A Randomized Controlled Trial of Functional Communication Training via Telehealth for Young Children with Autism Spectrum Disorder

Promoting Reciprocal Relationships with Flexibility, Coaching, and Teaching (PRRFCT Match): A Virtual Parent-Mediated Intervention Package for Young Children with Developmental Disabilities

This study aimed to evaluate Promoting Reciprocal Relationships with Flexibility, Coaching, and Teaching (PRRFCT Match), a parent-mediated naturalistic developmental behavioral intervention package. An expansion from an earlier pilot study (see Kunze et al., 2021), PRRFCT Match incorporates virtual coaching between a novice coach and parent to implement evidence-based, applied behavior analytic (ABA) techniques during play to increase engagement and decrease unengaged behavior exhibited by their young child with developmental delays (26-50 months old). Ten parent-child dyads were matched with a coach in this concurrent multiple baseline design across participants. Simulating the clinical training level of a novice early interventionist, nine graduate student clinicians received training as coaches on PRRFCT Match implementation and weekly supervision by a research team member. All aspects of training and intervention were delivered virtually. A visual analysis of the data combined with Tau-U revealed a strong basic effect between clinician coaching and parent strategy use. For child participants, a visual analysis and Tau-U results suggest that most increased engagement and decreased their unengaged behavior during the intervention. High variability, overlap, and high engagement at baseline are discussed. This study shows promise for the PRRFCT Match intervention package. The ABA technologies mediated by parents during play increased child engagement and decreased unengagement for most participants.

The teleNIDA: Early Screening of Autism Spectrum Disorder Through a Novel Telehealth Approach

The COVID-19 pandemic has fast-tracked interest in telehealth methods to guarantee the continuity of care of children with Autism Spectrum Disorder (ASD). Store-and-forward telehealth approaches offer the opportunity to facilitate timely screening of ASD, allowing parents to record videos of their child's behaviors, subsequently shared with clinicians that provide an assessment remotely. This study aimed to examine the psychometric properties of a new telehealth screening tool, the teleNIDA, administered in home settings for remote observation of early signs of ASD in toddlers aged 18-30 months. Results showed good psychometric properties of the teleNIDA, as compared to the gold standard in-person assessment, and the predictive validity on the diagnosis of ASD at 36 months was demonstrated. This study supports the teleNIDA as a promising level 2 screening tool for ASD able to speed up diagnostic and intervention processes.

Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior

OBJECTIVE

To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period.

STUDY DESIGN

In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, through December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using non-parametric statistical analysis with odds ratios presented for significant factors.

RESULTS

Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least one psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall.

CONCLUSIONS

Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.

Implementation of Peer-Assisted Physical Activity Via Telehealth for Adults on the Autism Spectrum: A Mixed Methods Feasibility Study

OBJECTIVE

Adults on the autism spectrum are at risk for physical inactivity, obesity, and related health conditions. Physical activity provides physical, social, and mental health benefits across the lifespan. Previous research examined feasibility and effectiveness of physical activity intervention in autistic children, but very few studies target autistic adults. This study examined the feasibility and acceptability of Physical Activity Connections via Telehealth, implemented during the coronavirus disease 2019 (COVID-19) pandemic lockdown as an alternative to in-person programming for autistic adults aged 18 to 32.

METHODS

The 10-week intervention utilized telehealth and remote technologies to deliver a theoretically grounded program to improve physical activity. Strategies included peer-guidance, coaching, individualized wellness goals, customized exercise programs, and wearable activity trackers. Feasibility and acceptability were examined using a mixed-methods design including observational and survey data collection, as well as participant interviews. Data were analyzed using descriptive statistics and content analysis.

RESULTS

Findings support feasibility and acceptability of telehealth to promote physical activity among autistic adults who have cognitive capacity and ability to utilize remote technology, with applicability beyond pandemic-imposed challenges.

CONCLUSION

Telehealth delivery of physical activity interventions is a viable alternative to in-person programs and may enable autistic adults to overcome barriers to physical activity participation and access.

IMPACT

As the rate of autism continues to rise globally, rehabilitation professionals will play a significant role in promoting health and wellness for autistic individuals across the lifespan. Findings promote informed practice based on the health needs of this growing segment of society.

Individualized Parent-Mediated Behavioral Treatment for Challenging Behavior: A Program Description

Past research suggests behavioral treatments are effective for challenging behavior in children and young adults with neurodevelopmental disorders, such as autism spectrum disorder (ASD). However, access to these services can be limited and require substantial resources. To address this issue, the current study provides a programmatic description of an individualized parent-mediated service model targeting moderate challenging behavior. In the program, therapists coached parents to implement functional analyses and individualized function-based treatment packages. Forty-one families of children and young adults with neurodevelopmental disorders participated. Most clients (75.6%) met all admission treatment goals and parents reported significant decreases in frequency and severity of challenging behaviors at discharge. Parents also reported less stress at discharge. Outcomes of the study suggest this parent-mediated treatment model is a viable option to treating moderate challenging behavior in children and young adults with intellectual and developmental disorders.

Telehealth services for children with neuro-developmental disabilities in the Asia-Pacific region: A systematic review

BACKGROUND

In recent years telehealth became a popular and a rational health service delivery approach, especially amidst multiple challenges posed while providing health care interventions during the COVID-19 pandemic.

AIM

We synthesized available evidence on telehealth for managing children with NDDs in the Asia-Pacific region with the aim of identifying successful methods.

METHODOLOGY

We systematically reviewed six electronic databases: MEDLINE, AMED, EMBASE, PsychInfo, Web of Science, and (CINAHL plus) using the keywords and database-specific subject headings from their inception to 25th August 2021. Review findings were synthesized narratively, and harvest plots were used to demonstrate the effect of interventions. The protocol and reporting the findings of this review adhered to PRISMA 2020 guidelines. PROSPERO registration: CRD 340690.

