature; individuality of programming is prioritised over consistency of service between participants, allowing for optimal individual progress. Finding a quality rating capable of equitably com-paring single subject and group research designs is paramount when assessing EBP. One such rating is the Evaluative Method for Evaluating and Determining Evidence-Based Practices in Autism (Reichow 2011; Reichow et al. 2008) which includes rubrics allowing to assess key indicators of quality in both single subject and group research designs. Scores on these rubrics can be combined to provide an overall level of EBP for the selected population.

The purpose of the current study is to systematically review and synthesise extant literature studying the effects of using telehealth to provide ABA-based provisions to indi-viduals with a diagnosis of ASD. Main intervention com-ponents and outcomes will be extracted and combined to provide an overall picture of research aims, procedures, par-ticipants and effects. This will allow for analysis of success and identification of gaps in the literature. The Evaluative Method for Evaluating and Determining Evidence-Based Practices in Autism will be used to assess the methodologi-cal rigor of each study leading to an overall estimation of the status of telehealth as an EBP for the provision of ABA services to individuals with ASD.

Method

Commencing in October 2017 with search dates ending in February 2018, we conducted a systematic search using four databases, ERIC, Medline, PsycInfo and Scopus. The review

was conducted following the PRISMA checklist as a guide (Moher et al. 2009). Identified studies were screened by title and abstract, then merged with duplicates removed, followed by full text screening. Additionally, references of included studies and reviews on the topic were hand searched. A descriptive synthesis of eligible studies was then completed summarising the main objectives, variables and outcomes of each study. All selected studies were assessed for quality using standards set out by Reichow et al. (2008).

Search Terms

Search terms included Autis* OR ASD OR Asperger OR PDD-NOS OR Developmental Disabil* AND Telehealth OR Telemedicine OR Teleconferencing OR Telecare OR Elearn* OR Distance Learn* (Fig. 1).

Inclusion and Exclusion Criteria

For inclusion in the review, articles were examined against the following inclusion criteria: (1) peer review published journal article, (2) study involved telehealth technology in the provision of training, supervision or consultation to interventionists (parents or professionals) utilising behav-ioural principles in the treatment or education of at least one participant with a diagnosis of ASD, Asperger’s or PDD, (3) study was original empirical research with quantitative data and a primary analysis of the effect of an intervention conducted via telehealth and (4) was written in the English language.

Studies were excluded from the review if: (1) they did not include original research, (2) telehealth technology did not include a two-way communication system with a profes-sional, (3) participants without a diagnosis of ASD or PDD were included and outcomes for the participants with ASD were not reported in isolation from other diagnoses.

Data Extraction

Full texts of selected studies were reviewed and informa-tion was extracted (Table 1). The following measures were examined in order to develop an overview of the main inter-vention characteristics present in the research: (1) research design (2) participant characteristics (3) technology descrip-tions (4) dependent variables (5) intervention characteristics. Additionally, efficacy outcomes were reported to determine the overall success of the interventions. Research quality was scored following a quality assessment (Reichow et al. 2008) to provide an indication of research rigor. Additional infor-mation was collected, including measures of inter-observer agreement (IOA), generalisation and follow-up data.


1 3

Reliability of Search Procedures and Inter‑coder Agreement (ICA)

To ensure internal validity within the review, the first and second authors independently assessed identified studies against inclusion and exclusion criteria. The two resulting

lists of eligible studies were subsequently compared. ICA was calculated by dividing the total number of agreed eligi-ble studies by the sum of all studies and multiplying by 100. A total number of two studies were disagreed upon leading to an ICA of 93%. Consensus was reached by discussing disagreements as a team leading to a final ICA of 100%

Fig. 1 PRISMA diagram show-ing search strategy


1 3

Tabl

e 1

Des

crip

tive

info

rmat

ion

from

sele

cted

stud

ies

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Bar

retto

et a

l. (2

006)

Sing

le su

bjec

t res

earc

h;

mul

ti el

emen

t des

ign

Inte

rven

tioni

sts: t

wo

fem

ales

, one

teac

her

and

one

psyc

holo

gist

No

ages

repo

rted

Parti

cipa

nts w

ith A

SD:

one

mal

eA

ge: 5

yea

rsD

iagn

osis

: ASD

tool

no

t rep

orte

d

Iow

a C

omm

unic

atio

ns

Net

wor

k (I

CN

)C

amer

a th

at tr

ansm

itted

an

d re

cord

ed a

udio

an

d vi

sual

info

rma-

tion.

Tou

ch to

spea

k M

icro

phon

es D

eskt

op

with

Pow

erPo

int

Func

tiona

l ana

lysi

sB

rief f

unct

iona

l A

naly

sis c

ondu

cted

vi

a vi

deo

conf

eren

c-in

g. 5

min

sess

ions

. Fr

ee p

lay,

esc

ape

and

alon

e. In

terv

entio

nists

re

ceiv

ed c

ontin

uous

liv

e vi

deo

conf

eren

ced

coac

hing

thro

ugho

ut

Inte

rven

tioni

st va

ri-ab

les:

non

e re

porte

dA

SD p

artic

ipan

t var

i-ab

les:

chi

ld d

isru

ptiv

e be

havi

our;

scre

amin

g,

nonc

ompl

ianc

e an

d pr

oper

ty d

estru

ctio

n

Posi

tive

Succ

essf

ul fu

nctio

nal

anal

ysis

iden

tified

es

cape

func

tion

for

beha

viou

r

Wea

k

Bar

kaia

et a

l. (2

017)

Sing

le su

bjec

t res

earc

h;

mul

tiple

bas

elin

e de

sign

Inte

rven

tion-

ists:

thre

e fe

mal

e th

erap

ists.

Age

: 24–

32

(M =

27 y

ears

)Pa

rtici

pant

s with

ASD

: th

ree

mal

esA

ge: 4

–6 y

ears

(M

= 5

year

s 4

mon

ths)

Dia

gnos

is: A

SD n

o di

agno

stic

tool

pro

-vi

ded

Lapt

ops a

nd w

ebca

ms

used

from

cen

treSk

ype

Vib

er/M

obile

pho

ne

used

for c

alls

. vid

eos

sent

to se

cure

d dr

opbo

x

Nat

ural

istic

teac

hing

Did

actic

trai

ning

: sp

oken

and

writ

ten

instr

uctio

ns d

escr

ib-

ing

man

d an

d ec

hoic

op

eran

ts, p

ract

ice

exer

cise

to d

iscr

imi-

nate

. 1–2

hC

oach

ing:

vid

eo

conf

eren

ced

coac

hed

sess

ions

focu

sed

on

man

d tra

inin

g an

d ec

hoic

s, te

achi

ng c

on-

tinge

ncie

s of p

ositi

ve

cons

eque

nces

, fee

d-ba

ck a

nd p

rom

ptin

g op

portu

nitie

s. 10

min

at

end

of c

oach

ing

sess

ion

reco

rded

for

anal

ysis

Inte

rven

tioni

st va

ri-ab

les:

fide

lity/

corr

ect

impl

emen

tatio

n of

se

quen

ce a

nd fe

ed-

back

Soci

al v

alid

ity q

uesti

on-

naire

ASD

par

ticip

ant:

man

ds

and

echo

ic re

spon

ses

Mix

edA

ll th

erap

ists i

ncre

ased

co

rrec

t com

man

ds

from

bas

elin

eSm

all i

ncre

ase

in

feed

back

for t

wo

parti

cipa

nts l

arge

r in

crea

se fo

r one

Leve

ls o

f fide

lity

wer

e lo

w <

60%

Mix

ed in

crea

ses i

n m

ands

and

ech

oics

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Bea

rss e

t al.

(201

7)G

roup

rese

arch

des

ign;

qu

asi e

xper

imen

tal

pre-

post

test

with

no

com

paris

on g

roup

Inte

rven

tioni

sts: 1

3 pa

rent

sG

ende

r not

spec

ified

Age

s: m

othe

rs

(M =

38.3

), fa

ther

s (M

= 39

.8)

Not

cle

ar w

hich

par

ent

took

par

t in

trial

Parti

cipa

nts w

ith A

SD:

13, 9

mal

es, 5

fem

ales

Age

: (M

= 5.

8 ye

ars)

Dia

gnos

is: A

SD D

iag-

nosti

c to

ol: A

DO

S

Equi

pmen

t: C

ompu

ters

, sc

anne

rs, p

roje

ctor

s, ca

mer

as. N

o de

taile

d sp

ecifi

cs re

porte

dV

ideo

conf

eren

cing

So

ftwar

e: n

ot re

porte

d

Beh

avio

ur su

ppor

t6-

mon

th d

irect

instr

uc-

tion

pare

nt tr

aini

ng

prog

ram

des

igne

d to

te

ach

pare

nts b

ehav

-io

ur m

anag

emen

t str

ateg

ies,

cond

ucte

d vi

a vi

deoc

onfe

renc

-in

g. T

rain

ers f

ollo

wed

m

anua

lised

trai

ning

te

chni

ques

incl

udin

g sc

ripts

and

vid

eos

Inte

rven

tioni

st va

ri-ab

les:

trea

tmen

t fide

l-ity

che

cklis

tC

oach

es ra

tings

of

succ

ess

Pare

nt tr

eatm

ent

enga

gem

ent s

cale

Tele

heal

th c

areg

iver

sa

tisfa

ctio

n su

rvey

Tele

heal

th p

rovi

der

satis

fact

ion

surv

eyH

ome

Situ

atio

ns

Que

stion

naire

-ASD

Pa

rent

Sat

isfa

ctio

n Q

uesti

onna

ireA

SD p

artic

ipan

t var

i-ab

leV

inel

and

Ada

ptiv

e B

ehav

iour

Che

cklis

tsA

bhor

rent

beh

avio

ur

chec

klist

Mix

edH

igh

pare

nt a

ccep

t-ab

ility

Trai

ners

scor

ed h

igh

leve

ls o

f fide

lity

train

-in

g vi

a te

lehe

alth

No

sign

ifica

nt d

iffer

-en

ces i

n sc

ore

of

Vin

elan

dSi

gnifi

cant

impr

ove-

men

ts o

n th

e So

cial

W

ithdr

awal

, Ste

reo-

typi

esH

yper

activ

ity, a

nd

Inap

prop

riate

Spe

ech

subs

cale

s of t

he

Abh

orre

nt b

ehav

iour

ch

eckl

ist

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Ben

son

et a

l. (2

017)

Sing

le su

bjec

t res

earc

h de

sign

; mul

ti el

emen

t/fo

llow

ed b

y an

ABA

B

reve

rsal

des

ign

Inte

rven

tioni

stsFa

mili

es o

f ASD

par

-tic

ipan

t no

info

rma-

tion

prov

ided

Parti

cipa

nts w

ith A

SD:

one

mal

eA

ge: 5

yea

rsD

iagn

osis

: ASD

di

agno

stic

tool

not

re

porte

d

Del

l™ D

eskt

op c

om-

pute

rex

tern

al L

ogite

ch

cam

era

and

Han

gout

s™ c

om-

mun

icat

ions

plat

form

for v

ideo

co

nfer

enci

ngD

ebut

vid

eoC

aptu

res s

oftw

are

to

reco

rd se

ssio

ns

Func

tiona

l Ana

lysi

s and

fu

nctio

nal c

omm

uni-

catio

n tra

inin

gH

ome

base

d as

sess

men

t an

d In

terv

entio

n co

m-

plet

ed b

y pa

rent

s with

vi

deo

conf

eren

ced

coac

hed

train

ing.

Pa

rtici

pant

s wer

e liv

e co

ache

d th

roug

h th

e fu

nctio

nal a

naly

sis

This

was

follo

wed

by

FCT

Bas

elin

e co

n-si

sted

of p

artic

ipan

t be

ing

give

n ac

cess

to

mai

ntai

ning

rein

-fo

rcem

ent (

tang

ible

) af

ter e

xhib

iting

SIB

. Th

e ch

ild w

as th

en

prom

pted

to u

se

pict

ure

card

as F

CT

to

rece

ive

the

item

. Par

-en

ts w

ere

live

coac

hed

thro

ugho

ut

Inte

rven

tioni

st va

riabl

esFi

delit

y of

par

ent

proc

edur

es a

gain

st ta

sk a

naly

sis o

f the

as

sess

men

t and

trai

n-in

g ph

ases

ASD

par

ticip

ant v

ari-

able

sSI

B b

ehav

iour

, fac

e sl

appi

ngM

ands

by

touc

hing

or

hand

ing

over

com

-m

unic

atio

n ca

rd

Posi

tive

SIB

dec

reas

ed a

fter

inte

rven

tion

intro

-du

ced

and

rem

erge

d up

on re

turn

to

base

line

and

man

ds

incr

ease

d an

d de

crea

sed

on re

turn

to

base

line

Wea

k

Gib

son

et a

l. (2

010)

Sing

le su

bjec

t res

earc

h de

sign

; ABA

B re

ver-

sal d

esig

n

Inte

rven

tioni

ststw

o fe

mal

es, o

ne p

re-

scho

ol te

ache

r, on

e te

achi

ng a

ssist

ant

Age

s not

pro

vide

dPa

rtici

pant

s with

ASD

one

mal

eA

ge: 4

yea

rsD

iagn

osis

: ASD

di

agno

stic

tool

not

re

porte

d

Lap

top

with

dig

ital

cam

era

with

inbu

ilt

mic

roph

one.

Sky

peD

ell L

atitu

de D

820

note

book

com

pute

r w

ith a

Mic

roso

ft W

indo

ws X

PLo

gite

ch Q

uick

cam

Func

tiona

l com

mun

ica-

tion

train

ing

Witt

en d

irect

instr

uc-

tions

em

aile

d, in

clud

-in

g a

task

ana

lysi

s of

inte

rven

tion.

