In addition, there are only a few direct comparisons of training provided via telehealth with training provided via in-person methodology. This limitation may therefore relate to the theoretical understanding of telehealth-based support, rather than its clinical utility. Many studies included in the review did not report fidelity data for either the trainer or trainee which is a key methodological limitation, although this limitation is also applicable to behavioral research more widely e.
Comparisons with fidelity when trainees receive training via in-person methodology would again be useful, given one study in this review finding that variable fidelity was common across both training modalities Hay-Hansson and Eldevik Finally, some technical difficulties were reported in the studies, suggesting a need to document and refine the technological requirements for successful telehealth interventions.
This is likely to be a common concern for telehealth interventions across a number of fields and Lee et al. More demonstrations of sufficient technology for conducting telehealth and troubleshooting guidelines are undoubtedly needed if practitioners are to adopt such methodology within their practice.
In addition to limitations in the evidence base, there are also limitations relating to the current review which must be considered when interpreting results. Firstly, it was beyond the scope of the review to consider interventions that did not include additional support from a trainer e. In addition, due to the nature of systematic review methodology, some relevant articles may not be included if they were not identified as part of the search strategy and it was not possible to include gray literature such as unpublished manuscripts, dissertations, or book chapters.
As a result, some relevant evidence may not have been included in the review. Despite this, the methodology of a systematic review requires adherence to tight inclusion criteria and this is therefore a limitation of systematic reviews in general. Finally, due to the small number of studies identified, it was not possible to assess the effectiveness of the interventions quantitatively; therefore, conclusions relating to effectiveness are only tentatively made. Despite limitations, this review has highlighted a number of specific areas that require further study.
Any future research should aim to overcome methodological limitations highlighted in this review, and be conducted in a range of countries and contexts in order to demonstrate the applicability of telehealth to ABA support internationally. Additional research is also needed for wider target populations, as nearly all studies in this review focused on children with disabilities, for a greater range of outcomes e.
Finally, a component analysis of telehealth training would add to the evidence base by determining which elements of training are necessary or sufficient for behavioral change, as many studies used multiple approaches including initial training, real-time coaching, accompanying manuals, and logistical support from other individuals during sessions. Some wider issues relating to the use of telehealth also warrant further discussion and will require investigation and clarification if the field of ABA is to adopt telehealth methodology more widely.
The articles included in this review often contained only limited details about the characteristics of the trainer, trainee, and clients, with no evaluation of the characteristics of those who would be most able to deliver training via telehealth or benefit from the use of this technology. Some authors highlighted a need to investigate this further Suess et al. It is possible that some individuals may have difficulty engaging with or benefiting from support provided via telehealth due, for example, to difficulty accessing or using the technology required, cultural and language barriers, or preferences for support provided in a particular way.
Identifying the characteristics of those who would benefit most and engage with telehealth support would ensure that such methodology is used when it is most appropriate and useful. Although a full overview of this debate is beyond the scope of this review, there may be important implications relating to this for behavior analytic support provided via telehealth.
These implications will need to be investigated and taken into account when implementing support via telehealth. Other limitations relating to the use of telehealth in ABA may also exist, with some authors highlighting that use of the methodology may be limited to particular types of target behaviors Machalicek et al.
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Although some authors have applied telehealth methodology to more broad training see, for example, Heitzman-Powell et al. Finally, the motivations and context for adopting telehealth support in ABA services must be considered. Although providing support via telehealth has preliminarily been shown to reduce costs or travel burdens Gibson et al.
Furthermore, there is some evidence that despite reduced professional costs, client related costs may increase as a result of the use of telehealth see Lindgren et al. It may be important, therefore, to ensure that services do not adopt telehealth methodology solely to reduce professional costs where in-person training is possible, but instead adopt telehealth to support populations who may be unable to otherwise access support e. Although these broader issues require further investigation and the methodological quality of articles included in this review presents a significant limitation, the findings presented here and the literature relating to telehealth more generally may have important implications for clinical practice.
In early evaluations, telehealth methodology appeared to be effective for training individuals in a number of ABA techniques.