RESULTS

We harvested 30,823 records; 17,563 duplicates were removed, and 196 full-text articles were assessed for eligibility. 16 studies with multiple research designs were included in the review. Eight were from the Pacific region and eight represented Asia. The interventions targeted families and children with a variety of NDDs (autism spectrum disorder, Down syndrome, cleft lip and palate, hearing impairment, cerebral palsy etc.) via telehealth. Telehealth packages consisted of direct and indirect methods of synchronous, asynchronous, and hybrid approaches. All studies used parent-led intervention strategies. Telehealth reported a positive effect in 7/16 studies while five showed a neutral effect.

CONCLUSIONS

According to published evidence telehealth for children with NDDs is an evolving, evidence-based service facilitation modality in the Asia-Pacific region, with only a few published randomized controlled trials. The systematic review shows promising telehealth practices emerging across the region despite the diversity in NDDs studied.

Teaching Requesting to Individuals with Rett Syndrome Using Alternative Augmentative Communication (AAC) Through Caregiver Coaching via Telehealth

Rett syndrome is a severe neurodevelopmental disorder that results in both motor and language skill regression with a wide range of severity in symptom presentation. Communication intervention may be particularly challenging for this population due to the decline in speech, motor skills, and motor planning difficulties that characterize the disorder (Townend et al., 2020), often resulting in the need for augmentative and alternative communication (AAC) technology. Very limited research has evaluated communication interventions for individuals with Rett syndrome and even fewer have targeted expressive communication, an important skill required for improved autonomy and quality of life (Sigafoos et al., 2009; Townend et al., 2020). The current study sought to systematically replicate the Simacek et al. (2017) mand training procedures to teach three girls with Rett Syndrome to use AAC to make requests through caregiver coaching by researchers via telehealth. Results suggest that mand training was successful in increasing AAC use for all three participants. Barriers to intervention for this population and implications of results for future research and clinical practice are discussed.

Effects of Parent-Implemented Interventions on Outcomes of Children with Autism: A Meta-Analysis

Children with autism spectrum disorder (ASD) have been shown to benefit from parent-implemented interventions (PIIs). This meta-analysis improved on prior reviews of PIIs by evaluating RCTs and multiple potential moderators, including indicators of research quality. Fifty-one effect sizes averaged moderately strong overall benefits of PIIs (g = 0.553), with studies having lower risk of research bias yielding lower estimates (g = 0.47). Parent and observer ratings yielded similar averaged estimates for positive behavior/social skills (g = 0.603), language/communication (g = 0.545), maladaptive behavior (g = 0.519), and to a lesser extent, adaptive behavior/life skills (g = 0.239). No other study, intervention, or participant characteristic moderated outcomes. PIIs with children with ASD tend to be effective across a variety of circumstances.

Effectiveness of videoconference-delivered psychotherapy for children, adolescents, and their parents: A meta-analysis of randomized controlled trials

INTRODUCTION

Over the last years, videoconference-delivered psychotherapy (VCP) has found its way into clinical practice. This meta-analysis is the first to evaluate the effectiveness of VCP for children and adolescents with a mental disorder and their parents.

METHODS

A systematic literature search was performed to identify randomized controlled trials (RCTs) that compared the effectiveness of VCP for youths with a mental disorder to a control condition. Twelve studies were included. Two reviewers independently extracted data and rated study quality.

RESULTS

Effect size estimates for measures of children's symptoms of mental disorders were large for comparison between VCP and waitlist (posttreatment: Hedges's g = -1.26, k = 5) and negligible for comparisons between VCP and in-person treatment (posttreatment: g = 0.00, k = 6; follow-up: g = -0.05, k = 3). Similarly, effect size estimates for measures of children's functional impairments were large for comparison between VCP and waitlist (posttreatment: g = -1.10, k = 3) and negligible for comparisons between VCP and in-person treatment (posttreatment: g = -0.23, k = 3; follow-up: g = 0.04, k = 2). VCP more effectively reduced symptoms in children with an internalizing disorder (g = -0.88, k = 5) compared to externalizing disorders (g = 0.25, k = 2) or tic disorders (g = -0.08, k = 3).

DISCUSSION

The results provide preliminary evidence that VCP is an effective treatment for youths with a mental disorder and their parents. VCP was equally effective as in-person treatment in reducing children's symptoms and functional impairments. Limitations include the limited number of RCTs and incomplete reporting of methodological features.

Aggression Is Associated With Social Adaptive Functioning in Children With ASD and Anxiety

Social adaptive functioning is notably compromised and may be further impaired by aggressive behavior in children with autism spectrum disorder (ASD). This study examined the association between aggressive behavior and social adaptive skills in children with ASD and the contribution of aggressive behavior to social adaptive skills in a combined sample of children with and without ASD. Participants consisted of children, ages 8 to 15 years, with ASD (n = 52) and who were typically developing (n = 29). Results indicate that aggressive behavior is negatively associated with social adaptive skills in children with ASD and that it contributes to reduced social adaptive functioning above and beyond ASD diagnosis. Findings underscore the importance of considering the role of aggressive behavior when evaluating and promoting social functioning in children with ASD.

Distance-Based Collaborations for Assessing and Treating Challenging Behavior

An interview-informed synthesized contingency analysis (IISCA; Hanley et al. in J Appl Behav Anal 47:16-36, 2014) and related skill-based treatment process can result in socially valid outcomes for clients exhibiting severe challenging behavior when implemented by professionals and then transferred to parents (e.g., Santiago et al. in J Autism Dev Disord 46:797-811, 2016). However, many families do not have access to professionals trained to implement functional analyses or function-based treatments (Deochand & Fuqua Behav Anal Pract 9:243-252, 2016). Experimenters in the present study coached three parents of children with autism exhibiting severe challenging behavior through implementing an IISCA and resulting skill-based treatment process through distance-based collaborative consulting. All parents achieved differentiated functional analyses, taught their children to emit functional replacement skills, and reduced challenging behavior relative to baseline.

Provider Perspectives on Telehealth Services for Children With Autism Spectrum Disorder During the Coronavirus Disease 2019 Pandemic

OBJECTIVE

The purpose of the current study was to explore provider perspectives on the strengths and challenges of telehealth services (e.g., behavioral interventions, physical, speech, and occupational therapy, medication management) for children with autism spectrum disorder during coronavirus disease 2019 related shutdowns.

