Using this article: Ferguson, J., Craig, E. A., & Dounavi, K. (2019). Telehealth as a Model for Providing Behaviour Analytic Interventions to Individuals with Autism Spectrum Disorder: A Systematic Review.Journal of autism and developmental disorders,49(2), 582-616.https://doi.org/10.1007/s10803-018-3724-5

Summarize the main points in a short paragraph form then relate to telehealth. I am on the con side of the resolution "Telehealth technology threatens the future of Special Education & ABA," you're arguing against the idea that Telehealth is a threat meaning you're saying telehealth is beneficial and does not threaten the field. Here is some of the key information below just in case you need it.

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 procedures 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 highlighting methodological flaws.

Findings from the synthesis of 28 studies suggested that telehealth can be an acceptable platform for behaviour analytic interventions and assessments. A total of 293 interventionists 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 minor methodological flaws, an overall rating of 'not an evidence-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 categorise intervention aims and procedures. A variety of ABA-based procedures were targeted within the literature: FA and FCT, naturalistic teaching, preference assessments, behaviour 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 successfully teach skills to children with ASD across developmental 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. Further 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 everyday 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 training period. Initial training has been recognised as a key component 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, practice using role play and tests of knowledge (Fetherstone and Sturmey 2014; Miltenberger 2004). All 28 studies incorporated 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 performance feedback. Due to using a combination of training variables it was not possible to isolate the most successful 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 providing extensive information on this aspect. Video conferencing 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 computers, 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 interventionist 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 Education, Department of Health 2015; Department of Education Northern Ireland 2005).

The largest proportion of studies (64%; n=18) used parent training to support the provision of home-based intervention 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 identified 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 1.75-16years, with the majority of participants being under 6years old. Current research trends indicate that young age is a crucial predictor of success in behavioural interventions (Perry et al. 2011). The UK government initiatives 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. Outcomes were measured for both interventionists and participants 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 procedural 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 acceptable. Several other studies reported the need to perform 'top up' training in order for agents to reach pre-set fidelity criteria. Despite these few discrepancies, the literature does demonstrate the capabilities of telehealth and goes some way to answering the pertinent question of whether behaviour 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 collected 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 interventionists. 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 improvement 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; Machalicek 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). Overall ratings of quality were low and telehealth-based applications 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 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. 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 internal 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 lowest score, with 79% (n=22) of studies being deemed unacceptable. Only two studies were rated highly in this indicator (Neely et al. 2016; Wacker et al. 2013a) and age and gender of interventionists was rarely reported. Detailed demographics allow for the generalisation and replication of findings; by omitting this information, researchers undermine external validity. It is vital that future research reports detailed demographics 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 additional 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 difference from the original score. It could be argued that this is a weakness of the quality assessment, which allows relatively 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 validity therefore collecting and reporting key information is of crucial importance. Interestingly, no group research design studies were rewarded an acceptable rating for the participant 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 behavioural interventions but to complement or boost their results. Future reviews are needed to assess the outcomes of a combination of telehealth and face-face models of delivery, which were excluded from this current review. Additionally, 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 countries 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 effective. Small improvements in research rigor could lead to this delivery model being deemed an EBP. Future researchers should familiarise themselves with quality indicators to ensure methodologically robust research is conducted.