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1 Telehealth and Autism: Treating Challenging Behavior at Lower Cost Sott Lindgren, PhD, a,b David Waker, PhD, a,b Alyssa Suess, PhD, a,b Kelly Shieltz, PhD, Kelly Pelzel, PhD, b Todd Kopelman, PhD, d John Lee, BA, b Patrik Romani, PhD, e Debra Waldron, MD a OBJECTIVE: To determine whether hallenging behavior in young hildren with autism and other developmental disabilities an be treated suessfully at lower ost by using telehealth to train parents to implement applied behavior analysis (ABA). METHODS: We ompared data on the outomes and osts for implementing evidene-based ABA proedures to redue problem behavior by using 3 servie delivery models: in-home therapy, lini-based telehealth, and home-based telehealth. Partiipants were 107 young hildren diagnosed with autism or other neurodevelopmental disorders, and data analysis foused on the 94 hildren who ompleted treatment. RESULTS: All 3 servie delivery models demonstrated suessful redution of problem behavior by training parents to ondut funtional analysis and funtional ommuniation training. The mean perentage redution in problem behavior was >90% in all 3 groups after treatment, and treatment aeptability based on parent ratings was high for all groups. Total osts for implementing treatment were lowest for home telehealth, but both telehealth models were signifiantly less ostly than in-home therapy. CONCLUSIONS: This researh demonstrated that parents an use ABA proedures to suessfully treat behavior problems assoiated with autism spetrum disorders regardless of whether treatment is direted by behavior onsultants in person or via remote video oahing. Beause ABA telehealth an ahieve similar outomes at lower ost ompared with in-home therapy, geographi barriers to providing aess to ABA for treating problem behavior an be minimized. These findings support the potential for using telehealth to provide researhbased behavioral treatment to any family that has aess to the Internet. abstrat NIH a Stead Family Department of Pediatris, University of Iowa Carver College of Mediine; d Department of Psyhiatry, University of Iowa Carver College of Mediine, Iowa City, Iowa; b Center for Disabilities and Development, University of Iowa Children s Hospital, Iowa City, Iowa; College of Eduation, University of Missouri, Columbia, Missouri; e Munroe Meyer Institute, University of Nebraska Medial Center, Omaha, Nebraska Drs Lindgren and Waker oneptualized and designed the study, oversaw data olletion, analysis, and interpretation, and drafted the initial manusript; Drs Suess and Shieltz ontributed to the data olletion and analysis and reviewed and revised drafts of the manusript; Drs Pelzel and Kopelman ontributed to the design of the study, oordinated study implementation and data olletion, ontributed to data analysis and interpretation, and reviewed and revised drafts of the manusript; Mr Lee and Dr Romani ontributed to data olletion and analysis and reviewed drafts of the manusript; Dr Waldron ontributed to the design of the study, supervised staff providing support to families during study implementation and data olletion at regional linis, and provided ritial review of the manusript; and all authors approved the final manusript as submitted. DOI: /peds O Aepted for publiation Nov 9, 2015 Address orrespondene to Sott Lindgren, PhD, University of Iowa Children s Hospital, 100 Hawkins Dr, 341A CDD, Iowa City, IA sott-lindgren@uiowa. edu PEDIATRICS (ISSN Numbers: Print, ; Online, ). To ite: Lindgren S, Waker D, Suess A, et al. Telehealth and Autism: Treating Challenging Behavior at Lower Cost. Pediatris. 2016;137(S2):e O PEDIATRICS Volume 137, Number S2, February 2016 :e SUPPLEMENT ARTICLE

2 Applied behavior analysis (ABA) is the most widely researhed intervention for autism spetrum disorder (ASD), and the majority of evidene-based treatments for ASD use ABA strategies (eg, reinforement, extintion). 1 ABAbased interventions for ASD have typially foused on either (a) skill aquisition through ore ABA strategies (eg, disrete trial training, 2 pivotal response training 3 ), often performed within a developmental framework (eg, Early Start Denver Model 4 ), or (b) treatment of linially signifiant behavior. 5 Among ABA methods for treating problem behavior in ASDs, funtional ommuniation training (FCT) 6 is the most widely used, and previous researh has demonstrated that FCT an effetively treat many types of behavior problems aross a variety of settings. 7 FCT begins with a funtional analysis (FA) 8 to identify the funtion that maintains hallenging behavior for eah hild. 9 Typial soial funtions inlude esape (avoiding a nonpreferred ativity), attention (gaining attention from an adult or peer), and tangible (obtaining a desired objet or ativity). After the funtion of a problem behavior has been identified, hildren are taught to use alternative ommuniation strategies that serve the same funtion as the problem behavior. 