METHODS

From September 2020 to May 2021, we conducted qualitative interviews with 35 providers across multiple disciplines from 17 sites in the Autism Care Network. Qualitative data were analyzed using a framework approach and common themes were identified.

RESULTS

Providers across clinical disciplines identified strengths of the virtual model, such as its flexibility and the opportunity it provided to see children in their home environment. They also indicated that some interventions worked better virtually than others, and that there were several factors that impacted their success. Respondents were generally satisfied providing parent-mediated interventions but expressed mixed satisfaction in using telehealth for direct-to-patient care.

CONCLUSIONS

Results suggest that telehealth services for children with autism spectrum disorder could be a helpful tool in decreasing barriers and improving service delivery, especially when tailored to the individual needs of the patient. More research is needed on the factors contributing to its success in order to eventually inform clinical guidelines regarding the prioritization of children seen for in-person visits.

A mixed-methods examination of clinicians' perceived barriers to telehealth delivered applied behavior analysis

Following the COVID-19 pandemic, clinicians relied on telehealth to ensure continuity of essential healthcare services, such as Applied Behavior Analysis (ABA). Identifying barriers and examining them in the context of other implementation outcomes is important to support appropriate adaptations and sustainability of telehealth-delivered ABA services. Convergent mixed methods design was utilized to identify barriers experienced by ABA clinicians (N = 388) when delivering ABA services over telehealth to autistic children and their families following the first six months of the COVID-19 pandemic. Additionally, barriers were examined in relation to telehealth implementation outcomes and intentions for continued adoption. Findings reveal that clinicians rated providing direct services (M = 3.52, SD = 1.14) as more difficult than conducting assessments (M = 3.29, SD = 1.06), and both as more difficult than providing parent-mediated interventions [(M = 2.47, SD = 1.11), F(2, 381) = 162.26, p < 0.001]. A principal components analysis indicated a 3-factor solution of barriers related to: (1) technology (α = 0.82), (2) administrative tasks (α = 0.88), and (3) client characteristics (α = 0.88). The most frequently endorsed barriers were related to client characteristics, including increased difficulty providing telehealth services to children who elope (M = 4.37, SD = 0.81), children who exhibit challenging behaviors (M = 4.31; SD = 0.83), and children who are in the preverbal stage or use nonverbal language to communicate (M = 4.07; SD = 1.00). Fewer barriers related to client characteristics uniquely predicted implementation variables including acceptability, appropriateness, and feasibility. Thematic analysis revealed challenges related to technology, caregiver involvement, child engagement, implementation of intervention strategies over telehealth, and administrative or logistical barriers. These findings highlight the need for targeted strategies that facilitate telehealth use to address specific client needs and support the implementation of telehealth services in usual care settings.

Report of the ABAI Task Force on Contingent Electric Skin Shock

As a task force appointed by the Executive Council of the Association for Behavior Analysis International (ABAI), we investigated the clinical use of contingent electric skin shock (CESS) in behavior analytic treatments for severe problem behavior. We studied how CESS is used in contemporary behavior analysis, reinforcement-based alternatives to CESS, and current ethical and professional guidelines for applied behavior analysts. We recommended that ABAI uphold clients' right to receive CESS when it is restricted to extreme cases and used under rigorous professional and legal oversight. Our recommendation was rejected by a vote of the full members of ABAI, who instead endorsed an alternative recommendation, developed by members of the Executive Council, that opposed the use of CESS under any condition. Here we present for the record our report and initial recommendations, the formal statement that was rejected by the members of ABAI, and the statement that was endorsed.

Recommendations Regarding Use of the Term "Ignore" in Applied Behavior Analysis

Ignore is a common term used in behavioral assessment, behavior intervention plans, textbooks, and research articles. In the present article, we recommend against the typical usage of the term in most applications of behavior analysis. First, we briefly outline some history of the use of the term in behavior analysis. Then, we describe six main concerns about ignore and the implications for its continued use. Finally, we address each of these concerns with proposed solutions, such as alternatives to the use of ignore.

Additional Comments on the Use of Contingent Electric Skin Shock

Prior to the ABAI member vote to decide between two alternative position statements on contingent electric skin shock (CESS), the current authors helped draft a consensus statement supporting the abolition of CESS. In this commentary, we provide additional, supporting information for that consensus statement by (1) showing that the extant literature does not support the supposition that CESS is more efficacious than less-intrusive interventions; (2) providing data showing that implementing interventions that are less intrusive than CESS does not lead to overreliance on the use of physical or mechanical restraint to control destructive behavior; and (3) discussing the ethical and public relations issues that arise when behavior analysts use painful skin shock to reduce destructive behavior in persons with autism or intellectual disability.

Behavioral Parent Training via Telehealth for Autistic Children: Further Exploration of Feasibility During the COVID-19 Pandemic

Objectives

Many autistic children exhibit challenging and disruptive behaviors that can present challenges for both children and their families by interfering with acquisition of adaptive skills and affecting family and peer relationships. Behavioral parent training (BPT) is an evidence-based approach to reducing autistic children's disruptive behavior, but many families face a number of barriers to accessing BPT, such as availability of BPT in their community, and transportation and scheduling challenges. Therefore, we sought to explore the feasibility and promise of effectiveness of adapting an established BPT program to a telehealth format during the COVID-19 pandemic.

Methods

A feasibility trial of BPT via telehealth was conducted with fourteen parents of autistic children.

Results

Parents and clinicians were able to implement BPT via telehealth with a high degree of fidelity, and parents rated both BPT and the telehealth format favorably. The program also showed promise of effectiveness in reducing autistic children's disruptive behavior, improving their adaptive skills, as well as reducing parents' stress, and improving parents' sense of parenting competence.

Conclusions

The findings replicate and extend findings from previous studies, further demonstrating the promise of telehealth as a viable alternative format for delivering BPT. We also explore implications for future research, including the opportunity for more thorough evaluation of the effectiveness of BPT via telehealth.