Vid

eo

cons

ulta

tion

took

pl

ace

just

befo

re

and

afte

r pro

vide

d de

scrip

tive

feed

back

Chi

ld ta

ught

to ra

ise

hand

to a

cces

s esc

ape

and

toys

dur

ing

circ

le

time

Inte

rven

tioni

st va

ri-ab

les:

Non

e re

porte

dA

SD p

artic

ipan

t var

i-ab

les

Elop

emen

t of A

SD p

ar-

ticip

ant f

rom

ass

igne

d w

ork

area

Posi

tive

ABA

B d

esig

n sh

owed

cl

ear r

etur

n to

bas

e-lin

e an

d im

prov

emen

t in

trea

tmen

t con

ditio

n

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Hei

tzm

an-P

owel

l et a

l. (2

014)

Gro

up re

sear

ch d

esig

n;

quas

i exp

erim

enta

l de

sign

with

pre

-pos

t te

st, n

o co

mpa

rison

gr

oup

Inte

rven

tioni

stsse

ven

pare

nts f

rom

four

fa

mili

es, g

ende

rs n

ot

prov

ided

Age

s: 3

2–47

yea

rs.

(M =

37.3

yea

rs)

Parti

cipa

nts w

ith A

SD:

no d

etai

ls p

rovi

ded,

re

ferr

ed a

s ‘ch

ildre

n w

ith a

utis

m’ i

n th

e ab

strac

t onl

y

Onl

ine

train

ing

deliv

-er

ed th

roug

h an

onl

ine

lear

ning

man

agem

ent

syste

mPo

lyco

m®

vid

eoco

nfer

-en

cing

softw

are

Com

preh

ensi

veTr

aini

ng p

acka

ge o

n pr

inci

ples

of A

BA

deliv

ered

thro

ugh

an o

nlin

e le

arni

ng

plat

form

OA

SIS.

Pr

e an

d po

st tra

inin

g kn

owle

dge

asse

ss-

men

ts c

ompl

eted

Vid

eo-c

onfe

renc

ed

coac

hing

sess

ions

w

ith d

iscu

ssio

n of

the

topi

c an

d liv

e co

ache

d se

ssio

ns w

ith p

artic

i-pa

nts o

wn

child

Inte

rven

tioni

st va

riabl

esPa

rent

skill

Ass

essm

ent

(Fid

elity

) com

plet

ed

befo

re a

nd a

fter

train

ing.

Sco

red

from

vi

deot

aped

sess

ion

Pare

nt K

now

ledg

e Te

stPa

rent

Sat

isfa

ctio

n w

ith

the

train

ing

ASD

par

ticip

ant v

ari-

able

s: n

one

Und

eter

min

edPa

rent

al g

ains

on

know

ledg

e an

d fid

elity

w

ere

repo

rted

and

appe

ared

hig

h, n

o st

atist

ical

mea

sure

s of

this

cha

nge

wer

e re

porte

d

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Hig

gins

et a

l. (2

017)

Sing

le su

bjec

t res

earc

h de

sign

; mul

tiple

bas

e-lin

e de

sign

Inte

rven

tioni

sts: t

hree

fe

mal

e di

rect

-car

e st

aff. A

ll w

orke

d in

EI

BI f

or le

ss th

an

6 m

onth

s no

expe

ri-en

ce w

ith p

refe

renc

e as

sess

men

tsA

ge: 2

1–24

yea

rs

(M =

22.6

6 ye

ars)

Parti

cipa

nts w

ith A

SD:

two

mal

es a

nd o

ne

fem

ale

Age

: 4–5

yea

rs

(M =

4 ye

ars)

Dia

gnos

is: A

SD

diag

nosti

c to

ol n

ot

repo

rted

No

pre-

inte

rven

tion

asse

ssm

ent i

nfor

ma-

tion

prov

ided

Ado

be C

onne

ct 8

vi

deoc

onfe

renc

ing

softw

are

Secu

re fi

le e

ncry

pted

fil

e tra

nsfe

rrin

g so

ftwar

eLa

ptop

com

pute

r and

Lo

gite

ch W

ebca

m

Softw

are

v2.2

Pref

eren

ce a

sses

smen

tsPa

rtici

pant

s tau

ght t

o ad

min

ister

pre

fere

nce

asse

ssm

ents

via

vid

eo

conf

eren

cing

Parti

cipa

nts g

iven

ac

cess

to w

ritte

n in

struc

tions

prio

r to

vide

o co

nfer

enci

ngB

asel

ine

take

n on

im

plem

enta

tion

of

thes

e in

struc

tions

. Fi

rst b

asel

ine

was

co

nduc

ted

usin

g A

SD p

artic

ipan

t, al

l su

bseq

uent

trai

n-in

g in

volv

ed u

sing

a

conf

eder

ate

acto

r. Tr

aini

ng c

ompo

sed

of

mul

ti-m

edia

pre

sent

a-tio

n. F

eedb

ack

on

prev

ious

per

form

ance

an

d on

role

pla

y pr

actic

e se

ssio

ns.

Follo

wed

by

an

asse

ssm

ent a

nd tw

o po

st tra

inin

g as

sess

-m

ents

, one

with

ASD

pa

rtici

pant

Inte

rven

tioni

st pa

rtici

-pa

nts:

per

cent

age

of

mas

tere

d co

mpo

nent

sSo

cial

val

idity

que

stion

-na

ireA

SD p

artic

ipan

t var

i-ab

les:

non

e

Posi

tive

Incr

ease

d fid

elity

for

all p

artic

ipan

ts in

the

impl

emen

tatio

n of

sk

ills,

how

ever

onl

y th

ree

data

poi

nts w

ere

com

plet

ed w

ith P

ar-

ticip

ants

with

ASD

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Inge

rsol

l and

Ber

ger

(201

5)G

roup

rese

arch

des

ign;

ra

ndom

ly a

ssig

ned

com

paris

on g

roup

Inte

rven

tioni

sts: 2

7 pa

rent

s, 96

% fe

mal

eA

ge: n

ot re

porte

dPa

rtici

pant

s with

ASD

: 27

par

ticip

ants

70%

m

ale

Age

: 23–

73 m

onth

s. (M

= 3.

7 ye

ars)

Dia

gnos

is: A

SD d

iag-

nosti

c to

ols:

AD

OS,

D

SM-I

V-TR

Tele

heal

th g

roup

n =

14

Com

paris

on g

roup

n =

13Pr

e in

terv

entio

n as

sess

-m

ent:

info

rmat

ion

on

verb

al m

enta

l age

, no

n-ve

rbal

men

tal a

ge

and

via

Mul

len

scal

e of

Ear

ly L

earn

ing

Hom

e co

mpu

ters

and

w

ebca

ms

ImPA

CT

onlin

e tra

inin

g w

ebsi

te a

s per

Inge

r-so

ll et

al.

(201

6)Sk

ype

Nat

ural

istic

teac

hing

ImPA

CT

onlin

e tra

inin

g de

sign

ed to

incr

ease

so

cial

com

mun

icat

ion

Gro

up 1

: pro

vide

d w

ith

acce

ss to

web

site

for

6 m

onth

sW

ebsi

te c

onsi

sted

of

11 ×

75 m

in le

sson

s, vi

deo

libra

ry, e

xer-

cise

s and

add

ition

al

reso

urce

sG

roup

2: i

n ad

ditio

n to

th

e w

ebsi

te p

artic

i-pa

nts w

ere

prov

ided

w

ith 2

x w

eekl

y 30

min

vid

eo c

onfe

r-en

cing

sess

ion

with

tra

ined

coa

chO

ne se

ssio

n in

trodu

ced

the

topi

c th

e se

cond

pr

ovid

ed li

ve fe

edba

ck10

-min

reco

rdin

g of

pa

rent

/chi

ld in

tera

c-tio

n du

ring

play

or

snac

k sc

ored

at

base

line,

pos

t tre

at-

men

t and

at 3

mon

ths

follo

w u

p

Inte

rven

tioni

st va

riabl

es: d

epre

ssiv

e sy

mpt

oms o

f par

ents

Inte

rven

tion

know

ledg

eIn

terv

entio

n fid

elity

Prog

ram

eng

agem

ent

Prog

ram

eva

luat

ion

ASD

par

ticip

ant v

ari-

able

s: N

one

Posi

tive

Pare

nt a

ssist

gro

up

mor

e lik

ely

to e

ngag

e w

ith th

e w

ebsi

tePa

rent

eng

agem

ent h

igh

for b

oth

grou

psB

oth

grou

ps si

gnifi

-ca

ntly

incr

ease

d th

eir

inte

rven

tion

know

l-ed

ge a

nd fi

delit

y, th

e vi

deo

coac

hed

grou

ps

had

sign

ifica

ntly

hi

gher

scor

es o

f fide

l-ity

pos

t tre

atm

ent

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Inge

rsol

l et a

l. (2

016)

Gro

up re

sear

ch d

esig

n;

rand

omly

ass

igne

d co

mpa

rison

gro

upQ

uasi

exp

erim

enta

l pr

e-po

st an

alys

is fo

r w

ithin

gro

up a

naly

sis

Inte

rven

tioni

st pa

rtici

-pa

nts:

27

pare

nts

Ther

apist

Ass

isted

G

roup

(n =

14)

Self-

Dire

cted

gro

up

(n =

13)

Gen

der a

nd a

ge n

ot

prov

ided

Parti

cipa

nts w

ith A

SD:

ther

apist

ass

isted

gr

oup

(n =

14)

21%

fem

ale

and

79%

m

ale

Age

: (M

= 41

.57

mon

ths)

Self-

Dire

cted

gro

up

(n =

13)

13. 3

9% fe

mal

e an

d 61

% m

ale

Age

: (M

= 46

.08

mon

ths)

Dia

gnos

is: A

SD o

r PD

D-N

OS

Dia

gnos

tic to

ol: D

SM-

IV a

nd A

DO

SPr

e-as

sess

men

t sco

res

on th

e M

ulle

n Sc

ale

of

Early

lear

ning

ImPA

CT

onlin

e tra

inin

g w

ebsi

te w

ith 1

2 se

lf-di

rect

ed le

sson

sV

ideo

con

fere

ncin

g so

ftwar

e no

t spe

cifie

d

Nat

ural

istic

teac

hing

ImPA

CT

onlin

e tra

inin

g de

sign

ed to

incr

ease

so

cial

com

mun

icat

ion.

C

ompa

rison

of t

wo

grou

ps, o

ne u

tilis

ing

vide

o co

nfer

enci

ng o

n to

p on

onl

ine

train

ing

Gro

up 1

: pro

vide

d w

ith

acce

ss to

web

site

for 6

m

onth

sW

ebsi

te c

onsi

sted

of

11 ×

75 m

in le

sson

s, vi

deo

libra

ry, e

xer-

cise

s and

add

ition

al

reso

urce

sG

roup

2: i

n ad

ditio

n to

th

e w

ebsi

te p

artic

i-pa

nts w

ere

prov

ided

w

ith 2

x w

eekl

y 30

min

vid

eo c

onfe

r-en

cing

sess

ion

with

tra

ined

coa

ch

Inte

rven

tioni

st va

ri-ab

les:

par

ent i

nter

ven-

tion

fidel

ityFa

mily

Impa

ct q

uesti

on-

naire

(soc

ial v

alid

ity)

ASD

par

ticip

ant

varia

bles

: rat

e of

use

of

indi

vidu

alis

ed

lang

uage

targ

ets,

prom

pted

and

in

depe

nden

t use

of

lang

uage

scor

edM

acA

rthur

Bat

es C

om-

mun

icat

ion

Dev

el-

opm

ent I

nven

tory

(P

aren

t sco

red)

Vin

elan

d A

dapt

ive

Beh

avio

ur sc

ales

(par

-en

t sco

red)

Posi

tive

Sign

ifica

nt p

re v

s pos

t-te

st in

crea

se in

par

ent

use

of in

terv

entio

n sc

ores

of fi

delit

y fo

r bo

th g

roup

sTh

erap

ist a

ssist

ed g

roup

sc

ored

sign

ifica

ntly

hi

gher

at p

ost i

nter

-ve

ntio

n fid

elity

but

th

is d

id n

ot h

old

for 3

m

onth

follo

w u

pIn

crea

se in

par

enta

l sc

ores

of s

elf-

effica

cy

and

decr

ease

in p

aren

-ta

l stre

ssSi

gnifi

cant

lang

uage

in

crea

ses i

n ch

ild la

n-gu

age

use

over

tim

e fo

r lan

guag

e ta

rget

s Sm

all s

igni

fican

t eff

ect f

or g

roup

, the

ra-

pist

assi

sted

grou

p sc

ored

slig

htly

bet

ter

MC

DI a

nd v

inel

and

scor

e si

gnifi

cant

ly

incr

ease

d

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Kur

avac

kel e

t al.