10 By replaing a hild s problem behavior with appropriate soial ommuniation, FCT an help a hild adapt to the demands of daily life. The urrent study ompared the outomes and osts assoiated with 3 different models for delivery of FA and FCT to treat problem behavior in young hildren with ASD and other developmental disabilities (DDs). In all 3 models, parents were oahed by behavior onsultants to ondut FA and FCT during weekly sessions. Waker et al 5 demonstrated that weekly oahing for parents an identify the soial funtions of problem behavior and replae these behaviors with alternative ommuniation In the initial studies in this series, 12,13 behavior onsultants traveled to family homes weekly to oah parents in onduting FA and FCT. The same strategies have subsequently been tested via telehealth, initially by having families travel to outpatient linis near their homes 5,11 and later by providing telehealth oahing to parents in their own homes. 14 The purpose of the urrent study was to ompare the behavioral outomes, osts, and family aeptane of in-home telehealth with the results obtained when onsultants oahed parents in person at home or via telehealth at regional linis. If these 3 models for delivering FA and FCT an ahieve omparable behavioral outomes, then treatment an be seleted based on ost, provider availability, or family preferene. METHODS Partiipants Children Partiipants were 107 hildren with ASD or other DD (ages months; mean age = months) who were treated between 1996 and 2014 for problem behavior. Group 1 inluded hildren with ASD (n = 16) or other DD (n = 36) who were treated in their homes by behavior onsultants between 1996 and The onsultants trained the hild s parents to ondut FA and FCT to replae problem behavior with appropriate soial ommuniation. Group 2 inluded hildren with onfirmed ASD (n = 23) who were treated in 2009 to 2012 as part of a study to train parents to ondut FA and FCT when oahed via telehealth at a regional lini near their home. Group 3 inluded hildren with ASD (n = 32) who were treated in 2012 to 2014 as part of a randomized ontrolled trial of FCT treatment onduted by parents who reeived telehealth oahing at home. This trial is ongoing, and all hildren enrolled in the trial eventually reeive FCT treatment. Children whose problem behavior served a soial funtion as identified by FA were referred for treatment with FCT. Only hildren who ompleted FA and were started in FCT were inluded in the urrent analysis. Information on a subsample of hildren from group 1 was reported previously by Waker et al. 12 Waker et al 5,11 reported seleted data from 20 of the partiipants from group 2, and Suess et al 14 desribed treatment fidelity data from the first 3 partiipants in group 3. Among the 107 hildren who started FCT in these 3 groups, 8 disontinued treatment in group 1 (3 with ASD, 5 with other DD), 3 disontinued treatment in group 2, and 2 disontinued treatment in group 3. Rates of treatment ompletion did not differ signifiantly aross groups. Parents Children s parents (or grandparents) onduted all FA and FCT sessions with oahing from trained behavior onsultants. Parent data were available only for groups 2 and 3. Parent ages ranged from 23 to 51 years; eduational levels ranged from grade 11 to a dotorate. Behavior Consultants Behavior onsultants were experiened behavior analysts or advaned graduate students with 2 years of experiene in behavior analysis. Eah week, they reviewed data from FA and FCT sessions with a supervising dotoral-level behavioral psyhologist. Family navigators from Iowa s Child Health Speialty Clini network assisted families in the Clini Telehealth group, as desribed in Waker et al. 5,11 S168 LINDGREN et al

3 Proedures Diagnosti Assessment Researh proedures for the protetion of human subjets were approved by the University of Iowa Institutional Review Board. Only hildren with signifiant behavior problems (aggression, destrution, tantrums, self-injury) were referred for these studies, and this referral proess was onsistent over time. Diagnoses for partiipants reeiving in-home ABA therapy in group 1 were determined by review of medial reords and interviews with parents or aregivers. For both groups reeiving telehealth, a diagnosis of ASD was onfirmed with the Autism Diagnosti Interview Revised, 15 Autism Diagnosti Observation Shedule, 16 and Diagnosti and Statistial Manual of Mental Disorders, Fourth Edition. 17 In group 1, 30% of partiipants had an ASD diagnosis, whereas 100% of hildren in groups 2 and 3 were diagnosed with ASD. Intelletual disability (ID) was determined based on lini reords for group 1 and standardized assessments of development and adaptive skills for groups 2 and 3. 