The Intersection of Genome, Epigenome and Social Experience in Autism Spectrum Disorder: Exploring Modifiable Pathways for Intervention

The number of children diagnosed with autism spectrum disorder (ASD) has increased substantially over the past two decades. Current research suggests that both genetic and environmental risk factors are involved in the etiology of ASD. The goal of this paper is to examine how one specific environmental factor, early social experience, may be correlated with DNA methylation (DNAm) changes in genes associated with ASD. We present an innovative model which proposes that polygenic risk and changes in DNAm due to social experience may both contribute to the symptoms of ASD. Previous research on genetic and environmental factors implicated in the etiology of ASD will be reviewed, with an emphasis on the oxytocin receptor gene, which may be epigenetically altered by early social experience, and which plays a crucial role in social and cognitive development. Identifying an environmental risk factor for ASD (e.g., social experience) that could be modified via early intervention and which results in epigenetic (DNAm) changes, could transform our understanding of this condition, facilitate earlier identification of ASD, and guide early intervention efforts.

Acceptability and Access Metrics for Telehealth Consultation of Pediatric Neurodevelopmental Disabilities During COVID-19

INTRODUCTION

We report caregiver agreement to attend telehealth neurodevelopmental consultation during COVID-19, demographic differences in agreement, reasons families declined, and clinical access metrics before and during COVID-19.

METHOD

Data were gathered from telehealth referrals and consultations from April to July 2020. Schedulers documented agreement status and reasons for the decline. Wait time, lag time, and missed appointment rates were calculated to measure access.

RESULTS

Ninety-one percent agreed to attend telehealth consultation; 55% of those who declined preferred in-person services. There were no demographic differences between those who accepted, declined, or did not respond. The median wait time from referral to appointment was 60 days. Missed appointment rates were consistent with prepandemic rates.

DISCUSSION

Findings support literature suggesting patients are agreeable to telehealth. They diverged from evidence suggesting telehealth reduces missed appointments. Overall, results indicate telehealth is an acceptable alternative; however, further telehealth innovation is needed to address existing disparities.

Barriers to Accessing Effective Treatments for Destructive Behavior

The field of applied behavior analysis has developed and refined a comprehensive methodology for the assessment and successful treatment of destructive behavior: An individualized approach emphasizes (a) function of responding (or its cause) over its form; (b) objective and reliable measurement of behavior; (c) systematic procedures and their application; (d) rigorous, single-case experimental designs; and (e) determinations of successful intervention judged by improvements in the same individual's performance. Outcomes of this approach are often dramatic and reliably surpass those obtained by alternative means. However, significant barriers limit the accessibility of this proven therapy. Too few intensive behavioral intervention units, diagnosis- and age-dependent insurance authorization and reimbursement practices, long waitlists and slow approval processes, and the possibility of treatment relapse represent a few such barriers. This article describes these barriers and suggests some potential solutions.

A Retrospective Analysis of Therapists' Coaching Behavior When Directing Parents to Conduct Behavioral Assessments and Treatments Via Telehealth

Research on the delivery of behavioral assessment and treatment via telehealth has focused largely on child outcomes and parent procedural fidelity. By contrast, the behavior of the therapists coaching parents to conduct assessment and treatment has garnered little research consideration. In this study, we conducted a retrospective analysis of behavior therapists' coaching behaviors when directing parents to conduct functional analysis (FA) and functional communication training (FCT) with their young children with autism via telehealth. Coaching behaviors for five experienced behavior therapists across seven parent-child dyads were scored using a combination of standardized and novel behavior codes. Therapists displayed more social engagement behaviors than any other type of behavior throughout the study, and rates of antecedent and consequence behaviors shifted across the FA and FCT phases. Results are discussed in relation to therapists' goals during behavioral assessment and treatment and the implications for training behavioral therapists to coach parents via telehealth.

Telepsychiatry: The future is already present

This review paper analyzes the state of knowledge on Telepsychiatry (TP) after the crisis caused by COVID and the resulting need to use new modalities of care. Six essential aspects of TP are addressed: patient's and mental health staff satisfaction, diagnostic reliability, effectiveness of TP interventions, cost-effectiveness in terms of opportunity cost (or efficiency), legal aspects inherent to confidentiality and privacy in particular and the attitude of professionals toward TP. Satisfaction with TP is acceptable among both patients and professionals, the latter being the most reluctant. Diagnostic reliability has been demonstrated, but requires further studies to confirm this reliability in different diagnoses and healthcare settings. The efficacy of TP treatments is not inferior to face-to-face care, as has been proven in specific psychotherapies. Finally, it should be noted that the attitude of the psychiatrist is the most decisive element that limits or facilitates the implementation of TP.

The Use of Tele-Occupational Therapy for Children and Adolescents with Different Disabilities: Systematic Review of RCT Articles

Background

Due to the limited access of clients in non-urban areas to rehabilitation and the difficulty of specialized counseling in such conditions, the need for telehealth services has increased. The purpose of this study is to evaluate the effectiveness of Tele occupational therapy in common disorders of children and adolescents.

Methods

In this systematic review study, a research method published from 2010 to 2022 focusing on the effectiveness of tele-rehabilitation and its impact on children and adolescents with different physical disabilities was done in Google Scholar, PubMed, Scopus and EMBASE databases. 467 articles were obtained in the review, and finally, 18 articles were reviewed.

Results

In children with CP, Tele occupational therapy will be effective on gross motor function and balance skills, but the impact on the executive function needs more studies. In children with ASD, it will be effective on behavioral problems, but the effect on pro-social behavior needs further studies. In children and adolescents with other movement disorders, it will have an impact on the progress of their physical activity and in children and adolescents with Traumatic Brain Injury (TBI), it will be effective, but the effectiveness of MitiiTM programs needs further studies.

Conclusion

The findings of this study showed that tele-occupational therapy could be performed in line with face-to-face occupational therapy, and it can lead to the satisfaction of families, but there is still a need to assess the effectiveness of various interventions and tools on different disorders, outcomes and settings.