(201

8)G

roup

rese

arch

des

ign;

ra

ndom

ised

con

trol

trial

Inte

rven

tioni

st: 3

3 pa

rent

sN

o ge

nder

or a

ge

repo

rted

Parti

cipa

nts w

ith A

SD33

par

ticip

ants

, sev

en

mal

es a

nd 2

6 fe

mal

esFa

ce to

face

com

paris

on

grou

p (n

= 13

)A

ge: 5

0–14

8 m

onth

s (M

= 10

4.62

mon

ths)

Wai

t list

com

paris

on

grou

p (n

= 10

)A

ge: 3

9–15

3 m

onth

s (M

= 10

1.8

mon

ths)

Tele

heal

th g

roup

(n

= 10

)A

ge: 4

3–12

2 m

onth

s (M

= 82

.3 m

onth

s)D

iagn

ostic

tool

: M

odifi

ed C

heck

list f

or

Aut

ism

in T

oddl

ers

(M-C

HA

T), S

ocia

l C

omm

unic

atio

n Q

ues-

tionn

aire

(SC

Q),

DSM

-IV

and

A

DO

S

No

info

rmat

ion

pro-

vide

dPo

sitiv

e be

havi

our

supp

ort/b

ehav

iour

m

anag

emen

tR

ando

mis

atio

n to

face

-to

-face

, tel

ehea

lth

or w

aitli

st co

ntro

l. Pa

rent

s pro

vide

d w

ith

know

ledg

e of

ASD

, an

d ev

iden

ce b

ased

pr

actic

es. D

eliv

ered

vi

a te

lehe

alth

vid

eo

conf

eren

cing

in e

ither

a

grou

p or

indi

-vi

dual

ised

form

at. A

m

anua

lised

cop

y of

tra

inin

g pr

oced

ures

al

so p

rovi

ded

Inte

rven

tioni

st va

ri-ab

les:

par

enta

l stre

ss

inde

xB

eing

a p

aren

t sca

leC

onsu

ltatio

n sa

tisfa

c-tio

n qu

estio

nnai

reG

roup

sess

ion

ratin

g sc

ale

Pare

nt fi

delit

y ra

ting

form

ASD

par

ticip

ant v

aria

-bl

es: E

YEB

ERG

chi

ld

beha

viou

r inv

ento

ryM

odifi

ed c

heck

list f

or

autis

m in

todd

lers

Soci

al C

omm

unic

atio

n qu

estio

nnai

re

Mix

edSi

gnifi

cant

diff

eren

ce in

ch

ild p

robl

em b

ehav

-io

ur sc

ores

No

effec

ts o

n pa

rent

ou

tcom

es

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Lind

gren

et a

l. (2

015)

Gro

up re

sear

ch d

esig

n;

quas

i-exp

erim

enta

l de

sign

with

com

-pa

rison

gro

ups,

no

rand

om a

ssig

nmen

t

Inte

rven

tioni

st; 5

0 pa

rent

’s g

ende

rs n

ot

prov

ided

Age

: 23–

51 y

ears

old

Parti

cipa

nts w

ith A

SD:

Gro

up 1

did

not

mee

t in

clus

ion

crite

ria fo

r A

SD d

iagn

osis

as

outc

omes

wer

e no

t re

porte

d se

para

tely

Gro

up 2

: 20

parti

ci-

pant

s, 19

mal

es a

nd

one

fem

ale

Age

: 29–

80 m

onth

s (M

= 50

.3 m

onth

s)G

roup

3: 3

0 pa

rtici

pant

sA

ge: 2

1–84

mon

ths

(M =

50.3

)D

iagn

osis

: ASD

, di

agno

stic

tool

not

re

porte

d

Tele

heal

th w

orks

tatio

ns

equi

pped

with

Win

-do

ws b

ased

PC

, vid

eo

mon

itor a

nd h

eads

etSk

ype

Func

tiona

l Ana

lysi

s and

Fu

nctio

nal c

omm

uni-

catio

n tra

inin

gG

roup

2 p

aren

ts w

ere

coac

hed

via

tele

heal

th

to c

ondu

ct F

As

and

com

plet

e FC

T in

terv

entio

ns in

clin

ic

setti

ngG

roup

3 c

ondu

cted

in

hom

e se

tting

Inte

rven

tioni

st va

ri-ab

les:

acc

epta

bilit

y ra

tings

of t

he in

ter-

vent

ion

ASD

par

ticip

ant v

ari-

able

s: %

redu

ctio

n in

pr

oble

m b

ehav

iour

% in

crea

se in

man

ds%

incr

ease

in ta

sk

com

plet

ion

Posi

tive

Posi

tive

outc

omes

re

porte

d fo

r red

uc-

tion

and

incr

ease

s in

all

DV

s usi

ng

with

in g

roup

ana

lysi

s, ho

wev

er n

o st

atist

i-ca

l pre

-pos

t ana

lysi

s co

mpl

eted

No

sign

ifica

nt d

iffer

-en

ces b

etw

een

hom

e an

d ce

ntre

bas

ed

grou

ps fo

und

afte

r A

NO

VA

Wea

k

Mac

halic

ek e

t al.

(200

9a)

No

expe

rimen

tal d

esig

nIn

terv

entio

nist:

thre

e gr

adua

te st

uden

ts in

sp

ecia

l edu

catio

nN

o ag

e or

gen

der

prov

ided

Parti

cipa

nts w

ith A

SD:

thre

e m

ale

parti

ci-

pant

sA

ge: 3

4 m

onth

s to

7 ye

ars (

M =

4 ye

ars

11 m

onth

s)D

iagn

osis

: tw

o A

SD

and

one

PDD

-NO

Sdi

agno

stic

tool

not

re

porte

d

Mac

Boo

kTM

lapt

opiS

ight

TM c

amer

asiM

acTM

des

ktop

iCha

tTM

vid

eoco

nfer

-en

cing

softw

are

Jabr

aTM

blu

etoo

thw

ire-

less

head

set

Pref

eren

ce A

sses

smen

tTr

aine

e te

ache

rs ta

ught

pa

ired

choi

ce p

refe

r-en

ce a

sses

smen

ts v

ia

vide

o co

nfer

enci

ngPa

rtici

pant

s pro

vide

d w

ith ta

sk a

naly

sis

Tria

ls w

ere

run

thro

ugh

vide

o co

nfer

enci

ng

with

feed

back

and

de

scrip

tive

erro

r cor

-re

ctio

n

Inte

rven

tioni

st va

riabl

es: fi

delit

y of

pr

oced

ures

Soci

al v

alid

ity o

f the

ta

skA

SD p

artic

ipan

t var

i-ab

les:

freq

uenc

y of

ite

ms c

hose

n

Und

eter

min

edN

o gr

aphe

d da

ta in

re

port,

teac

hers

wer

e re

porte

d to

reac

h 10

0% fi

delit

y w

ithin

tra

inin

g pe

riod

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Mac

halic

ek e

t al.

(201

0)Si

ngle

subj

ect r

esea

rch

desi

gn; m

ultip

le

base

line

desi

gn w

ith

addi

tiona

l em

bedd

ed

mul

ti el

emen

t com

-po

nent

s

Inte

rven

tioni

sts: s

ix

teac

hers

all

fem

ale

Age

: 22–

32

(M =

27 y

ears

)Pa

rtici

pant

s with

ASD

: si

x pa

rtici

pant

sN

o ge

nder

s pro

vide

dA

ge: 4

–10

year

s (M

= 6

year

s)D

iagn

osis

5 A

SD, 1

w

ith a

utist

ic li

ke

beha

viou

rs D

iagn

ostic

to

ols n

ot re

porte

d

Mac

Boo

k la

ptop

with

ad

ditio

nal s

peak

ers

and

mic

roph

one

iSig

ht c

amer

aiM

ac d

eskt

op u

sed

to

film

ass

essm

ents

iCha

t sof

twar

e us

ed in

vi

deo

conf

eren

cing

Func

tiona

l ana

lysi

sD

urin

g ba

selin

e pa

r-tic

ipan

ts w

ere

film

ed

com

plet

ing

an F

A fo

r ea

ch c

ondi

tion

seve

ral

times

Dur

ing

vide

o co

nfer

-en

ce tr

aini

ng p

ar-

ticip

ants

wer

e gi

ven

perfo

rman

ce fe

edba

ck

in re

al ti

me

and

wer

e er

ror c

orre

cted

by

the

supe

rvis

or

Inte

rven

tioni

st Va

ri-ab

les:

teac

her fi

delit

y ag

ains

t a ta

sk a

naly

sis

for e

ach

cond

ition

Supe

rvis

or/c

oach

be

havi

our w

as

asse

ssed

for fi

delit

y ag

ains

t a p

re-d

eter

-m

ined

task

list

ASD

par

ticip

ant v

ari-

able

s: N

one

Posi

tive

All

teac

hers

dem

on-

strat

ed a

larg

e in

crea

se

in th

e fid

elity

of

treat

men

t and

reac

hed

fidel

ity c

riter

ion

Wea

k

Mac

halic

ek e

t al.

(201

6)Si

ngle

subj

ect r

esea

rch

desi

gn; m

ulti-

elem

ent/

alte

rnat

ing

treat

men

ts

Inte

rven

tioni

ststh

ree

pare

nts,

one

mal

e an

d tw

o fe

mal

es. A

ges

not r

epor

ted

Parti

cipa

nts w

ith A

SD:

thre

e pa

rtici

pant

sA

ge: 8

–16

year

s (M

= 11

yea

rs)

Dia

gnos

is: A

SDD

iagn

ostic

tool

: DSM

-VPr

e-as

sess

men

t inf

o re

porte

d C

hild

hood

A

utis

m R

atin

g Sc

ale

(CA

RS)

2.4

Ghz

/250

GB

har

d dr

ive/

Supe

rDriv

e M

acB

ook™

Logi

tech

Qui

ckC

am P

ro 9

000™

Supe

rDriv

e Mac

Boo

k™

lapt

op c

ompu

ter w

ith

a bu

ilt-in

iSig

ht™

web

cam

era

iCha

t™ v

ideo

conf

er-

enci

ngso

ftwar

eeC

amm

™ c

all r

ecor

d-in

g so

ftwar

e

Func

tiona

l Ana

lysi

s, FC

T an

d B

ehav

iour

su

ppor

t stra

tegi

esPh

ase

one:

initi

al te

l-ec

onfe

renc

ed P

aren

ts

cond

ucte

d an

FA

with

te

lehe

alth

supp

ort,

prom

ptin

g, e

rror

-cor

-re

ctio

n an

d pr

aise

Phas

e tw

o: tr

eatm

ent

com

paris

on p

aren

ts

wer

e tra

inin

g in

in

divi

dual

ised

supp

ort

plan

s inv

olvi

ng: a

nte-

cede

nt st

rate

gies

, FC

T an

d D

RA

pro

cedu

res

Vid

eo m

odel

ling

via

tele

heal

th w

as u

sed

to d

emon

strat

e ea

ch

proc

edur

e

Inte

rven

tioni

st va

ri-ab

les:

par

enta

l fide

lity

of F

A p

roce

dure

s ta

ken

on 3

9%, 3

5%

and

35%

of F

A se

s-si

ons

Pare

ntal

pro

cedu

ral

fidel

ity fo

r 89%

, 100

%

and

100%

of F

CT

cond

ition

sSo

cial

Val

idity

que

s-tio

nnai

reA

SD p

artic

ipan

t var

i-ab

les:

occ

urre

nces

of

indi

vidu

alis

ed ta

rget

be

havi

our t

hat c

hal-

leng

es

Mix

edFu

nctio

nal a

naly

sis

indi

cted

func

tion

for e

ach

parti

cipa

nt,

alth

ough

un-

labe

lled

grap

hs m

ake

hard

to

dete

rmin

eC

halle

ngin

g be

havi

our

was

low

for a

ll co

ndi-

tions

but

ther

e w

as n

o cl

ear d

iffer

entia

tion

betw

een

cond

ition

s as

the

inte

rven

tion

was

im

plem

ente

d

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Mac

halic

ek e

t al.

(200

9b)

Sing

le su

bjec

t res

earc

h de

sign

; mul

ti el

emen

t/al

tern

atin

g tre

atm

ents

Inte

rven

tioni

sts: t

wo

grad

uate

stud

ents

N

o ag

es o

r gen

der

prov

ided

Parti

cipa

nts w

ith A

SD:

two

fem

ale

parti

ci-

pant

sA

ge: 1

1 an

d 7

year

sD

iagn

osis

: ASD

Dia

gnos

tic to

ol: c

hild

-ho

od ra

ting

scal

e

2.0

Ghz

Mac

-Boo

k™

lapt

op c

ompu

ters

with

M

ac O

S X

ope

ratin

g sy

stem

, 2 e

xter

nal

iSig

ht™

cam

eras

, iC

hat™

vid

eoco

nfer

-en

cing

softw

are

One

lapt

op c

ompu

ter

with

iSig

ht™

cam

era

Func

tiona

l ana

lysi

sSt

uden

ts w

ere

train

ed

to c

ondu

ct fu

nctio

nal

anal

ysis

via

live

vid

eo

conf

eren

ced

coac

hing

Inte

rven

tioni

st va

ri-ab

les:

non

eA

SD p

artic

ipan

t var

i-ab

le: i

ndiv

idua

lised

ta

rget

ed b

ehav

iour

th

at c

halle

nges

Posi

tive

Dem

onstr

ated

cle

ar

func

tion

of b

ehav

iour

fo

r bot

h pa

rtici

pant

s

Wea

k

Mea

dan

et a

l. (2

016)

Sing

le su

bjec

t res

earc

h de

sign

; mul

tiple

bas

e-lin

e de

sign

Inte

rven

tioni

sts: t

hree

fe

mal

e pa

rent

s Age

s no

t pro

vide

dPa

rtici

pant

s with

ASD

: th

ree

parti

cipa

nts,

two

mal

es a

nd o

ne fe

mal

eA

ge: 2

–4 (M

= 3)

Dia

gnos

is: A

SDD

iagn

ostic

tool

: pre

-sc

hool

lang

uage

scor

e an

d A

ges a

nd S

tage

s Q

uesti

onna

ire—

soci

al

emot

iona

l

iPad

s pro

vide

d to

fam

i-lie

s use

d fo

r vid

eo

reco

rdin

g Sk

ype

Elec

troni

c m

ater

ials

sh

ared

via

a se

cure

on

line

file

shar

-in

g B

ox. C

amta

sia

softw

are

to re

cord

se

ssio

ns

Nat

ural

istic

teac

hing

Inte

rnet

-Bas

ed P

aren

t-Im

plem

ente

d C

om-

mun

icat

ion

Stra

tegi

es

(i-Pi

CS)

Firs

t pha

se c

onsi

sted

of tr

aini

ng d

eliv

ered

w

ith a

coa

ch v

ia

skyp

e la

sting

45

min

Seco

nd p

hase

was

dire

ct

coac

hing

thro

ugh

the

inte

rven

tion

whi

ch

invo

lved

a 5

-7-m

inut

e te

achi

ng se

ssio

n w

ith

the

ASD

par

ticip

ant

Coa

chin

g to

ok p

lace

tw

o tim

es p

er w

eek

and

an a

nnot

ated

vi

deo

feed

back

was

pr

ovid

ed e

very

4th

co

achi

ng se

ssio

n

Inte

rven

tioni

st va

ri-ab

les:

qua

lity

and

rate

w

ith w

hich

the

par-

ent’s

impl

emen

ted

the

natu

ralis

tic te

achi

ng

strat

egy

(Fid

elity

)A

SD p

artic

ipan

t var

i-ab

les:

chi

ldre

n’s s

ocia

l co

mm

unic

atio

n in

itia-

tions

and

resp

onse

sA

dditi

onal

fide

lity

test-

ing

on th

e co

achi

ng

and

train

ing

proc

e-du

res t

o as

certa

in

the

fidel

ity o

f the

co

achi

ng

Mix

edTh

erap

ists d

emon

strat

ed

an in

crea

se in

fide

lity

of im

plem

enta

tion-

on

of st

rate

gies

With

ver

y cl

ear r

elat

ions

hips

de

mon

strat

ed in

2 o

ut

of 3

day

sC

hild

ren’

s ini

tiatio

ns

incr

ease

d ov

er th

e in

terv

entio

n as

did

the

perc

enta

ge o

f suc

cess

-fu

l com

mun

icat

e-on

in

tera

ctio

ns fo

r 2 o

ut

of 3

par

ticip

ants

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Nee

ly e

t al.