5,14 Funtional Analysis For all 3 study groups, parents were taught to ondut FA within a multielement single-ase design based on proedures desribed by Iwata et al. 8 FA sessions were 5 minutes in duration and were reorded for later oding by independent data olletors; typially 3 to 5 sessions were ompleted during eah 60-minute home or telehealth visit. All FA sessions were onduted by the parents with oahing from the behavior onsultant aording to proedures desribed in Harding et al. 18 Funtional Communiation Training Eah weekly treatment visit lasted ~60 minutes; individual sessions during eah visit were 5 minutes in duration and were reorded for later data oding. A word/piture ard or miroswith with voie output was paired with any preexisting mand (appropriate request) to assist hildren in overoming ommuniation diffiulties. Requests were reinfored, and engagement in problem behavior was ignored (plaed on extintion) or resulted in guided ompliane. Treatment was individualized based on the results of the FA. For example, if the FA showed that problem behavior funtioned to esape demands, then FCT involved teahing the hild to appropriately request breaks after ompliane. A small amount of developmentally appropriate work was plaed in front of the hild. When the task was ompleted, a word ard or miroswith was plaed in front of the hild, and the hild was prompted to request a break. Break ativities were mathed to a preferene assessment. 19 Problem behavior resulted in ontinuation of the task or re-presentation of the task if it ourred during a break. Parents were direted to pratie FCT proedures for 10 to 15 minutes daily at home. At the ompletion of FCT, parents used a 7-point sale to rate the aeptability of treatment by using the first item on the Treatment Aeptability Rating Form Revised. 20 Treatment ontinued for 25 weeks or until problem behavior dereased by 80% from baseline over 3 onseutive FCT sessions, the hild omplied with 80% of task requests, and the hild made requests independently at appropriate times. Thirteen hildren who started treatment did not ontinue in treatment long enough to reah these riteria. In group 1, 5 hildren disontinued treatment beause of hanges in parent work shedules that preluded ontinued treatment; 3 hildren moved to a different loality and did not maintain ontat with the study. In group 2, 1 family determined that problem behavior was no longer a serious onern at home, 1 hild moved to a different loality not served by the study, and 1 hild disontinued beause the parents wanted to fous on verbal ommuniation without using piture ards or miroswithes. In group 3, 1 hild moved out of state and did not maintain ontat with the study, and 1 hild ould not be managed by parents at home and was referred for out-of-home residential plaement. Settings and Equipment Homes Parents onduted sessions in rooms within their homes (eg, bedroom, living room) for groups 1 and 3. For group 1, onsultants brought video reording equipment on eah visit. For group 3, parents were given a Windows-based laptop, webam, and Ethernet able at the time of enrollment if they did not already own the neessary equipment (see Lee et al 21 ). Internet servie was also provided to families if needed. For groups 1 and 3, leisure ativities and work materials available in the home were used during FA and FCT. Behavior onsultants provided families with miroswithes and piture ards for FCT. Telehealth Center For groups 2 and 3, onsultants provided remote oahing from the telehealth enter at the University of Iowa Children s Hospital. 5,11 Telehealth workstations were equipped with a Windows-based PC, video monitor, webam, and headset. 21 For group 2, existing videoonferening software was used at the hospital site. 5,11 This software allowed the onsultant to reord the telehealth sessions for subsequent data olletion. For group 3, parent permission was obtained to use general-use videoonferening software (ie, Skype), and no privay issues were enountered during the study. Regional Clinis Parents onduted sessions at regional linis for group 2. Eah PEDIATRICS Volume 137, number S2, February 2016 S169