Effectiveness of a Brief Functional Analysis and Functional Communication Training Conducted Through Telehealth

This study evaluates the effectiveness of a brief functional analysis and functional communication training conducted via telehealth. Three interventionist-child dyads took part in the study including one speech and language pathologist and two school teaching assistants, each working with one child with autism spectrum disorder. Interventionists were trained using didactic training to implement a brief functional analysis as well as synchronous coaching from a BCBA^® to implement functional communication training. A multiple baseline across participants design was utilised to evaluate if interventionists could implement functional communication training to decrease challenging behaviours that included aggression, elopement and disruption. Sessions concluded earlier than planned due to school closures mandated by the COVID-19 outbreak for two of the three participants; however, existing data provide evidence that telehealth is a valid model for enabling clinicians to work in collaboration with school personnel to effectively deliver assessment and intervention procedures remotely via telehealth.

Examination of a Telehealth-Based Parent Training Program in Rural or Underserved Areas for Families Impacted by Autism

Families of children with disabilities in rural areas face challenges accessing services due to location and lack of health-care providers. Telehealth-based intervention can mitigate challenges in accessing services. The present study sought to replicate and extend the telehealth-based, behavioral parent-training program, the Online and Applied System for Intervention Skills (OASIS), utilizing a multiple-baseline approach. Four parent-child dyads participated, with all children diagnosed with autism spectrum disorder. All dyads resided in rural/underserved areas. All dyads demonstrated an improvement on skill and knowledge assessments. The mean gain from baseline-to-treatment completion on skills assessments was 80.9% (range: 67.6%-95.5% points). The mean gain on knowledge assessments was 35.3% (range: 19.0%-49.0% points). It should be noted that parent skill gains were maintained over time. The present results provided additional empirical evidence demonstrating the effectiveness of OASIS, a telehealth-based parent-training model.

Parent-Implemented Interventions via Telepractice in Autism Research: A Review of Social Validity Assessments

Purpose of Review

Parent-implemented autism interventions are considered empirically validated interventions and the use of telepractice in these interventions is reported as effective. However, little is known about the social validity assessments and outcomes of these interventions. The purpose of this review is to explore the current practices of conducting social validity assessment and reporting its outcomes within parent-implemented telepractice autism interventions.

Recent Findings

The 11 reviewed studies included caregivers as participants, telepractice intervention focusing on social communication outcomes of young autistic children, and were published in a peer-reviewed journal within the past five years.

Summary

The researchers in the reviewed articles reported positive outcomes for parent-implemented telepractice autism interventions. Notably, however, information about social validity assessments of the interventions was limited. Researchers are encouraged to evaluate the social validity of interventions using multiple data sources and methods, and report on their findings as they relate to other types of data.

A systematic review of emotion regulation in parent-mediated interventions for autism spectrum disorder

Autistic individuals are at elevated risk for difficulties with emotion regulation (ER) that emerge early in life and are associated with a range of internalizing and externalizing disorders. Existing interventions that support ER have focused on school-age autistic children and adolescents as well as adults. Proactive approaches to improving ER in early childhood are thus needed, as is understanding the approaches by which ER skills can be feasibly supported in this young population. This review summarizes how ER has been measured within parent-mediated interventions for children at or under the age of 6 years and the extent to which ER is measured concurrently with or distinctly from observable behaviors that have been referenced in existing literature as externalizing or challenging behavior. Using PsycInfo, EBSCOhost, and PubMed databases, we searched for peer-reviewed journal articles published through August 2021, that focused on the use of parent-mediated interventions targeting ER and/or challenging behavior. The systematic search resulted in 4,738 publications; following multi-stage screening, the search yielded 20 studies. Eighteen of 20 studies were designed to target challenging behavior using manualized curricula or behavior analytic methodologies and assessed child outcomes through validated caregiver rating scales and/or direct behavioral observation. One study measured changes in ER as secondary to the social communication skills that were targeted in the intervention. Only one study specifically supported ER skill development and measured changes in ER as the primary intervention outcome. Findings highlight the need for better assessment of ER outcomes within the context of parent-mediated interventions for toddlers and young autistic children.

Effectiveness of Remote Delayed Performance Feedback on Accurate Implementation of Caregiver Coaching

The supervision of field experiences is an indispensable component of Board-Certified Behavior Analyst (BCBA®) training. During the supervised field experience, supervisors regularly provide performance feedback to trainees for the purpose of improving fidelity of implementation of various assessments and interventions. Emerging evidence supports the efficacy of using telehealth to train teachers and parents to implement interventions, but no study has evaluated the effectiveness of the remote delayed performance feedback among individuals completing BCBA® training. We used videoconference equipment and software to deliver remote delayed performance feedback to seven participants enrolled in a graduate program and completing supervised field experience. Remote delayed performance feedback was provided regarding participants' implementation of caregiver coaching. The results indicate that delayed performance feedback provided remotely increased the correct implementation of caregiver coaching. These preliminary results indicate the efficacy of remote supervision and delayed performance feedback.

Extended Reality (XR) and telehealth interventions for children or adolescents with autism spectrum disorder: Systematic review of qualitative and quantitative studies

World Health Organization reported that almost one in 100 children is diagnosed with autism spectrum disorder (ASD) worldwide. Extended Reality (XR) and Telehealth interventions are evident to be effective for ASD treatments. While there is no comprehensive systematic review to summarize and evaluate the evidence for promoting the accessibility of different technology-based treatment regiments. This paper aims to verify the efficacy and validity of XR and Telehealth interventions for children and adolescents with ASD. We reviewed 112 studies from databases of PubMed, Web of Science and Cochrane Library, published in English between January 2010 to April 1st, 2022. We found that after interventions, positive improvements for ASD participants were observed in social interaction, acceptance, and engagement, communication and speech, emotion recognition and control, daily living skill, problem behavior reduction, attention, cost reduction, anxiety symptom reduction, pretend play, contextual processing, match to sample skill, and insomnia control. Our findings provide a solid and positive evidence of XR and Telehealth interventions in improving the treatment outcomes for children and adolescents with ASD. In the future, more research with RCTs and standardized outcome measurements are required to establish the therapeutic efficiency of the two interventions independently or combined.

Conducting In-Home Functional Analyses of Aggression and Self-Injury Exhibited by Boys with Fragile X Syndrome

OBJECTIVE

Boys with fragile X syndrome (FXS) are at increased risk for exhibiting aggression and self-injury that can be extremely disruptive to families. Few studies, however, have examined the extent to which social-environmental factors can influence these behaviors, particularly in home settings.