(201

6)Si

ngle

subj

ect r

esea

rch

desi

gn; m

ultip

le b

ase-

line

desi

gn

Inte

rven

tioni

sts: t

hree

fe

mal

es c

urre

ntly

w

orki

ng a

t Uni

vers

ity

ABA

clin

icA

ge: 2

0–22

(M =

21

year

s, 4

mon

ths)

Parti

cipa

nts w

ith A

SD:

thre

e pa

rtici

pant

s, tw

o fe

mal

es a

nd o

ne m

ale

Dia

gnos

is: t

wo

with

A

SD d

iagn

osis

1 w

ith

PDD

-NO

S D

iagn

ostic

To

ols:

Par

ticip

ant

A sc

ores

on

AD

OS,

A

SRS

and

Pres

choo

l La

ngua

ge S

ale

Stud

ent B

onl

y A

SRS

repo

rted.

Stu

dent

C

had

no re

porte

d pr

e-in

terv

entio

n la

ngua

ge

outc

omes

ipad

min

i use

d to

reco

rd

sess

ions

Vid

eos s

ubse

quen

tly

dow

nloa

ded

onto

ex

tern

al h

ard-

driv

eV

see

softw

are

used

to

cond

uct v

ideo

con

fer-

ence

d us

ing

lapt

op2.

5-G

Hz

Tosh

ibaT

M

com

pute

r2.

4-G

Hz

Mac

Boo

kTM

All

inte

rven

tioni

sts u

sed

pers

onal

Mac

Boo

ksV

ideo

conf

eren

cing

so

ftwar

e, H

IPPA

-co

mpl

iant

Nat

ural

istic

/inci

dent

al

teac

hing

Pre-

inte

rven

tion

train

-in

g; o

nlin

e m

odul

e,

self-

eval

uatio

n an

d de

laye

d fe

edba

ck

vide

o m

odel

ling

5-m

in b

asel

ine

vide

os

of th

erap

ist w

orki

ng

on ta

rget

man

dFo

llow

ed b

y se

cond

vi

deo

whi

ch w

as

eval

uate

d fo

r fide

lity

inde

pend

ently

by

ther

apist

and

trai

ner

and

subs

eque

ntly

di

scus

sed

thro

ugh

vide

ocon

fere

ncin

g.

Add

ition

al m

aint

e-na

nce

prob

es w

ere

carr

ied

out 2

and

4

mon

ths a

fter fi

delit

y re

ache

d

Inte

rven

tioni

st va

ri-ab

les:

freq

uenc

y of

co

mm

unic

atio

n op

portu

nitie

sPe

rcen

tage

of i

ncid

enta

l te

achi

ng st

eps p

er-

form

ed c

orre

ctly

Scor

es o

n so

cial

val

idity

Tota

l dur

atio

n of

trai

n-in

gA

SD p

artic

ipan

t var

i-ab

le: c

hild

man

ds

Posi

tive

All

ther

apist

s inc

reas

ed

corr

ect i

mpl

emen

ta-

tion

of in

cide

ntal

te

achi

ng a

nd re

ache

d fid

elity

All

Parti

cipa

nts w

ith

ASD

incr

ease

d m

and-

ing

Ade

quat

e


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Sim

acek

et a

l. (2

017)

Sing

le su

bjec

t res

earc

h de

sign

; mul

ti el

emen

t al

ongs

ide

a m

ultip

le

prob

e m

ultip

le b

ase-

line

and

ABA

B re

ver-

sal f

or fi

rst b

asel

ine

Inte

rven

tioni

st Pa

rtici

-pa

nts:

par

ents

of t

he

ASD

indi

vidu

als n

o de

tails

wer

e pr

ovid

edPa

rtici

pant

s with

ASD

: tw

o fe

mal

es p

artic

i-pa

nts

Age

: 3.5

and

4 y

ears

Dia

gnos

is: A

SDD

iagn

ostic

tool

not

re

porte

dFu

nctio

nal a

sses

s-m

ent a

nd st

ruct

ured

de

scrip

tive

asse

ssm

ent

com

plet

ed p

rior t

o in

terv

entio

nSc

ores

of V

AB

S,

Vin

elan

d pa

rent

in

terv

iew

repo

rted

alon

gsid

e pr

evio

us

and

curr

ent s

ervi

ces

incl

udin

g EI

BI f

or o

ne

parti

cipa

nt

Del

l Opt

iPle

x30

10 D

eskt

op w

ith

Del

l 24i

n m

onito

r, Lo

gite

ch H

D P

roW

ebca

m C

920,

Log

-ite

ch C

lear

Cha

t Com

-fo

rt/U

SB H

eads

etH

390

Goo

gle

Han

gout

for

vide

o co

nfer

enci

ngD

ebut

scre

en re

cord

ing

softw

are

Pare

nts u

sed

pers

onal

co

mpu

ter a

long

side

as

prov

ided

HD

Pro

Web

cam

C92

0

Func

tiona

l ana

lysi

s and

fu

nctio

nal c

omm

uni-

catio

n tra

inin

gC

oach

es c

ondu

cted

a

pre-

inte

rven

tion

tele

phon

e ca

ll to

ca

rry

out a

func

tiona

l as

sess

men

t int

er-

view

. Fol

low

ed b

y a

struc

ture

d de

scrip

-tiv

e as

sess

men

t to

mim

ic th

e oc

cur-

renc

es o

f tar

gete

d be

havi

ours

in th

e na

tura

l env

ironm

ent,

no c

oach

ing

occu

rred

. Pa

rtici

pant

s wer

e in

struc

ted

rem

otel

y on

how

to c

ondu

ct

the

FA, w

ith fe

edba

ck

bein

g pr

ovid

ed a

t the

st

art o

f eac

h se

ssio

n,

thro

ugho

ut th

e se

ssio

n an

d vi

a em

ail

FCT:

bas

elin

e co

n-du

cted

whe

re id

iosy

n-cr

atic

beh

avio

urs w

ere

rein

forc

ed. T

rain

ing

was

pro

vide

d in

the

use

of F

CT

usin

g di

rect

feed

back

and

w

ritte

n in

struc

tions

vi

a em

ail

Inte

rven

tioni

st va

ri-ab

les:

fide

lity

to st

udy

proc

edur

es w

as m

eas-

ured

for 2

0% o

f all

outc

omes

usi

ng a

task

an

alys

is o

f cor

rect

pr

oced

ures

Pare

nt ra

tings

of t

reat

-m

ent a

ccep

tabi

lity

ASD

par

ticip

ant

varia

bles

: ind

ivid

u-al

ised

idio

sync

ratic

be

havi

our (

inap

prop

ri-at

e w

ays t

o ac

quire

re

info

rcem

ent)

Indi

vidu

alis

ed A

AC

Posi

tive

Func

tions

of b

ehav

iour

id

entifi

ed th

roug

h FA

. B

oth

parti

cipa

nt’s

Idi-

osyn

crat

ic re

spon

ses

redu

ced

to 0

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Sues

s et a

l. (2

014)

Sing

le su

bjec

t res

earc

h de

sign

; mul

ti-el

emen

t an

d A

BAB

reve

rsal

de

sign

s

Inte

rven

tioni

st: th

ree

pare

nts g

ende

r not

pr

ovid

edA

ge: (

M =

37 y

ears

). N

o pr

e-in

terv

entio

n A

BA

expe

rienc

e pr

ovid

edPa

rtici

pant

s with

ASD

: th

ree

mal

esA

ge: 2

9–39

mon

ths

(M =

34 m

onth

s)D

iagn

osis

: PD

D-N

OS,

di

agno

stic

tool

not

re

porte

d. N

o pr

e-in

terv

entio

n as

sess

-m

ent i

nfor

mat

ion

prov

ided

Lapt

op a

nd S

kype

use

d fo

r Vid

eo C

onfe

renc

-in

g, D

ebut

vid

eoco

n-fe

renc

ing

softw

are

Elec

troni

c co

py o

f tra

inin

g m

anua

l

Func

tiona

l Ass

essm

ent

and

Func

tiona

l com

-m

unic

atio

n tra

inin

gPa

rent

s pro

vide

d w

ith

two

dida

ctic

trai

ning

se

ssio

ns v

ia v

ideo

co

nfer

enci

ng. C

over

-in

g FA

, FC

T an

d be

havi

our p

rinci

ples

Pa

rent

s sub

sequ

ently

co

ache

d vi

a te

lehe

alth

to

con

duct

FA

and

FC

T

Inte

rven

tioni

st va

ri-ab

les:

fide

lity

to F

CT

task

with

adh

eren

ce

with

per

sona

lised

task

an

alys

is fo

r ses

sion

sTy

pe o

f err

or re

cord

edSo

cial

val

idity

que

stion

-na

ireA

SD p

artic

ipan

t var

i-ab

les:

indi

vidu

alis

ed

chal

leng

ing

beha

viou

r

Mix

edFA

succ

essf

ully

com

-pl

eted

and

iden

tified

a

func

tion

for e

very

pa

rtici

pant

Fide

lity

of F

CT

incr

ease

d sl

ight

ly fo

r ea

ch p

artic

ipan

t and

be

havi

our t

hat c

hal-

leng

es d

ecre

ased

, no

func

tiona

l rel

atio

nshi

p be

twee

n co

ache

d an

d un

-coa

ched

sess

ions

an

d no

bas

elin

e co

m-

plet

ed

Wea

k

Sues

s et a

l. (2

016)

Sing

le su

bjec

t res

earc

h de

sign

; mul

ti el

emen

t de

sign

with

mul

tiple

ba

selin

e

Inte

rven

tioni

sts: p

aren

ts

of A

SD in

divi

du-

als.

No

info

rmat

ion

prov

ided

Parti

cipa

nts w

ith A

SD:

five

parti

cipa

nts

Thre

e m

ales

and

two

fem

ales

Age

: 2.5

–7.1

yea

rs

(M =

5)D

iagn

osis

: ASD

, di

agno

stic

tool

not

re

porte

dPr

e-in

terv

entio

n de

scrip

tive

func

tiona

l as

sess

men

t rep

orte

d

AS

per W

acke

r et a

l. (2

013a

)Sk

ype

Func

tiona

l ana

lysi

s and

Fu

nctio

nal c

omm

uni-

catio

n tra

inin

gPa

rent

s wer

e tra

ined

via

vi

deo

conf

eren

cing

to

con

duct

FA

s and

su

bseq

uent

FC

TIn

itial

1 h

mee

ting

was

co

nduc

ted

to d

iscu

ss

purp

ose

and

expl

ain

desc

riptiv

e as

sess

-m

ent

FA w

as su

bseq

uent

ly

perfo

rmed

with

ong

o-in

g in

struc

tion

from

th

e co

ach

3 × 15

min

coa

ched

FC

T se

ssio

ns su

bse-

quen

tly to

ok p

lace

as

per

Wac

ker e

t al.

(201

3a)

Inte

rven

tioni

st va

ri-ab

les:

non

eA

SD p

artic

ipan

t va

riabl

es: i

ndiv

idua

lly

targ

eted

beh

avio

ur

that

cha

lleng

esTa

sk c

ompl

etio

n m

ands

Posi

tive

Prob

lem

beh

avio

ur

redu

ced

for a

ll pa

rtici

-pa

nts I

ncre

ased

man

ds

and

task

com

plet

ion

Stat

istic

al te

sting

of

effec

t siz

e co

nclu

ded

that

cha

nged

wer

e si

gnifi

cant

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Vis

mar

a et

al.

(201

3)Si

ngle

subj

ect r

esea

rch

desi

gn; m

ultip

le b

ase-

line

desi

gn

Inte

rven

tioni

sts: e

ight

pa

rent

s of c

hild

ren

invo

lved

, sev

en

fem

ales

and

one

mal

eN

o ag

es re

porte

dEd

ucat

ion,

sala

ry,

empl

oym

ent s

tatu

s an

d m

arita

l sta

tus

repo

rted

Parti

cipa

nts w

ith A

SD:

eigh

t par

ticip

ants

, no

gend

ers p

rovi

ded

Age

: 18–

45 m

onth

s (M

= 27

)D

iagn

osis

: ASD

Dia

gnos

tic to

ols,

DSM

-IV

, AD

OS

used

as a

cu

t off

for i

nclu

sion

bu

t not

repo

rted.