4 lini site had aess to high-speed Internet and videoonferening software. 5,11 Parent assistants managed the equipment at the lini sites. The behavior onsultants provided parents in group 2 with leisure ativities, miroswithes, and piture ards to use in the lini. Data Analysis Single-Subjet Analyses Data for all partiipants were obtained within single-subjet designs, and observation sessions were reorded for eah FA and FCT visit. Eah 5-minute session was divided into 50 6-seond intervals, and problem behavior was oded if present in eah interval. 5,11 Interobserver agreement was obtained for 30% of sessions and averaged >95% agreement. The perentage redution in problem behavior was determined by omparing the number of 6-seond intervals that inluded problem behavior at baseline with the end of FCT. Similar data on inreases in manding and task ompletion were available only for groups 2 and 3. Comparisons Between Treatment Delivery Models The treatment groups were ompared with analysis of variane (ANOVA) for ontinuous variables and χ 2 or Fisher s exat test (to adjust for small ell sizes) for ategorial variables. When the ANOVA was signifiant, post ho testing with the Tukey honest signifiant differene test determined whih groups differed signifiantly. Although the sample size in eah treatment group was limited by the number of hildren reeiving eah treatment, the study had 80% power to detet a between-group differene of 9 perentage points on the primary outome variable (ie, perentage redution in problem behavior). In estimating osts for implementing FA and FCT proedures, staff osts, faility osts, and family osts were examined separately (in 2014 dollars) and estimated for linial use when grant funds were not available to over expenses. Staff osts inluded salaries and benefits for behavior onsultants ($30 per hour, 1.75 hours per hild per week), dotoral-level psyhologists ($50 per hour, 0.25 hours per hild per week), family navigators ($22 per hour, 1.5 hours per hild per week), and data oders ($20 per hour, 1 hour per hild per week). Consultant mileage ($0.56 per mile) for travel to family homes was also inluded. Faility osts inluded annual expenses for room spae (with utilities and maintenane) of $25 per square foot. The use of rooms was alloated using a per-hour rate (assuming a 40-hour week) derived from the annual ost rate for a teleonferening room of 100 square feet, an offie area (with onferene table and data oding desk) of 200 square feet, and a large regional lini room of 200 square feet. Computer osts were estimated by determining hourly osts based on annual expenses for omputer purhase and maintenane. These osts inluded $0.96 per hour for teleonferening omputers (with webam, monitor, and software) at the hospital and the regional linis, $0.72 per hour for use of a omputer for data oding and graphing, and $0.58 per hour for a laptop omputer for a traveling onsultant to reord sessions during home visits. Family osts were alulated based on the use of a general purpose omputer (with webam and software) that would be used for FA and FCT 5 hours per week. Costs would inlude a omputer ($2.90 per week) and Internet ($2.00 per week) for group 3 or travel to a regional lini ($0.235 per mile) for group 2. The ost of parent time was estimated at the 2014 US average TABLE 1 Partiipant Charateristis for Children Who Reeived FA and FCT Treatment via Different Servie Delivery Models Variables Group 1: In-Home Therapy, (n = 44) Group 2: Clini Telehealth, (n = 20) Group 3: Home Telehealth, (n = 30) Age: mean (SD), mo (15.44) (15.53) (17.45).491 Range, mo Gender 13 F, 31 M 1 F, 19 M 5 F, 25 M.060 Primary diagnosis, n (%) ASD 13 (30%) a 20 (100%) b 30 (100%) b <.001 Other DD 31 (70%) 0 (0%) 0 (0%) ID, n (%) 42 (95%) a 10 (50%) b 15 (50%) b <.001 Distane from Children s Hospital Mean (SD), miles (40.33) a (95.25) b (77.85) d <.001 Range, miles Soial funtion identified, n (%) e Esape 36 (82%) 13 (65%) 17 (57%).056 Tangible 33 (75%) a 16 (80%) ab 29 (97%) b.035 Attention 19 (43%) a 2 (10%) b 3 (10%) b.001 F, female; M, male. a When there were signifiant between-group differenes, groups with the same supersript in the same row did not differ from eah other. b When there were signifiant between-group differenes, groups with the same supersript in the same row did not differ from eah other. Signifiant differenes were based on ANOVA for ontinuous variables and χ 2 (or Fisher s exat test for small ell sizes) for ategorial variables. d When there were signifiant between-group differenes, groups with the same supersript in the same row did not differ from eah other. e Children often had >1 soial funtion. P S170 LINDGREN et al