METHODS

Caregivers of 32 boys with FXS, aged 3 to 10 years, were coached by a board-certified behavior analyst to implement a functional analysis (FA) with their child in their home over 2 days. The functions identified in the FAs were validated by behavioral interventions conducted through telehealth over 12 weeks.

RESULTS

Social functions for aggression and self-injury were identified in 29 (90.6%) cases, with the most common functions identified being escape from demands/transitions and/or tangible reinforcement. Subsequent function-based behavioral interventions (i.e., functional communication training) implemented for 22 cases by telehealth resulted in decreased rates of aggression and self-injury by 74% to 100%.

CONCLUSION

These data underscore the significant impact that social-environmental factors can have on the development and maintenance of aggression and self-injury in FXS. Conducting early home-based behavioral interventions designed to increase functional communication skills may therefore be an effective solution for the treatment of aggression and self-injury in FXS in the long term.

Translating Quantitative Theories of Behavior into Improved Clinical Treatments for Problem Behavior

The most important advancement in the treatment of destructive behavior has been the development of the functional analysis, which is used to prescribe effective treatments like functional communication training. Although this approach can be highly effective, extinction bursts and forms of treatment relapse commonly occur when function-based treatments are implemented by caregivers in natural community settings. In recent years, researchers have increasingly applied quantitative theories of behavior like behavioral momentum theory (BMT) and the temporally weighted matching law (TWML) to understand, prevent, or mitigate extinction bursts and treatment relapse. In this paper, we describe BMT and TWML and selectively review the basic, translational, and applied research supporting and opposing each theory. Then, we describe how function-based treatments may be refined based on these theories to improve the effectiveness, generality, and durability of function-based treatments for individuals with autism spectrum and related disorders who display problem behavior.

A scoping review of telehealth diagnosis of autism spectrum disorder

Background

Considering the COVID-19 pandemic, understanding the reliability, validity, social validity, and feasibility of using telehealth to diagnose ASD is a critical public health issue. This paper examines evidence supporting the use of telehealth methods to diagnose ASD and outlines the necessary modifications and adaptations to support telehealth diagnosis.

Methods and procedures

Studies were identified by searching PubMed and PsychInfo electronic databases and references lists of relevant articles. Only peer reviewed articles published in English with a focus on using telehealth for the purposes of diagnosing ASD were included. Searches were conducted through June 3^rd, 2021.

Outcomes and results

A total of 10 studies were identified as meeting inclusion criteria. Of the eight papers that reported on reliability (e.g., accuracy), telehealth methods to diagnose ASD were between 80–91% accurate when compared with traditional in-person diagnosis. Six studies reported on validity (i.e., sensitivity and/or specificity). All six studies calculated sensitivity, with values ranging from 75% and 100%. Five of the six studies calculated specificity, with values ranging from 68.75% and 100%. The seven papers that reported social validity indicated that caregivers, as well as adult participants and clinicians, were mostly satisfied with telehealth. Feasibility was reported by seven studies and suggests that telehealth methods appear largely viable, though some challenges were reported.

Conclusions and implications

Although findings reviewed here are promising, more research is needed to verify the accuracy, validity, and feasibility of utilizing telehealth to diagnose ASD. Studies with larger sample sizes and samples across sites will be critical, as these will allow clinicians to identify subjects most likely to benefit from telehealth as well as those more likely to require an in-person assessment. This research is important not only due to the current pandemic, but also due to increased prevalence rates of ASD and an insufficient number of diagnostic providers—particularly in rural and/or otherwise under-served communities.

Home direct-to-consumer telehealth solutions for children with mental health disorders and the impact of Covid-19

Delivery of mental health treatment in the home can close gaps in care. Telehealth also provides access to healthcare that has been disrupted due to the COVID-19 pandemic. In 2016, a home direct-to-consumer telehealth program was initiated. Mental health encounters made up a significant portion of all telehealth encounters and COVID-19 had a significant impact on accelerating the utilization of telehealth. Telemental health has been more successful at meeting targeted volumes than the overall health system. Of all the mental health diagnoses before and during COVID-19, attention deficit hyperactivity disorder, Autism Spectrum Disorder, and Anxiety Disorder were most common. The direct-to-consumer telehealth program saved patients a significant amount of travel miles and associated time, based on data from the period before COVID-19. Payment reimbursement for direct-to-consumer telehealth professional services was similar to reimbursement for in-person visits. This program demonstrates direct-to-consumer telehealth is a feasible and acceptable care modality for a variety of youth mental health disorders.

Telehealth-delivered caregiver training for autism: Recent innovations

Providing treatment to children with autism is a global health priority, and research demonstrates that caregivers can be trained in techniques to promote their child's social interaction, communication, play, positive behavior and skills. These caregiver-mediated interventions have been shown to promote a number of positive outcomes in children with autism, as well as their caregivers. When provided by telehealth, data indicate that caregiver training is acceptable and feasible, and associated with similar positive outcomes as live face-to-face training. Telehealth innovations, which have accelerated during the COVID-19 era, have demonstrated advantages over in-person delivery of services in terms of cost effectiveness and increased accessibility, however, more research is needed on feasibility, acceptability and effectiveness for different populations in different contexts. This brief review will highlight recent caregiver skills training interventions for autism that have been successfully adapted or designed for telehealth delivery. Telehealth interventions that are scalable, adaptable, caregiver-mediated, open-access, and delivered as part of a stepped care model, have the potential to address the global treatment gap for families of children with autism and other neurodevelopmental disabilities. Considerations relevant to the global scale-up of caregiver-mediated interventions will also be discussed.

