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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 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. Abstract: Interventions 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 systematically 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. Autism spectrum disorder (ASD) is a neuro-developmental disorder categorised by impairments in social-communication and restrictions in behaviours or thought patterns (American Psychiatric Association 2013). Recent estimates have suggested 1 in every 59 individuals now have a diagnosis of ASD (Centres for Disease Control and Prevention 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 education 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 compared 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 interventions, which should be based solely upon sound empirical evidence and guided by current evidence based practice (EBP). Research has indicated that best practice in autism interventions should involve strategies based upon the principles 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 interventions 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 training 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 selection of services is available, access to funded ABA can often be either a postcode lottery or a testament of parental 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 analysis, undertake an extensive period of supervised practice and pass an exam (BACB 2014). Working under an appropriately 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 currently 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 professionals. Parents of children with ASD living in rural areas have shown lower levels of service satisfaction and greater difficulties in accessing professional expertise when compared with their urban counterparts (Bulgren 2002; Murphy 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 conditions. The availability of internet connections has been growing 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 training platforms. The application of telehealth has been investigated 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 (Department 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 interventions 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, effectiveness and limitations of using telehealth was required. To date there have been five published reviews summarising 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, education, 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 individuals 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 Functional Communication Training (FCT) (e.g., Barretto et al. 2006; Wacker et al. 2013a, b) or naturalistic teaching strategies (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 behaviour analysts will allow for a unique analysis of the methodology 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 parent’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 considered a crucial factor in intervention and has itself been identified 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. 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 telehealth 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 quality 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-subject 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 comparing 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 individuals with a diagnosis of ASD. Main intervention components and outcomes will be extracted and combined to provide an overall picture of research aims, procedures, participants 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 methodological 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). 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 behavioural 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 professional, (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 information was extracted (Table 1). The following measures were examined in order to develop an overview of the main intervention characteristics present in the research: (1) research design (2) participant characteristics (3) technology descriptions (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 information was collected, including measures of inter-observer agreement (IOA), generalisation and follow-up data A score sheet created by the authors was used to score each of the identified variables against the operational definitions 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 amalgamated 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.

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