A

dditi

onal

serv

ices

re

ceiv

ed re

porte

d

Early

Sta

rt D

enve

r M

odel

onl

ine

train

ing

prog

ram

Lapt

op fo

r vid

eo c

alls

, sp

ecifi

c so

ftwar

e de

tails

not

pro

vide

d

Nat

ural

istic

trea

tmen

t pr

ogra

mV

ideo

con

fere

ncin

g an

d us

e of

a se

lf- g

uide

d w

ebsi

te o

n pa

rent

tra

inin

g in

Ear

ly

Star

t Den

ver M

odel

(E

SDM

)B

asel

ine

was

10

min

fil

min

g pa

rent

chi

ld

inte

ract

ion

Wee

kly

pare

nt tr

aini

ng

sess

ions

alo

ngsi

de

vide

o co

nfer

enci

ng

pare

nt c

oach

ing

ses-

sion

s las

ting

1.5

h

Inte

rven

tioni

st va

riabl

es: p

aren

t sat

-is

fact

ion,

inte

rven

tion

skill

s, pa

rent

eng

age-

men

t sty

les

mat

erna

l beh

avio

ur ra

t-in

g sc

ale

Pare

nt w

ebsi

te u

sage

ASD

indi

vidu

al

outc

omes

: fun

ctio

nal

verb

al u

ttera

nces

non

-ve

rbal

join

t atte

ntio

nIm

itativ

epl

ay a

ctio

ns o

n ob

ject

s an

d ge

sture

s

Mix

edPa

rent

eng

agem

ent

scor

es a

nd fi

del-

ity sc

ores

incr

ease

d fro

m b

asel

ine

for a

ll pa

rtici

pant

sA

SD p

artic

ipan

t sco

res

of v

erba

l utte

ranc

es

and

join

t atte

ntio

n in

crea

sed

for s

ome

put

not a

ll of

par

ticip

ants

(m

ultip

le b

asel

ine

not

grap

hed)

Wea

k

Vis

mar

a et

al.

(201

2)Si

ngle

subj

ect r

esea

rch

desi

gn; m

ultip

le b

ase-

line

desi

gn

Inte

rven

tioni

sts: n

ine

pare

nts o

f chi

ldre

n,

seve

n fe

mal

es a

nd tw

o m

ale

No

ages

pro

vide

d N

o pr

e-in

terv

entio

n ex

pe-

rienc

e re

porte

dPa

rtici

pant

s with

ASD

: ni

ne p

artic

ipan

ts, n

o ge

nder

s pro

vide

dA

ge: 1

6-38

mon

ths

(M =

28.8

9)D

iagn

osis

: six

with

A

SD a

nd th

ree

with

PD

D-N

OS

Dia

gnos

tic

tool

s: A

DO

SPr

e-as

sess

men

t inf

orm

a-tio

n pr

ovid

ed in

clud

-in

g M

ulle

n Sc

ales

of

Early

Lea

rnin

g an

d V

inel

and

Ada

ptiv

e B

ehav

iour

scal

es

Inte

r-bas

ed v

ideo

con

-fe

renc

ing

softw

are

Com

pute

r, La

ptop

s and

w

ebca

ms

Trai

ning

DV

D in

ES

DM

Nat

ural

istic

trea

tmen

t pr

ogra

mV

ideo

con

fere

nced

co

achi

ng o

f ESD

M10

-min

vid

eo p

robe

s w

ere

com

plet

ed a

t the

st

art o

f eac

h se

ssio

n,

cons

istin

g of

nat

ural

ly

occu

rrin

g si

tuat

ions

an

d ev

alua

ted

skill

s us

ing

ESD

M c

heck

list

Targ

et b

ehav

iour

s wer

e se

lect

ed fr

om th

ese

resu

ltsTr

aini

ng D

VD

was

pr

ovid

ed12

wee

kly

vide

o co

nfer

-en

cing

sess

ions

teac

h-in

g ES

DM

con

duct

ed

Inte

rven

tioni

st va

riabl

es: fi

delit

y of

im

plem

enta

tion

usin

g th

e ES

DM

fide

lity

scal

e M

ater

nal B

ehav

-io

ur R

atin

g sc

ale

Feas

ibili

ty a

nd a

ccep

t-ab

ility

que

stion

naire

ASD

par

ticip

ant v

ari-

able

sC

hild

Soc

ial C

omm

u-ni

catio

n B

ehav

iour

s, pr

ompt

ed v

erba

lisa-

tions

, spo

ntan

eous

ve

rbal

isat

ions

and

sp

onta

neou

s im

itatio

nM

acA

rther

Bat

es sc

ores

on

voc

abul

ary

Vin

elan

d A

dapt

ive

Beh

avio

ur R

atin

g sc

ale

Posi

tive

Pare

nt fi

delit

y sc

ores

si

gnifi

cant

ly im

prov

ed

over

tim

e

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Vis

mar

a et

al.

(201

6)G

roup

rese

arch

des

ign;

ra

ndom

ised

com

pari-

son

grou

p

Inte

rven

tioni

sts 2

4 pa

rent

sG

roup

1: t

hree

mal

es

and

11 fe

mal

eG

roup

2: t

wo

mal

e an

d ei

ght f

emal

esA

ges n

ot re

porte

dPa

rtici

pant

s with

ASD

: 24

par

ticip

ants

Age

: (M

= 31

.9 m

onth

s)D

iagn

osis

: ASD

Dia

gnos

tic to

ol: A

DO

STe

lehe

alth

gro

up:

six

mal

es a

nd fo

ur

fem

ales

Com

paris

on g

roup

: 11

mal

es a

nd th

ree

fem

ales

Add

ition

al se

rvic

es

repo

rted

Citr

ix p

rogr

am G

oTo-

Mee

ting®

Pare

nts a

cces

sed

usin

g ho

me

com

pute

r, w

eb-

cam

or t

able

t. A

cces

s to

ESD

M tr

aini

ng

web

site

Nat

ural

istic

trea

tmen

t pr

ogra

mIn

vesti

gatin

g pa

rent

’s

use

of E

SDM

Tele

heal

th g

roup

Rece

ived

acc

ess t

o ES

DM

onl

ine

train

-in

g on

goin

g w

eekl

y vi

deoc

onfe

renc

ing

to

coac

h th

em th

roug

h ES

DM

pro

cedu

res

Com

paris

on g

roup

Com

mun

ity tr

eatm

ent

as u

sual

gro

upRe

ceiv

ed m

onth

ly

vide

ocon

fere

ncin

g no

t ba

sed

upon

the

ESD

M

but d

iscu

ssin

g th

eir

curr

ent t

reat

men

t, al

ongs

ide

acce

ss to

th

e ES

DM

web

site

Ass

essm

ents

wer

e 5

min

free

-pla

y tim

e

Inte

rven

tioni

st va

ri-ab

les:

P-E

SDM

fide

l-ity

che

cklis

tPa

rent

web

site

dur

atio

nPa

rent

satis

fact

ion

ques

tionn

aire

ASD

par

ticip

ant v

ari-

able

s: sp

onta

neou

s fu

nctio

nal v

erba

l ut

tera

nces

, Im

itativ

e fu

nctio

nal p

lay

actio

ns

with

or w

ithou

t ob

ject

s Non

-ver

bal

join

t atte

ntio

n

Mix

ed fo

r ASD

indi

vid-

ual’s

beh

avio

ur o

nly

sign

ifica

nt b

ehav

iour

di

ffere

nce

betw

een

grou

ps w

as im

itatio

nSi

gnifi

cant

ly m

ore

par-

ents

in th

e te

lehe

alth

gr

oup

met

fide

lity

afte

r coa

chin

g

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Vis

mar

a et

al.

(200

9)G

roup

rese

arch

des

ign;

no

n ra

ndom

ised

com

-pa

rison

gro

up

Inte

rven

tioni

sts: t

en

prof

essi

onal

s rec

ruite

d fro

m se

lect

ed c

entre

s, oc

cupa

tion,

num

ber

of y

ears

’ exp

eri-

ence

wor

king

with

in

divi

dual

s with

ASD

an

d pr

evio

us tr

aini

ng

prov

ided

Age

and

gen

der n

ot

repo

sted

Parti

cipa

nts w

ith A

SD:

29 p

artic

ipan

tsA

ge: 2

4–51

mon

ths.

(M =

32) t

eleh

ealth

gr

oup

and

(M =

33)

mon

ths f

or li

ve g

roup

Dia

gnos

is: A

SDD

iagn

ostic

tool

: AD

OS

ESD

M tr

aini

ng D

VD

2 da

y vi

deo

conf

eren

ced

train

ing

sem

inar

(te

chno

logy

det

ails

no

t pro

vide

d)

Nat

ural

istic

trea

tmen

t pr

ogra

mPh

ase

1B

asel

ine

10-m

in p

robe

2-da

y tra

inin

g co

nfer

-en

ce2

h tra

inin

g fo

r eac

h pr

ofes

sion

al c

on-

duct

ed v

ia te

lehe

alth

to

dis

cuss

indi

vidu

al

need

s. 1-

h ph

one-

call

follo

w u

pPh

ase

2Pr

ofes

sion

als w

ere

give

n a

pare

nt tr

ain-

ing

DV

D a

nd a

3-h

di

dact

ic se

min

ar

on p

aren

t tra

inin

g,

alon

gsid

e a

2 h

grou

p su

perv

isio

n an

d 1

h te

leph

one

conf

eren

ce.

Parti

cipa

nts s

ubm

itted

a

1 h

vide

o of

par

ent

coac

hing

sess

ion,

self

rate

d fid

elity

scor

es

Inte

rven

tioni

st va

ri-ab

les:

inte

rven

tioni

st an

d pa

rent

fide

lity

of im

plem

enta

tion

and

inte

rven

tioni

st sa

tisfa

ctio

n w

ith th

e pr

oced

ures

ASD

par

ticip

ant v

ari-

able

s: fr

eque

ncy

of

child

soci

o-co

mm

uni-

cativ

e be

havi

ours

Imita

tive

play

act

ions

on

obje

cts

and

gestu

res

Obs

erva

tion

ratin

gs o

f ch

ild e

ngag

emen

t

Posi

tive

Teac

hing

via

dist

ance

le

arni

ng w

as a

s effe

c-tiv

e as

teac

hing

usi

ng

live

inte

ract

ion

No

diffe

renc

e in

ther

a-pi

st fid

elity

Atte

ntio

n an

d so

cial

in

itiat

ion

beha

viou

rs

incr

ease

d si

gnifi

cant

ly

from

bas

elin

e

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Wac

ker e

t al.

(201

3a)

Sing

le su

bjec

t res

earc

h de

sign

: mul

ti el

emen

t w

ith m

ultip

le b

asel

ine

acro

ss p

artic

ipan

ts fo

r FC

T co

mpo

nent

Inte

rven

tioni

sts18

par

ents

, 16

fem

ales

an

d tw

o m

ales

Age

: M

= 33

yea

rs o

ld N

o fo

rmal

trai

ning

in

beha

viou

ral t

reat

men

tPa

rtici

pant

s with

ASD

: 17

par

ticip

ants

, gen

-de

r not

pro

vide

dA

ge: 2

9–80

mon

ths

Dia

gnos

is: A

SD o

r PD

D-N

OS

diag

nosti

c to

ol: D

SM-I

V, A

DI

and

AD

OS.

Aut

hors

st

ate

that

furth

er

diag

nosti

c an

d de

mo-

grap

hic

info

rmat

ion

can

be fo

und

in su

bse-

quen

t pub

licat

ion

Sess

ions

took

pla

ce in

re

gion

al te

lehe

alth

cl

inic

sW

indo

ws b

ased

PC

w

ith te

leco

nfer

enci

ng

softw

are

and

basi

c w

ebca

m a

nd m

icro

-ph

one

FA a

nd F

CT

train

ing

Pare

nts a

ttend

ed a

re

gion

al c

linic

whe

re

they

wer

e ta

ught

usi

ng

vide

o-co

nfer

enci

ng

to c

ompl

ete

FA o

f pr

oble

m b

ehav

iour

an

d su

bseq

uent

FC

TFA

pro

cedu

res

desc

ribed

in m

ore

deta

il in

Wac

ker e

t al.

(201

3b) b

elow

FCT

train

ing

via

vide

o co

nfer

enci

ng in

1 h

w

eekl

y se

ssio

n to

co

ach

thro

ugh

FCT

proc

edur

esFi

ve m

inut

e bl

ocks

w

ere

reco

rded

th

roug

hout

eac

h se

s-si

on fo

r sco

ring

Inte

rven

tioni

st va

ri-ab

les:

acc

epta

bilit

y of

in

terv

entio

nA

SD p

artic

ipan

t var

i-ab

les:

% re

duct

ion

in

targ

eted

cha

lleng

ing

beha

viou

r

Posi

tive

All

parti

cipa

nts h

ad

larg

e re

duct

ion

in

targ

eted

beh

avio

ur, s

ix

sam

ples

onl

y gr

aphe

dPa

rent

s rat

ed th

e in

ter-

vent

ion

high

ly

Wea

k

Wac

ker e

t al.