Although more high-quality research is warranted, these findings suggest that telehealth support may have the potential to improve the reach and scope of behavior analytic support and enable professionals to effectively support populations that would otherwise struggle to access such support. This may be particularly important in contexts where expertise in behavior analysis is scarce or not geographically widespread such as the UK, where only professionals are registered with the Behavior Analyst Certification Board as Board Certified Behavior Analysts or Board Certified Assistant Behavior Analysts Behavior Analyst Certification Board This is equivalent to one certified professional per , people and is much lower than other countries such as the USA, where there is one certified professional for every 12, people based on total population data as of 1st July [the most recent available data for the UK]: United States Census Review Telehealth support in ABA services also necessitates a focus on training stakeholders, as it may be difficult to provide direct behavioral interventions to a client using telehealth due to the need to be able to deliver reinforcement and manipulate aspects of the environment directly.
Training stakeholders is consistent with best practice in Positive Behavioral Support Gore et al. In addition to this, telehealth-based interventions were considered highly socially valid by trainees which is another important determinant of the likelihood that the intervention will be continued in the absence of direct professional support Baer et al.
Finally, in initial investigations, telehealth training appears to be an efficient and cost-effective way to provide support, given evidence of potentially large cost savings overall and reduced travel burdens Gibson et al. Although caution should be exercised in solely using financial benefits to justify the adoption of telehealth methodology as discussed above, this may be an important consideration for the field in the current economic and political climate. Skip to main content Skip to sections.
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Open Access. First Online: 01 March Introduction Technology is increasingly becoming a part of everyday life, with smart phones, tablets, laptops, and high-speed internet connections becoming more accessible and affordable. Search Strategy A three-phase search strategy was adopted for the current review, and all searches were conducted in July encompassing literature published up to this date.
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These databases are most commonly used in the behavioral sciences, and index relevant articles relating to these topics. It was therefore expected that these databases would identify the highest number of relevant articles for the current review. After applying inclusion and exclusion criteria to the retained articles, 17 were included in the review.
Secondly, a hand search was conducted of the three journals Journal of Applied Behavior Analysis , Research in Autism Spectrum Disorders , Journal of Behavioral Education that published the highest number of included articles. One additional article was identified, which did not meet inclusion criteria after full text review. Finally, the reference lists of all included articles were searched which resulted in an additional 9 articles being identified, of which 2 were included. One of these articles met inclusion criteria and was included in the review.
A total of 20 articles were included in the review with 17 of these utilizing single case designs. An overview of the search strategy and reasons for exclusion of articles at each stage can be seen in Fig. Open image in new window. Methodological Quality The Evaluative Method was applied 23 times for the 17 single case design articles i. As stated above, 20 articles were identified which focused on using telehealth methodology to train stakeholders in behavioral techniques.
Across these 20 articles, agents were trained in behavioral techniques via telehealth by at least 27 trainers it was not possible to determine the number of trainers for three articles: Alnemary et al. In some cases, additional individuals were also trained including four trainees as part of a wait list control group Fisher et al.
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Both children displayed challenging behavior FA In session coaching via videoconferencing Adoptive mother also received instructions via telephone and in writing before session Social functions identified for each child Result not verified using function-based intervention Barkaia et al. Disruptive behavior was targeted for one child and decreased during DRO Fisher et al. Whole class challenging behaviors recorded Interventions provided within a Positive Behavior Intervention and Support model: praise contingent and noncontingent , prompting and precorrection, opportunities to respond Online training modules Written feedback provided via email after every observation and biweekly videoconferencing coaching session involving feedback and video self-modeling Teacher target behaviors increased following training Whole class challenging behaviors decreased Lindgren et al.
All displayed challenging behavior FA. Antecedent strategies social narratives, timer , FCT, DRA, differential negative reinforcement of alternative behavior DNRA Initial training via videoconferencing involving written task analyses, video modeling and practice with child Functional analysis results differentiated for each child Intervention comparisons resulted in reduced challenging behavior for each child across all intervention strategies Neely et al.
Parent assistants also used Clients: 5 children with ASD aged 2. All children displayed challenging behavior FA Initial training via videoconferencing Parent manual In session coaching via videoconferencing Social functions identified for 18 children Results verified for 13 children in Wacker et al. In all cases, training was provided via videoconferencing i. However, the specific methods used to conduct training differed across the articles. In most cases, initial training was provided in some way to trainees using a variety of methods.
This initial training was usually provided via videoconferencing and was provided via telephone in one study Barretto et al.
In other cases, trainees undertook self-instruction using online modules or videos Fisher et al. Methodological Quality of Evidence Base Although these initial results are promising, a key limitation of the evidence base for telehealth training in ABA procedures relates to the methodological quality of the studies. Limitations and Areas for Further Study Some additional limitations of the evidence base must also be considered.