Direct observation in a large-scale randomized trial of parent training in children with autism spectrum disorder and disruptive behavior

A direct observation strategy (Standardized Observation Analogue Procedure, SOAP) was used in a large-scale randomized trial of parent training versus parent education in young children with autism spectrum disorder (ASD) and disruptive behavior. The 16-minute SOAP, modified from an earlier version of this same measure, included parentchild interaction to assess child behavior in a clinical laboratory setting. Despite study entry criteria for all child participants requiring moderate levels of disruptive behavior in this project, 126 of 168 children with complete SOAP data at baseline showed no disruptive behavior on this measure. Although the primary purpose of the study was to determine whether the SOAP could detect differences between the two conditions (i.e.,parent training (PT) and parent education (PE)), baseline observation data was not consistent with parent ratings at baseline or subsequent follow up visits, leaving little room to demonstrate improvement with this observation measure. This and the challenging, time-consuming and resource intensive effort involved in using such a measure in a large randomized scale trial, raises fundamental questions about the validity of the SOAP as an outcome measure in such a study. Further consideration related to the feasibility and practicality of using direct observation as a primary measure in larger scale efforts overall are also discussed.

A Technology-Enabled Adaptation of Face-to-Face Caregiver-Mediated JASPER Intervention: Preliminary Examination of Video Conferenced Caregiver Coaching

Family-centered practices that involve direct participation of caregivers as part of intervention is critical to effective early intervention. However, regularly scheduled, in person service delivery is not always possible in remote communities, prompting a need for adaptations to the delivery of services, such as the use of live video conferencing to coach caregivers in strategies to promote their children's development. In this study, caregivers and their children ages 2-9 with autism who were living in rural and remote Canadian communities were included. A concurrent multiple baseline design across participants was applied to examine the effects of live video conference caregiver coaching on children's time jointly engaged with caregivers and caregivers' intervention strategy implementation. Results indicated that all children demonstrated greater time jointly engaged and caregivers demonstrated greater use of strategies in comparison to baseline. The results of this study offer preliminary evidence of the effectiveness of real time video conference coaching for caregivers engaging their children with ASD in play.

Telehealth and Autism Prior to and in the Age of COVID-19: A Systematic and Critical Review of the Last Decade

There has been growing interest in the use of telehealth; however, the COVID-19 pandemic and the subsequent isolation and restrictions placed on in-person services have fast-tracked implementation needs for these services. Individuals with autism spectrum disorder (ASD) have been particularly affected due to the often-intensive service needs required by this population. As a result, the aim of this review was to examine the evidence base, methodology, and outcomes of studies that have used telehealth for assessment and/or intervention with children and adolescents with ASD as well as their families over the last decade. Further, the goal is to highlight the advances in telehealth and its use with this special population. A systematic search of the literature was undertaken, with 55 studies meeting inclusion criteria and quality analysis. Specified details were extracted from each article, including participant characteristics, technology, measures, methodology/study design, and clinical and implementation outcomes. Services provided via telehealth included diagnostic assessments, preference assessments, early intervention, applied behavior analysis (ABA), functional assessment and functional communication training, and parent training. Findings, although still emerging, encouragingly suggested that services via telehealth were equivalent or better to services face-to-face. Results support the benefits to using telehealth with individuals with ASD. Future research should continue to explore the feasibility of both assessments and interventions via telehealth with those having ASD to make access to assessment services and interventions more feasible for families, while acknowledging the digital divide it could create.

Meta-Analysis of RCTs of Technology-Assisted Parent-Mediated Interventions for Children with ASD

Technology-assisted parent-mediated interventions improve accessibility and are acceptable but not proven to be effective. We conducted a systematic search of 6 databases. We included and analysed results from studies on social and communication outcomes. Sixteen Randomised-Controlled-Trials (RCTs) with 748 participants were included. Most studies were rated as of good quality. Meta-analysis suggested that interventions were probably effective in improving emotion recognition. No significant differences were found in social communication, social functioning or language outcomes. At present, isolated tech interventions do not fulfil criteria for promising or established evidence-based interventions for ASD. Future research needs to focus on improving the effectiveness of technology-assisted parent-mediated interventions for ASD. Prospero Registration Number: CRD42020162825.

Parent Ratings of Generalized and Indirect Effects of Functional Communication Training for Children with Autism Spectrum Disorder

Functional communication training (FCT) is a behavioral treatment that has been shown to reduce problem behavior and increase appropriate communication in young children with autism spectrum disorder (ASD). In this study, we assessed the effects of FCT on targeted and nontargeted problem behaviors outside of the training context, as well as parent stress, for 30 young children with ASD and their parents. Indirect measures of generalization treatment effects were administered prior to and following FCT treatment delivered via telehealth. Children demonstrated significant improvement on both targeted (measured via observation) and nontargeted (measured via checklist) problem behaviors, both within and outside of the training context, and parent stress was significantly reduced following treatment. These results suggest that the impact of FCT may extend beyond the training context for both the children being treated and the parents delivering treatment, even when generalization is not specifically programmed for during treatment.

Looking at Europe's recent behavioral telehealth practices for children and families impacted by neurodevelopmental disabilities

There is a widespread lack of behavioral professionals available to support children and families affected by neurodevelopmental disabilities. As a result of limited availability, services that can be provided from a distance have developed. Telehealth is a modality that can increase access to services, lessen financial constraints, and support assessments of generalization. Using either synchronous or asynchronous components it can foster evaluation and coaching. Guidelines for usage have surfaced in North America and been integrated into the continent's existing model of behavioral care. However, in Europe where all modalities of behavioral services are fighting to receive funding, frameworks are scarce. Understanding more about telehealth in behavioral care, its various applications throughout Europe, and the local context into which it can be applicable may promote system growth. To support this cause, a scoping review of recent behavioral telehealth practices for children and families impacted by neurodevelopmental disabilities in Europe was undertaken; looking specifically to assess types of studies, their targets and outcomes, telehealth modality components, barriers, and directions for future work. Although few studies surfaced, valuable conclusions can be drawn about the model's empirical validation, creating a groundwork for sustainability, and the need for developing policy and standardized application.

An intensive telehealth assessment and treatment model for an adult with developmental disabilities

Over the last decade, the provision of applied behavior analysis (ABA) services within a telehealth delivery format has had a flourishing literature base. Research has demonstrated that caregivers can successfully conduct functional analyses and functional communication training to treat challenging behavior with coaching from practitioners via telehealth. Previous limitations include research that has only been conducted with children, typically in 1hr, weekly meetings, so the utility of providing ABA therapy via telehealth across the lifespan is unknown. Additionally, the effects of a more intensive treatment format delivered via telehealth has not been evaluated. The purpose of the current study was to coach caregivers to conduct the assessment and treatment process for a young man with developmental disabilities using an intensive-outpatient model in a telehealth format. Functional analysis procedures led to the development of a function-based treatment to reduce challenging behavior and increase functional communication. Caregivers demonstrated high procedural integrity across all phases of the study and found the intervention highly acceptable and effective. Areas for future research and directions are discussed.