(201

3b) b

Con

duct

ion

Func

tiona

l A

naly

se o

f Pro

b-le

m b

ehav

iour

via

te

lehe

alth

Sing

le su

bjec

t res

earc

h de

sign

; mul

ti el

emen

t de

sign

Inte

rven

tioni

sts: 2

0 pa

rent

s of c

hild

ren,

19

fem

ales

and

one

mal

eA

ge: (

M =

34 y

ears

)Pa

rtici

pant

s with

ASD

: 20

par

ticip

ants

, gen

-de

rs n

ot p

rovi

ded

Dia

gnos

is: s

even

with

A

SD a

nd 1

3 w

ith

PDD

-NO

S D

iagn

ostic

to

ols:

DSM

-IV,

AD

I an

d A

DO

S

Sony

PC

S-16

00 v

ide-

ocon

fere

ncin

g sy

stem

w

ith P

TZ c

amer

aSo

ny G

520

vide

o m

onito

rTe

leco

nsul

tatio

nD

ell W

indo

ws X

PLo

gite

ch 6

00 W

ebca

mLo

gite

ch G

330

Embl

aze-

VCO

N v

Poin

t H

D so

ftwar

eV

ideo

LAN

VLC

med

ia

play

erW

indo

ws M

ovie

Mak

er

Func

tiona

l ana

lysi

sV

ideo

conf

eren

cing

use

d to

car

ry o

ut tr

aini

ng

and

com

plet

ion

of F

A

acro

ss fo

ur p

hase

s of

train

ing

Initi

al tr

aini

ng in

pha

se

1 an

d 2

focu

sed

beha

viou

r ana

lytic

al

proc

edur

esPa

rent

s int

ervi

ewed

ab

out c

halle

ngin

g be

havi

ours

and

com

-pl

eted

log

and

pref

er-

ence

ass

essm

ent

Phas

e 4

Pare

nts c

ondu

cted

an

FA w

ith su

ppor

t fro

m

the

coac

h

Inte

rven

tioni

st va

riabl

es: P

roce

dura

l in

tegr

ityA

SD p

artic

ipan

t var

i-ab

les:

indi

vidu

alis

ed

targ

et c

halle

ngin

g be

havi

our,

iden

tified

an

d op

erat

iona

lly

defin

ed u

sing

pre

-as

sess

men

t int

ervi

ews

and

logs

Posi

tive

Func

tions

wer

e su

c-ce

ssfu

lly id

entifi

ed

in 9

0% o

f cas

es, w

ith

the

addi

tiona

l tw

o ca

ses n

ot id

entif

ying

a

func

tion

due

to lo

w

leve

ls o

f beh

avio

ur

that

cha

lleng

es

Wea

k


1 3

Tabl

e 1

(con

tinue

d)

Stud

yRe

sear

ch d

esig

nPa

rtici

pant

sTe

chno

logy

Inte

rven

tion

cate

gory

an

d ai

ms

Dep

ende

nt V

aria

bles

Out

com

esQ

ualit

y

Wai

ner a

nd In

gers

oll

(201

5)Si

ngle

subj

ect r

esea

rch

desi

gn: m

ultip

le b

ase-

line

desi

gn

Inte

rven

tioni

st: fi

ve p

ar-

ents

, all

fem

ale

Age

s no

t rep

orte

dPa

rtici

pant

s with

ASD

: fiv

e pa

rtici

pant

s, ge

n-de

r not

pro

vide

dA

ge: 2

9–59

mon

ths

(M =

42.2

)D

iagn

osis

: ASD

Dia

gnos

tic to

ol n

ot

repo

rted

Onl

ine

Reci

proc

al Im

i-ta

tion

Trai

ning

(RIT

) w

ebsi

teC

orre

spon

ding

PD

F m

anua

lFa

mili

es o

wn

hom

e co

mpu

ters

and

web

-ca

ms C

omm

erci

ally

av

aila

ble

vide

ocon

fer-

enci

ng so

ftwar

e, n

ot

nam

ed

Nat

ural

istic

teac

hing

Hyb

rid a

ppro

ach

of

an o

nlin

e tra

inin

g pr

ogra

m a

nd v

ideo

co

nfer

enci

ng to

inve

s-tig

ate

RIT

10-m

in b

asel

ine,

film

ed

prob

es w

here

par

ents

in

tera

cted

with

thei

r ch

ildre

n in

pla

ySe

lf -d

irect

ed c

ondi

tion

pare

nts u

sed

onlin

e tra

inin

g pr

ogra

m in

R

IT w

ith fo

ur le

sson

s, pr

e an

d po

st kn

owl-

edge

test

vide

o ex

am-

ples

, act

ive

lear

ning

se

lf-m

onito

ring

and

hom

ewor

k3 ×

30 m

in c

oach

ing

sess

ions

invo

lvin

g 10

min

pro

bes a

the

star

t of s

essi

on

Inte

rven

tioni

st va

ri-ab

les:

RIT

fide

lity

Pare

ntal

eng

agem

ent

Pare

ntal

kno

wle

dge

Pare

ntal

vie

ws o

n tre

at-

men

t acc

epta

bilit

yA

SD p

artic

ipan

t var

i-ab

les:

chi

ld’s

spon

ta-

neou

s im

itatio

n

Mix

edPa

rent

al k

now

ledg

e of

R

IT m

etho

ds si

gnifi

-ca

ntly

incr

ease

dPr

ogra

m fi

delit

y in

crea

sed

from

bas

e-lin

e fo

r all

parti

ci-

pant

s, no

t sig

nific

antly

fro

m se

lf-di

rect

ed to

vi

deo

conf

eren

cing

Incr

ease

d im

itatio

n fo

r so

me

child

ren

but n

ot

all,

how

ever

sig-

nific

ant r

elat

ions

hip

betw

een

pare

nt fi

del-

ity a

nd c

hild

imita

tion

Wea

k

Wilc

zyns

ki e

t al.

(201

7)N

o ex

perim

enta

l des

ign

Inte

rven

tioni

sts: o

ne

fem

ale

spec

ial e

duca

-tio

n te

ache

r Age

not

pr

ovid

edA

SD p

artic

ipan

t: on

e m

ale

parti

cipa

ntA

ge: 5

yea

rsD

iagn

osis

: ASD

, di

agno

stic

tool

not

re

porte

d

PC a

nd w

ebca

mA

utis

m T

rain

ing

Solu

tions

web

bas

ed

train

ing

GoT

oMee

ting

vide

o co

nfer

enci

ng so

ftwar

e

Com

preh

ensi

ve tr

aini

ngC

ompl

etio

n of

onl

ine

beha

viou

r ski

lls tr

ain-

ing;

aut

ism

trai

ning

so

lutio

ns c

over

ing

beha

viou

r ana

lytic

al

prin

cipl

es F

ollo

wed

by

vid

eo c

onfe

renc

ed

coac

hing

sess

ion,

tra

inin

g m

anua

l and

pr

ovid

ed fe

edba

ck o

n pr

e-re

cord

ed v

ideo

s

Inte

rven

tioni

sts

varia

bles

: fide

lity

of

impl

emen

tatio

n of

ea

ch tr

aini

ng c

ompo

-ne

nt a

sses

sed

Kno

wle

dge

of in

terv

en-

tions

ASD

par

ticip

ant b

ehav

-io

ur: c

ompl

ianc

e w

ith ta

sks c

ompl

eted

, in

itial

com

plia

nce

and

com

plet

ion

of ta

sk

Mix

edIm

plem

enta

tion

of m

ost

train

ing

com

pone

nts

incr

ease

d af

ter t

rain

-in

gK

now

ledg

e of

key

com

-po

nent

s inc

reas

edA

SD p

artic

ipan

t var

i-ab

le: s

mal

l inc

reas

e in

in

itial

com

plia

nce

but

com

plet

ion

of c

ompl

i-an

ce w

as a

t cei

ling

leve

ls p

re-in

terv

entio

n

Wea

k


1 3

on selected 28 studies. Likewise, ICA was calculated for the descriptive synthesis. The second coder scored 100% of selected studies across all extracted information. ICA was calculated by dividing the total number of agreed variables divided by total number of variables scored and multiplied by 100. There was a 92% agreement on coding. ICA was also calculated on the quality assessment at 96% following discussion on one disagreed study.

Efficacy Outcomes

Intervention outcomes were rated for efficacy on an ordinal scale of ‘Positive’, ‘Mixed’ or ‘Negative’. Visual analysis of graphed data was used for studies employing single subject research designs, while statistical testing was employed to determine outcomes of group designs. Studies were consid-ered ‘positive’ if improvements were made by all partici-pants across all dependent variables. They were considered ‘Mixed’ if positive results were visible but did not apply to all dependent variables and ‘Negative’ if no improvements were made for any dependent variable.

Quality Assessment

Studies included in the review were independently assessed for rigor by the first and second authors using the stand-ards created by Reichow et al. (2008). Disagreements were discussed with the third author. This assessment used two rubrics to measure research quality, one for group research and one for single-subject research. Both consist of meth-odological elements deemed important for research rigor. Selected studies were assessed against the appropriate rubrics and an overall rigor rating was created using guide-lines on how to synthesis rubrics ratings (Reichow et al. 2011, p. 30). This process evaluated study quality across two levels of methodological features: primary and secondary indicators. Primary indicators were considered vital com-ponents in research design in order to demonstrate validity. Secondary indicators were deemed as important but not vital components of research.

Primary indicators for group research included: partici-pant characteristics, independent variables, comparison con-ditions, and dependent variable (Table 2). Primary indicators for single subject research included: participant characteris-tics, independent variables, baseline conditions, dependent variables, visual analysis and experimental control (Table 3). Secondary indicators for group research design included: (1) random assignment, (2), Inter-observer agreement (IOA), (3) blind raters, (4), fidelity, (5) attrition, (6) generalisation or maintenance, (7), effect size and (8) social validity. Sec-ondary indicators for single subject research included: (1) inter-observer agreement (IOA), (2) kappa, (3), blind raters, Ta

ble

2 Q

ualit

y in

dica

tor a

sses

smen

t for

gro

up re

sear

ch d

esig

ns

IV in

depe

nden

t var

iabl

e, R

A ra

ndom

ass

ignm

ent,

ES e

ffect

siz

e, U

una

ccep

tabl

e, E

evi

denc

e of

Com

, Con

com

paris

on c

ondi

tion,

IOA

inte

robs

erve

r agr

eem

ent,

SV s

ocia

l val

idity

, A a

ccep

tabl

e,

N n

o ev

iden

ce o

f DV

depe

nden

t var

iabl

e, B

R bl

ind

rate

r, H

hig

h, S

tat s

tatis

tical

testi

ng, G

en/M

ain

gene

ralis

atio

n/m

aint

enan

ce

Parti

cipa

nts

IVC

om C

onD

VLi

nkSt

atR

AIO

AB

lind

Rat

erFi

delit

yA

ttriti

onG

en/M

ain

ESSV

Ove

rall

Bea

rss e

t al.

(201

7)H

HU

HH

HN

NN

EE

NE

EW

eak

Hei

tzm

an-P

owel

l et a

l. (2

014)

UH

UH

HU

NE

NE

EN

NE

Wea

kIn

gers

oll a

nd B

erge

r (20

15)

UH

HH

HH

EN

NN

NN

NE

Wea

kIn

gers

oll e

t al.

(201

6)U

HH

HH

HE

EN

EN

EN

EW

eak

Kur

avac

kel e

t al.

(201

8)U

HH

HH

HE

NN

NN

NE

EW

eak

Lind

gren

et a

l. (2

015)

UH

AH

HH

NE

NN

EN

NE

Wea

kV

ism

ara

et a

l. (2

016)

UH

HH

HH

EN

EE

EE

NE

Wea

kV

ism

ara

et a

l. (2

009)

UH

AH

HU

NE

EE

EN

NE

Wea

k


1 3

Tabl

e 3

Qua

lity

indi

cato

r ass

essm

ent f

or si

ngle

subj

ect r

esea

rch

desi

gns

IV in

depe

nden

t var

iabl

e, U

una

ccep

tabl

e, E

evi

denc

e of

DV

depe

nden

t var

iabl

e, A

acc

epta

ble,

N n

o ev

iden

ce o

f IO

A in

tero

bser

ver a

gree

men

t, H

hig

h, G

en/M

ain

gene

ralis

atio

n/m

aint

enan

ce

Stud

y N

ame

Parti

cipa

nt

char

acte

ristic

sIV

Bas

elin

eD

VV

isua

l an

alys

isEx

perim

enta

l co

ntro

lIO

AK

appa

Fide

lity

Blin

d ra

ters

Gen

eral

isat

ion

or m

aint

Soci

al

valid

ityO

vera

ll

Bar

retto

et a

l. (2

006)

UH

UH

HH

EN

NN

NE

Wea

kB

arka

ia e

t al.

(201

7)A

HA

HA

AE

NE

NN

EW

eak

Ben

son

et a

l. (2

017)

UH

UH

AA

EE

EN

NE

Wea

kG

ibso

n et

al.

(201

0)U

HH

HH

HE

NE

NN

EW

eak

Hig

gins

et a

l. (2

017)

AH

UH

UU

EN

EN

EE

Wea

kM

acha

licek

et a

l. (2

009b

)U

HU

HH

HE

NN

NN

EW

eak

Mac

halic

ek e

t al.

(201

0)A

HU

HA

UE

NN

NE

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1 3

(4) fidelity, (5) generalisation or maintenance and (6) social validity.

A score sheet created by the authors was used to score each of the identified variables against the operational defini-tions set out in Reichow et al. (2011). Each primary variable was scored as ‘High (H)’, ‘Acceptable (A)’ or ‘Unacceptable (U)’. Secondary indicators were scored as ‘evidence (E)’ or ‘no evidence (N)’. Each score was then combined to give an overall quality rating for each study of ‘strong’, ‘adequate’ or ‘weak’. To receive an overall ‘strong’ rating, studies must have received a high rating for all primary indicators and meet four of the secondary indicators. An overall ‘adequate’ rating was awarded to a study that received a high rating for four primary indicators and meet two secondary indicators with no unacceptable ratings in primary indicators. A study received an overall ‘weak’ rating if it was awarded less than four high ratings in primary indicators and less than two secondary indicators. Final ratings of each study were amal-gamated and assessed using the formula set out by Reichow (2011, p. 31), which allowed for an overall rating of EPB to be assigned to the field.

Results

According to the inclusion criteria, a total of 28 studies were deemed eligible and were incorporated in the descriptive synthesis with key data extracted and coded (Table 1). Each study was subsequently examined to determine its qual-ity according to the indicators identified by Reichow et al. (2008). In the following sections, a summary of coded vari-ables and quality measures is presented.

Study Design

All but two of the selected studies (Machalicek et al. 2009a; Wilczynski et al. 2017) used an experimental research design, with the majority (64%; n = 18) employing a single subject research design and fewer employing a group design (28%; n = 8). Of the single subject research multiple baseline designs were utilised in 36% of studies (n = 10), as were multielement designs. Reversal designs were rarely used in the research (14%; n = 4).

Participants

Interventionist Participant

A total number of 293 interventionists were included in the 28 studies. Of these, 68 were placed in a comparison group and did not undertake any training via telehealth, leaving 225 interventionists in experimental groups across all stud-ies. Of these, 86% (n = 194) were parents, 9% (n = 21) were

direct front line staff, including ABA therapists, graduates working in university clinics and other associated profes-sionals working in the field, and 4% (n = 10) were teachers.

Age and gender for the interventionists were reported rarely with only 25% (n = 7) of studies reporting both char-acteristics (Bearss et al. 2017; Barkaia et al. 2017; Hig-gins et al. 2017; Neely et al. 2016; Machalicek et al. 2010; Wacker et al. 2013a, b). Another 25% (n = 7) of studies reported neither age nor gender (Benson et al. 2017; Kura-vackel et al. 2018; Machalicek et al. 2009a, b; Simacek et al. 2017; Suess et al. 2016; Vismara et al. 2009). Gender alone was reported in 39% (n = 11) of studies (Barretto et al. 2006; Gibson et al. 2010; Ingersoll et al. 2016; Ingersoll and Berger 2015; Machalicek et al. 2016; Meadan et al. 2016; Vismara et al. 2012, 2013, 2016; Wainer and Ingersoll 2015; Wilczynski et al. 2017). Age alone was reported in 11% (n = 3) of studies (Suess et al. 2014; Lindgren et al. 2015; Heitzman-Powell et al. 2014).

In studies where interventionist demographics were reported, a total of 97 females and 14 males took part in the research. The average age of interventionists was 31.7. Few participants had previous experience implementing behav-ioural analytic procedures (14%; n = 16).

Participants with ASD

A total of 307 participants with ASD took part in the 28 studies. Of this, 76 were allocated to a control or compari-son group and did not receive telehealth interventions, leav-ing 231 participants in telehealth experimental groups. Of these 57%, (n = 231) took part in group research, while 42% (n = 96) were included in single subject research designs and 2% (n = 4) were included in studies that did not operate an experimental research design.

Age and gender of participants with ASD were reported more frequently than for interventionists, with both varia-bles being reported in 75% (n = 21) of studies (Barretto et al. 2006; Barkaia et al. 2017; Bearss et al. 2017; Benson et al. 2017; Gibson et al. 2010; Higgins et al. 2017; Ingersoll and Berger 2015; Kuravackel et al. 2018; Lindgren et al. 2015; Machalicek et al. 2009a, b, 2010, 2016; Meadan et al. 2016; Neely et al. 2016; Simacek et al. 2017; Suess et al. 2014, 2016; Vismara et al. 2016; Wilczynski et al. 2017). Only 3% (n = 1) of studies did not report any information about the age or gender of participants with ASD (Heitzman-Powell et al. 2014). Participants’ age was stated in 21% (n = 6) of studies in which gender was omitted (Vismara et al. 2009, 2012, 2013; Wacker et al. 2013a, b; Wainer and Ingersoll 2015), while no studies reported gender in isolation.

Diagnostic tools used to provide the participants with their diagnoses of ASD or PDD-NOS were reported spo-radically throughout the literature. Of the demographics reported for participants with ASD, 93 were male and 61


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were female. The average age from each study where age was reported was 4.73 years with the range being 1.75–16 years’ old.

Intervention Characteristics

Categorisation of Intervention Aims

Studies included in this review were organised according to the intervention techniques used (Fig. 2). The largest cate-gory was functional analysis (FA) and subsequent functional communication training (FCT), with 43% (n = 12) of studies investigating these topics (Barretto et al. 2006; Benson et al. 2017; Gibson et al. 2010; Lindgren et al. 2015; Machalicek et al. 2009b, 2010, 2016; Simacek et al. 2017; Suess et al. 2014, 2016; Wacker et al. 2013a, b). Techniques derived from naturalistic and incidental teaching were employed in 36% (n = 10) of studies (Barkaia et al. 2017; Ingersoll et al. 2016; Ingersoll and Berger 2015; Meadan et al. 2016; Neely et al. 2016; Vismara et al. 2009, 2012, 2016; Wainer and Ingersoll 2015). Behaviour support strategies, including positive behaviour support were investigated in 7% (n = 2) of studies (Bearss et al. 2017; Kuravackel et al. 2018). Training participants to conduct preference assessments was examined in 7% (n = 2) of studies (Higgins et al. 2017; Machalicek et al. 2009a). The final two studies focused on comprehensive training packages designed to provide par-ticipants with an overview of behaviour analytic principles (Heitzman-Powell et al. 2014; Wilczynski et al. 2017).

Training Characteristics

When examining eligible studies, it was apparent that sev-eral commonalities occurred across training techniques and

platforms used. These included technology-based train-ing and video-conference sessions that provided coaching. Coaching was defined as providing individualised training and feedback regarding the implementation of the interven-tion of choice; this could be conducted via telephone, email or video-conferencing. Feedback on performance was deliv-ered live or retroactively using recorded footage. Coaching was used as a standalone training strategy 25% (n = 7) of studies (Barretto et al. 2006; Benson et al. 2017; Lindgren et al. 2015; Machalicek et al. 2009b, 2016; Simacek et al. 2017; Suess et al. 2016).

Technology-based training involved the utilisation of technology to provide interventionists with the theoreti-cal background knowledge of procedural techniques in preparation of intervention commencement. Twenty stud-ies included a technology based training components were included in 71% (n = 20) of studies. Written instructions, websites including interactive modules, a training DVD, manuals or with video-conferenced didactic training were utilised to provide this training. Equipment included laptops, cameras, scanners and commercially available videoconfer-encing software. A hybrid approach including coaching and technology-based training was undertaken in 75% (n = 21) of studies (Barkaia et al. 2017; Bearss et al. 2017; Gibson et al. 2010; Heitzman-Powell et al. 2014; Higgins et al. 2017; Ingersoll and Berger 2015; Ingersoll et al. 2016; Kuravackel et al. 2018; Machalicek et al. 2009a, 2010; Meadan et al. 2016; Neely et al. 2016; Suess et al. 2014; Vismara et al. 2009, 2012, 2013, 2016; Wacker et al. 2013a, b; Wainer and Ingersoll 2015; Wilczynski et al. 2017).

Dependent Variables

Results indicate that 69% (n = 19) of studies measured vari-ables for both interventionists and participants with ASD, 11% (n = 3) of studies measured interventionist behaviour alone. All studies that measured interventionist behaviours included a measure of procedural fidelity via task analysis, a fidelity checklist or video-recorded probes. Knowledge tests were used in 14% (n = 4) of studies and these scores were compared to pre-intervention scores to determine the effect of the intervention (Heitzman-Powell et al. 2014; Ingersoll and Berger 2015; Wainer and Ingersoll 2015; Wilczynski et al. 2017).

Child behaviour was measured alone in 21% (n = 6) of studies and 68% (n = 19) of studies measured participant with ASD variables alongside interventionist variables. Data collection for child behaviours was conducted via video-recorded probes or questionnaires and standardised tests. Of these, 50% (n = 14) of studies measured individualised prob-lem behaviour as part of an FA to assess function or teach replacement behaviour (e.g. FCT). Examples of the indi-viduals’ challenging behaviour include elopement (Gibson

FA+FCT43% (n = 12)

Natrualistic36% (n = 10)

Preference Assessment 7% (n = 2)

Comprehensive 7% (n = 2)

Behaviour Support

7% (n = 2)

Fig. 2 Proportion of studies completing research in each intervention category


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et al. 2010), self-injurious behaviour and screaming (Benson et al. 2017), noncompliance and property destruction (Bar-retto et al. 2006). From the remaining studies, 43% (n = 12) investigated increases in social-communication responses (Barkaia et al. 2017; Benson et al. 2017; Ingersoll et al. 2016; Lindgren et al. 2015; Meadan et al. 2016; Neely et al. 2016; Simacek et al. 2017; Suess et al. 2016; Vismara et al. 2009, 2012, 2013, 2016) All studies attempted to teach chil-dren to request using either an alternative communication system (e.g., touching or handing over a communication card to access a tangible; Benson et al. 2017) or vocalisations (e.g., providing echoic prompts in contrived communica-tion opportunities to increase child vocal requesting; Barkaia et al. 2017). Other facets of social communication measured including joint-attention and initiation of communication (e.g., Neely et al. 2016).

The final dependent variable measured in the research was imitation skills. This was included in 18% of studies (n = 5) (Vismara et al. 2009, 2012, 2013, 2016; Wainer and Ingersoll 2015) all five studies trained parents in naturalis-tic teaching techniques and attempted to increase children’s imitation skills in play based or fun situations.

Efficacy Outcomes

Results of efficacy (Fig. 3) show that 61% (n = 17) of stud-ies were rated as ‘positive’ in which improvements were achieved by all participants across all dependent variables (Barretto et al. 2006; Benson et al. 2017; Gibson et al. 2010; Higgins et al. 2017; Ingersoll and Berger 2015; Ingersoll et al. 2016; Lindgren et al. 2015; Machalicek et al. 2010, 2009b; Neely et al. 2016; Simacek et al. 2017; Suess et al. 2016; Vismara et al. 2009, 2012, 2016; Wacker et al. 2013a, b). A closer examination reveals that 36% (n = 10) of stud-ies employed FA + FCT procedures (Barretto et al. 2006; Benson et al. 2017; Gibson et al. 2010; Lindgren et al. 2015; Machalicek et al. 2009b, 2010; Simacek et al. 2017; Suess et al. 2016; Wacker et al. 2013a, b) demonstrating a clear behaviour function for each participant and showing decreases in challenging behaviour following FCT; in terms of procedural fidelity, this was established for all interven-tionists. Of studies focusing on naturalistic teaching, 35% (n = 6) were also scored as positive (Ingersoll et al. 2016; Ingersoll and Berger 2015; Neely et al. 2016; Vismara et al. 2009, 2012, 2016), achieving an increase in interventionist knowledge or fidelity alongside improvements in child social communicative behaviour or imitation responses. The final positively scored study included a preference assessment (Higgins et al. 2017) and indicated a positive relationship between telehealth training and the correct implementation of preference assessment procedures.

Overall, 32% (n = 9) of studies received a ‘mixed’ efficacy rating (Barkaia et al. 2017; Bearss et al. 2017; Machalicek

et al. 2016; Meadan et al. 2016; Suess et al. 2014; Vismara et al. 2013, 2016; Wainer and Ingersoll 2015; Wilczynski et al. 2017). For example, 44% (n = 4) of these studies found improvements in interventionist treatment fidelity across all participants but failed to increase scores of social commu-nication or imitation behaviours consistently across par-ticipants (Meadan et al. 2016; Wainer and Ingersoll 2015; Vismara et al. 2013). None of the 28 studies included in this review received a ‘negative’ rating.

Quality Assessment

Of the eight studies employing a group research design, all (n = 8) received an overall weak quality rating (Fig. 4). Of the 71% (n = 20) of studies employing a single subject research design (Fig. 5), 5% (n = 1) received an overall ade-quate quality rating; the remaining 95% (n = 19) received an overall weak quality rating. An overall rating for each study can be found alongside individual indicator ratings in Tables 2 and 3.

The research scored highly on several primary indica-tors, including both the dependent and independent vari-ables, which were described thoroughly with replicable precision in 100% of single subject and group research. In group research links to past research were successfully made in 100% of studies meaning they provided strong links between the original research questions and the analysis of the data established in their studies. Comparison groups, when present, were described with high replicable detail in 50% (n = 4) of studies and with some details emitted in 25% (n = 2). The remaining studies operated a within group design and did not include a comparison group to describe. Statistical analyses were also completed to a high standard in 75% (n = 6) of studies (Bearss et al. 2017; Ingersoll and Berger 2015; Ingersoll et al. 2016; Kuravackel et al. 2018;

0

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3

4

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6

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8

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10

FA+FCT Naturalis�c BehaviourSupport

PreferenceAssessment

Comprehensive

Num

ber o

f Stu

dies

Intervention Category

Postive Mixed Negative Undetermined

Fig. 3 Efficacy outcomes of each intervention category


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Lindgren et al. 2015; Vismara et al. 2016) as all contained sample sizes > 10 participants per group and conducted appropriate statistical analysis across dependent variables.

However, high scores were not evident across all indi-cators. In single subject research design studies only 10% (n = 2) for studies were rated highly for baseline (Gibson et al. 2010; Wainer and Ingersoll 2015), meaning they had three measurable data points, were described in replicable details, appeared to be stable and did not include any trends, including counter therapeutic trends. An additional 35% (n = 7) were rated as ‘Acceptable’ as more than 50% but less than 100% of baselines in the study met the above criteria (Barkaia et al. 2017; Meadan et al. 2016; Neely et al. 2016; Simacek et al. 2017; Vismara et al. 2012, 2013; Wacker et al. 2013b). 55% of studies (n = 11) were rated as having unacceptable baseline conditions. Despite conditions being

accurately described and for the most part containing three data points, many failed to show stable levels or trends.

For both single subject and group research to be rated ‘High’ for participant characteristics studies needed to report information on participant age, gender, diagnostic instru-ment, interventionist characteristics and scores on stand-ardised tests if applicable. As many of the studies included measures of both interventionist and participants with ASD behaviour both were considered as participants for the pur-pose of this review. Overall only 11% (n = 3) of the studies were rated highly. This means they reported information on participant age, gender, diagnostic instrument, intervention-ist characteristics and scores on standardised tests if appli-cable. An ‘Acceptable’ rating was awarded to 15% (n = 3) of studies, as they provided demographics on all participant’s age and gender, and provided standardised test scores. The remaining 79% (n = 22) of studies all met the ‘Unacceptable’ rating, where age and gender for both the individual with ASD and the interventionists was not reported consistently.

The overall quality ratings for each study were combined to allow for an overall rating of EPB to be given to the field. Using the formula suggested by Reichow et al. (2011) the amount of ‘high’ and ‘adequate’ studies were combined to provide an overall score for the field, which due to meth-odological omissions discussed was designated as ‘Not an Evidence Based Practice’.

Discussion

The purpose of this review was to (a) identify and categorise key intervention properties and procedures used in research using telehealth to provide behaviour analytic provisions to individuals with ASD, (b) to assess the overall outcomes of selected studies both in the success of the training proce-dures and the outcomes for individuals with ASD, and (c) to examine the quality of selected research. It is the aim of the review that it can be used to guide future research and practice by identifying successful procedures and highlight-ing methodological flaws.