The Telehealth Program for Kindergarten and Nursery Teachers in Charge of Children with Behavioral Problems

This study provided a telehealth program for kindergarten and nursery teachers in charge of children with, or suspected of having, developmental disabilities. We examined teacher participation, behavior intervention plans (BIP), practice, and improvement of children's behavior. Six sessions of online lectures and two online consultations based on functional behavioral assessments (FBA) were held. All ten teachers conducted the FBA, and seven created the BIP. Additionally, six out of seven teachers recorded their children's problem behaviors, showing improvement in the problem behavior of these children. Moreover, the non-targeted problem behaviors also showed improvement following the intervention.

Brief Report: Impact of COVID-19 on Individuals with ASD and Their Caregivers: A Perspective from the SPARK Cohort

The impact of the 2019 coronavirus pandemic (COVID-19) in the United States is unprecedented, with unknown implications for the autism community. We surveyed 3502 parents/caregivers of individuals with an autism spectrum disorder (ASD) enrolled in Simons Powering Autism Research for Knowledge (SPARK) and found that most individuals with ASD experienced significant, ongoing disruptions to therapies. While some services were adapted to telehealth format, most participants were not receiving such services at follow-up, and those who were reported minimal benefit. Children under age five had the most severely disrupted services and lowest reported benefit of telehealth adaptation. Caregivers also reported worsening ASD symptoms and moderate family distress. Strategies to support the ASD community should be immediately developed and implemented.

The effects of transition to technician-delivered telehealth ABA treatment during the COVID-19 crisis: A preliminary analysis

Telehealth delivery of applied behavior analysis treatment has focused on supervision or staff and parent training, rather than the direct delivery of treatment to clients. The novel coronavirus (COVID-19) crisis had the potential to significantly disrupt access to direct treatment for individuals with autism. We report a sample of 17 cases that transitioned from in-person to telehealth delivery of treatment when shelter-in-place orders were issued. Of these cases, 76% of participants transitioned to technician-delivered telehealth services whereas the rest transitioned to a caregiver-implemented telehealth model. Participants continued to access a similar dosage of treatment hours per week in spite of the treatment model transition (in-person M = 12; telehealth M = 11) and maintained or improved correct independent responding across all targets from in-person treatment (M = 75%) to telehealth treatment (M = 80%). These findings provide initial evidence that some clients with autism benefit from technician-delivered telehealth services.

Telehealth-enabled behavioral treatment for problem behaviors in boys with fragile X syndrome: a randomized controlled trial

Background

Children with fragile X syndrome (FXS) are at increased risk for exhibiting problem behaviors such as aggression and self-injury. However, many children with FXS have limited access to behavioral treatments that have known efficacy due to the low availability of treatment providers and the wide geographical dispersion of families with FXS across the country. Telehealth may offer a cost-effective and practical solution to overcome these significant barriers. We examined the effect of administering an established behavior analytic intervention called functional communication training (FCT) via telehealth on levels of problem behaviors exhibited by boys with FXS. We also examined treatment acceptability, as well as the effect of the treatment on levels of parenting stress.

Methods

Boys with FXS, aged 3 to 10 years, who displayed problem behaviors daily, were randomized to receive FCT via telehealth (n = 30) or treatment as usual (n = 27) over 12 weeks. Outcome measures included in-session observations of problem behavior, the Aberrant Behavior Checklist—Community (ABC-C), the Treatment Acceptability Rating Form—Revised (TARF-R), and the Parenting Stress Index, 4th edition (PSI-4).

Results

Intention-to-treat analyses indicated that scores on the irritability subscale of the ABC-C, our primary outcome measure, decreased significantly for boys who received FCT via telehealth compared to boys who received treatment as usual (p < .001, Cohen’s d = 0.65). In-session observations conducted for those who received treatment showed that levels of problem behavior decreased by 91% from baseline. Levels of parenting stress related to child behavioral problems were also lower following FCT treatment, and caregivers reported that the intervention was acceptable.

Conclusions

These findings support telehealth-enabled FCT as a framework for expanding access to behavioral treatments for problem behaviors in children with FXS. Expanded delivery of behavior analytic treatment via telehealth also has the potential to lower healthcare costs, improve child and family quality of life, and lead to advances in the treatment of problem behavior in the broader population of individuals with neurodevelopmental disorders.

Trial registration

ClinicalTrials.gov, NCT03510156. Registered 27 April 2018

Coping, fostering resilience, and driving care innovation for autistic people and their families during the COVID-19 pandemic and beyond

The new coronavirus disease (COVID-19) pandemic is changing how society operates. Environmental changes, disrupted routines, and reduced access to services and social networks will have a unique impact on autistic individuals and their families and will contribute to significant deterioration in some. Access to support is crucial to address vulnerability factors, guide adjustments in home environments, and apply mitigation strategies to improve coping. The current crisis highlights that our regular care systems are not sufficient to meet the needs of the autism communities. In many parts of the world, people have shifted to online school and increased use of remote delivery of healthcare and autism supports. Access to these services needs to be increased to mitigate the negative impact of COVID-19 and future epidemics/pandemics. The rapid expansion in the use of telehealth platforms can have a positive impact on both care and research. It can help to address key priorities for the autism communities including long waitlists for assessment and care, access to services in remote locations, and restricted hours of service. However, system-level changes are urgently needed to ensure equitable access and flexible care models, especially for families and individuals who are socioeconomically disadvantaged. COVID-19 mandates the use of technology to support a broader range of care options and better meet the diverse needs of autistic people and their families. It behooves us to use this crisis as an opportunity to foster resilience not only for a given individual or their family, but also the system: to drive enduring and autism-friendly changes in healthcare, social systems, and the broader socio-ecological contexts.