Findings from the synthesis of 28 studies suggested that telehealth can be an acceptable platform for behaviour ana-lytic interventions and assessments. A total of 293 interven-tionists were trained across studies providing intervention to 307 individuals with ASD. Outcomes indicate positive gains across participants with 100% of studies (n = 28) studies reporting improvements in at least one dependent variable and 61% (n = 17) of studies reporting favourable outcomes across all dependent variables. None of the 28 studies met sufficient quality indicators to be determined as of ‘high’ quality and only one study was determined as being of ‘adequate’ quality. The remaining 96% (n = 27) of studies were rated as ‘weak’. Due to what we consider are

0

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9

Participants IndependentVariable

ComparisonGroup

DependentVariable

Link toResearch

Statistics

Num

ber o

f Stu

dies

Primary Indicators - Group Research Design

High Adequate Unacceptable

Fig. 4 Number of studies scoring on each primary indicator—group research design

0

5

10

15

20

25

Participants IndependentVariable

Baseline DependentVariable

VisualAnalysis

ExperimentalControl

Num

ber o

f Stu

dies

Primary Indicator - Single Subject Design

High Adequate Unacceptable

Fig. 5 Number of studies scoring on each primary indicator—single subject research design


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minor methodological flaws, an overall rating of ‘not an evi-dence-based practice’ was assigned to telehealth as a means of providing ABA-based interventions. Although positive outcomes were achieved for involved participants, there is a demand for further high quality research that can adhere to a rigorous methodological structure. Each of the research aims will now be discussed in more detail.

The first aim of this review was to synthesise and catego-rise intervention aims and procedures. A variety of ABA-based procedures were targeted within the literature: FA and FCT, naturalistic teaching, preference assessments, behav-iour support and comprehensive programs. The numbers of studies in each category were not evenly distributed, most studies investigated FA and FCT procedures (43%; n = 12) or naturalistic teaching (39%; n = 11). Research on using telehealth to conduct comprehensive treatment is lacking. Only 7% (n = 2) of selected studies were categorised as ‘comprehensive’ (Heitzman-Powell et al. 2014; Wilczynski et al. 2017), but both had methodological downfalls. Using telehealth to oversee comprehensive packages is a vital area for future research with potentially significant practical implications. Two other key ABA-based teaching strategies were overlooked in the research: Discrete Trial Training (DTT) and functional/daily living skills training. DTT is highly repetitious and includes very structured arrangements of consequences and antecedents. It has been shown to suc-cessfully teach skills to children with ASD across devel-opmental domains such as, communication, imitation and self-care (Sheinkopf and Siegel 1998). DTT implementation requires technical knowledge and success is linked to good training procedures (Symes et al. 2006). On the other hand, DTT has been criticised as teaching skills that present a lack of generality into typical, ecologically relevant settings. Fur-ther research is needed to determine its suitability through a telehealth model.

Conversely, functional/daily living skills may be ideally suited. Strategies of task analysis and chaining are used to systematically teach ‘chains’ of behaviours found in eve-ryday tasks, such as brushing teeth or preparing a snack. These methods have a strong empirical base, have been recognised as evidence-based practice (Wong et al. 2014) and have been demonstrated using a parent training model (Kroeger and Sorensen 2010), highlighting their generality and social validity. It is therefore relatively surprising that research into using telehealth to conduct this training is not forthcoming and future research in this direction is needed.

A total of 71% (n = 20) of studies included an initial train-ing period. Initial training has been recognised as a key com-ponent in achieving procedural fidelity in behaviour analytic practice (Denne et al. 2015; Symes et al. 2006). Researchers have translated proven face–face training techniques onto a telehealth platform, such as modelling of procedures, prac-tice using role play and tests of knowledge (Fetherstone and

Sturmey 2014; Miltenberger 2004). All 28 studies incor-porated a live coached component, in addition to initial training or as a stand-alone training procedure. Once again, proven training techniques were utilised, such as modelling appropriate behaviour, error correction procedures and per-formance feedback. Due to using a combination of training variables it was not possible to isolate the most success-ful training components. Future researchers may consider a component analysis to assess the best type of training and avoid unnecessarily waste of resources.

Information regarding the type of technology was limited within the research with only a small number of studies pro-viding extensive information on this aspect. Video confer-encing software used to conduct didactic training and video coaching was often free to access and readily available, e.g., Skype, Viber or iChat. Hardware such as personal comput-ers, web cameras or tablets were often reported as family’s own or pre-existing in the intervention centre. Initial training was conducted via a website in eight studies, where website training was utilised this was often already available from previous research, such as the Early Start Denver Model training website (e.g. Vismara et al. 2016).

The review synthesised participant information. By determining who can be trained to carry out interventions and who is likely to benefit from them, the scope of the telehealth model can be revealed. A total of 225 interven-tionist participants took part. Participants were employed in a number of different sectors: health, education, research and social care or were family members, primarily parents of the participants with ASD. This synthesis demonstrates the capacity of telehealth to train and supervise a multi-disciplinary team, highlighting the potential of the telehealth model amongst the reality of current ASD services in the UK, where interdisciplinary teams working together to plan provision is common practice (Department of Educa-tion, Department of Health 2015; Department of Education Northern Ireland 2005).

The largest proportion of studies (64%; n = 18) used par-ent training to support the provision of home-based interven-tion or assessments. The National Research Council (NRC) dictates that parent involvement is a fundamental component of effective ASD intervention (NRC 2001). Parent training and subsequent intervention implementation has been identi-fied as evidence-based practice (EBP), as long as treatment fidelity can be achieved (Wong et al. 2014). The outcomes of this review indicate that fidelity can be achieved using a telehealth model and combination of telehealth and parent training has a promising future.

The age of participants with ASD ranged from 1.75–16 years, with the majority of participants being under 6 years old. Current research trends indicate that young age is a crucial predictor of success in behavioural interven-tions (Perry et al. 2011). The UK government initiatives


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have highlighted early intervention as a crucial focus for future research (National Institute for Health Research 2017). The application of telehealth with this age cohort is very promising, enabling parents to receive training prior to the commencement of educational services could be key in future service models. Despite the promising prospects of early intervention, the research is limited to this narrow age range. Prior research shows that ABA-based intervention can have great success with both a teenage and adult age cohort (Bennet and Dukes 2013; Koegel et al. 2014; Santiago et al. 2016). Future research might focus on the application of these interventions with an older age group allowing for a greater concept of the scope of telehealth.

The second aim of the review was to assess the outcomes of the research in order to determine if the interventions were successful. An overview of selected research indicates at least some favourable outcomes in all 28 studies. Out-comes were measured for both interventionists and partici-pants with ASD and varied depending on intervention aims and category.

A total of 75% (n = 21) of studies collected data on at least one measure of interventionist behaviour. All but one collected data on procedural fidelity. Measures of fidelity have been shown to correlate with best outcomes for child participants (Penn et al. 2007; Symes et al. 2006; Whiteford et al. 2012). All 21 studies showed improvement in pro-cedural fidelity for all participants involved. However, one study (Barkaia et al. 2017) reported improved measures of fidelity but still achieved a relatively low fidelity level of around 60% which would not be considered widely accept-able. Several other studies reported the need to perform ‘top up’ training in order for agents to reach pre-set fidelity cri-teria. Despite these few discrepancies, the literature does demonstrate the capabilities of telehealth and goes some way to answering the pertinent question of whether behav-iour analytic provisions can be delivered via a telehealth with appropriate levels of fidelity to ensure best outcomes. Additional studies should also focus on collecting fidelity on the coach’s procedures whilst training interventionists, this data was collected by a small number of studies (e.g. Neely et al. 2016) and allows for a tertiary level of data collection to ensure a greater level of procedural integrity across all levels of the research.

Data on outcomes of participants with ASD were col-lected in 85% (n = 24) of studies. Measures differed based upon the intervention category but as a whole improvement was less consistent than measures of fidelity for interven-tionists. Measures of challenging behaviour were collected in 50% (n = 14) of studies, social-communication responses were collected in 46% (n = 13) of studies and motor imitation was measured in 17% (n = 5). Overall, there was improve-ment in target behaviour across studies, although several studies observed little or no improvements in some but not

all participant outcomes (e.g. Barkaia et al. 2017; Macha-licek et al. 2016; Meadan et al. 2016; Suess et al. 2014; Vismara et al. 2013; Wainer and Ingersoll 2015). A greater proportion of naturalistic interventions were rated as mixed when compared to FA + FCT studies (45% vs. 17%). For example, Barkaia et al. (2017) found clear gains in mand and echoic behaviour in one out of three participants. Whether this was a result of individual differences or a failure of the telehealth model remains to be seen, although as mentioned earlier this study reported low levels of therapist fidelity. In a similar study Neely et al. (2016) were able to achieve a high rating of fidelity across therapists and increased manding for all participants with ASD. This was the only study to be rated as of ‘adequate’ quality. Individual differences in outcome success have often perplexed ABA researchers. On-going research aims to identify factors which may predict success (Mudford et al. 2009; Perry et al. 2011; Whiteford et al. 2012). This area is somehow explored in several of the group design studies included in this review (e.g. Ingersoll et al. 2016; Vismara et al. 2009, 2016) but further research is needed in this area.

The final aim of the present systematic review was to rate the methodological quality of the existing body of evidence. All 28 eligible studies were assessed against the research quality indicators developed by Reichow et al. (2008). Over-all ratings of quality were low and telehealth-based applica-tions of ABA are currently deemed to have a status of ‘Not an EBP’.

In the single subject research design studies, more than half of the studies (39%; n = 11) were rated as having unac-ceptable baseline conditions. Despite conditions being accurately described and for the most part containing three data points, many failed to show stable levels or trends. This is perhaps a result of the applied nature of the research in which it is not always practical or even possible to wait for stable trends of baseline responding. Future research should aim to establish a stable baseline level, so that it can provide a stronger demonstration of a functional relation between the intervention and behaviour change and higher levels of inter-nal validity. Pre-planning resources so as to enable extension of baseline if stable levels of behaviour are not achieved in the first three data points should be conducted.

Experimental control was demonstrated to an acceptable level in 13 studies; similarly, 14 studies were adequate for visual analysis. Research deemed unacceptable failed to demonstrate experimental control as visual analysis showed an unacceptable level of overlapping data or absence of three instances of experimental control. Future studies should ensure that these essential aspects are present by increasing participants or replications.

The participant demographic indicator achieved the low-est score, with 79% (n = 22) of studies being deemed unac-ceptable. Only two studies were rated highly in this indicator


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(Neely et al. 2016; Wacker et al. 2013a) and age and gender of interventionists was rarely reported. Detailed demograph-ics allow for the generalisation and replication of findings; by omitting this information, researchers undermine external validity. It is vital that future research reports detailed demo-graphics of both interventionists and participants, including level of education and experience and diagnosis and pre-intervention assessment respectively. Future researchers should consider providing all participant demographics for both the participants with ASD and the interventionists. This should include age and gender, pre assessment tools and previous experience. High methodological rigor in this area is demonstrated by the three studies within this review that scored highly on the participant indicator (Bearss et al. 2017; Neely et al. 2016; Wacker et al. 2013a).

Omission of age or gender was quite often the limiting factor restricting quality ratings across studies amongst both single subject research design and group research design. If participant details had been reported even to an adequate standard, three additional group design studies and two addi-tional single subject studies would have gained an overall quality rating of ‘adequate’ (Gibson et al. 2010; Ingersoll et al. 2016; Kuravackel et al. 2018; Lindgren et al. 2015; Simacek et al. 2017) and one group design study would have achieved a ‘strong’ rating (Vismara et al. 2016). With this in mind the formula for determining EBP can be reapplied (Reichow 2011, p. 34). The research would now be provided with a higher score (z = 79), which would in turn translate to a rating of an ‘Established EBP’. This is a vast differ-ence from the original score. It could be argued that this is a weakness of the quality assessment, which allows rela-tively small omissions to have such a large effect on ratings; however, as discussed previously, participant information is a vital component in the establishment of external valid-ity therefore collecting and reporting key information is of crucial importance. Interestingly, no group research design studies were rewarded an acceptable rating for the partici-pant indicator, whilst 15% (n = 3) of single subject research design studies scored an acceptable rating. This may allow for conclusions that single subject research design holds a higher standard of research rigor in comparison to group research designs. It is also important to note that only 36% (n = 10) of the reviewed 28 studies included maintenance or follow-up probes. Again, of these studies just 25% (n = 2) of group research designs showed evidence of maintenance probes whilst 50% (n = 10) of single subject research designs reported this variable. This adds to the conclusion that a single subject research design may hold itself above group research design in research quality and the individualised nature and repeated measurements are more suited to the heterogeneity of behaviour analytic interventions. Of all 28 studies, just 30% (n = 3) had promising follow-up data. This should be a prioritised area of focus for future research.

Current research surrounding telehealth interventions as a means to train interventionists, although still limited, is progressing. The limitations we have identified will aid in the development of methodologically strong studies The use of telehealth is not aimed to replacing face-to-face behav-ioural interventions but to complement or boost their results. Future reviews are needed to assess the outcomes of a com-bination of telehealth and face–face models of delivery, which were excluded from this current review. Addition-ally, all eligible studies were conducted in the United States, therefore future research should focus on the feasibility and cost effectiveness of similar provisions in different coun-tries in which cultural differences might impact on existing models.

In sum, this systematic review suggests that training interventionists to implement behaviour analytic provisions for children with ASD via telehealth is feasible and effec-tive. Small improvements in research rigor could lead to this delivery model being deemed an EBP. Future research-ers should familiarise themselves with quality indicators to ensure methodologically robust research is conducted.

Author Contributions JF participated in the study design, data collec-tion and interpretation of findings, and production of first draft; EC participated in the study design, data collection and interpretation of findings and production of first draft; KD conceived of the study, led its design, made substantial contributions to analysis and interpretation of data, and critically revised manuscript drafts. All authors read and approved the final manuscript.

Funding First and second authors are in receipt of PhD research stu-dentships by the Department for the Economy Northern Ireland.

Compliance with Ethical Standards

Conflict of interest Authors declare that they have no conflict of inter-est.

Ethical Approval This article does not contain any studies with human participants or animals performed by any of the authors.

Open Access This article is distributed under the terms of the Crea-tive Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribu-tion, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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Telehealth as a Model for Providing Behaviour Analytic Interventions … · 2019-09-06 · Current reviews have not focused specifically on ABA-based interventions and have instead