5 hourly wage ($24.63 per hour 22 ), with time in session of 1 hour per week and pratie time of 1 hour per week for all groups, plus travel time of 0.75 mile per minute for group 2. Also, $100 was needed for eah family to over the ost of miroswithes and piture ards during treatment. RESULTS Partiipant Charateristis Table 1 lists harateristis of the partiipants who ompleted treatment in eah of the 3 groups. The hildren did not differ in age between groups, averaging 48 to 52 months of age at the beginning of treatment. ASD was the primary diagnosis for all hildren in groups 2 and 3 and for 30% of the hildren in group 1. Intelletual disability was present in most hildren in group 1 and half of the hildren in groups 2 and 3. All 3 groups inluded more boys than girls, espeially the groups with only partiipants with ASD. As expeted, hildren in group 1 lived loser to the Children s Hospital than those in either telehealth group. All partiipants showed 1 soial funtion, and most had >1. The frequeny of an attention funtion was espeially low in the groups restrited to hildren with ASD. Behavioral Outomes The mean perentage redution in problem behavior ahieved through FCT treatment was >90% for all groups and not signifiantly different between the 3 servie models (Table 2). However, the models that delivered servies in the home showed slightly greater redutions in problem behavior ompared with treatment at the regional linis, possibly related to more diffiulty generalizing treatment effets from lini to home. These differenes might have reahed statistial signifiane if this pattern were maintained in larger samples with greater power to detet small differenes in outome. Both manding and task ompletion improved in groups 2 and 3, but the groups did not differ and omparable data were not available for group 1. Parent ratings of treatment aeptability were onsistently high and did not differ aross groups. The number of weekly visits needed to omplete FA was similar aross treatment groups, but group 1 needed a greater number of FCT visits ompared with groups 2 and 3. This differene may have been aused by greater distrations during home visits, more extended testing of methods for maximizing treatment gains in group 1, or greater effiieny in ahieving behavior targets in the more reent studies. Treatment Costs Based on analysis of the proedures and settings involved in providing FA and FCT under the 3 servie models, we alulated the staff osts, faility osts, and family osts needed to implement these treatments. Figure 1 shows the relative expenses that ontributed to the ost per hild per week. Table 3 summarizes the total ost to omplete FA and FCT under these delivery systems. Costs were based on the number of weekly visits needed to omplete FA and FCT multiplied by the osts per hild per week in eah of the 3 models. Home telehealth was the least expensive model overall, though not signifiantly lower than lini telehealth, primarily TABLE 2 Behavioral Outomes and Aeptane by Parents of FA and FCT Treatment via Different Servie Delivery Models Variables Group 1: In-Home Therapy (n = 44) Perentage redution in problem behavior Group 2: Clini Telehealth (n = 20) Group 3: Home Telehealth (n = 30) Mean (SD) 95.76% (8.91) 91.00% (13.66) 97.27% (6.00).074 Range 59.07% 100% 47.40% 100% 77.01% 100% Perentage inrease in N/A mands (appropriate requests).832 Mean (SD) 78.42% (25.53) 76.67% (27.48) Range 20.5% 100% 13.3% 100% Perentage inrease in N/A task ompletion Mean (SD) 51.53% (30.89) 61.15% (34.81).301 Range 13% 100% 0.6% 100% FA weekly visits Mean (SD) 4.52 (1.57) 5.30 (1.49) 4.90 (1.92) Range FCT treatment weekly visits Mean (SD) (7.99) a 9.05 (3.58) b 9.10 (5.37) b Range <.001 Aeptability ratings (Treatment Aeptability Rating Form Revised; 1 7 sale) Mean (SD) 6.55 (0.68) 6.53 (0.61) 6.25 (0.91).457 Range ASD diagnosis was onfounded with group, but a separate ANOVA based on only subjets with ASD produed similar results to the ANOVA based on the full sample. a When there were signifiant between-group differenes, groups with the same supersript in the same row did not differ from eah other. b When there were signifiant between-group differenes, groups with the same supersript in the same row did not differ from eah other. Signifiant differenes were based on ANOVAs; main effets for group are presented beause there were no signifiant group ID interations. P PEDIATRICS Volume 137, number S2, February 2016 S171

6 beause of elimination of staff or parent travel expenses and the osts for the family navigator and additional failities at the regional linis. The slightly higher family osts in either of the telehealth models (ompared with in-home therapy) were still small and were offset by more effiient use of expensive professional time in the telehealth models. DISCUSSION This researh demonstrates that parents an suessfully use FA and FCT to treat moderate to severe behavior problems assoiated with ASD regardless of whether treatment is direted by behavior onsultants in person or via remote video oahing. The results showed no statistially or linially signifiant differenes in behavioral outomes that ould be attributed to the servie delivery methods. Treatment aeptability based on parent ratings was very high for all 3 groups, and disontinuation of treatment was infrequent for families in all groups. Overall osts for implementing treatment were lowest for home telehealth, but both telehealth models were signifiantly less ostly than in-home therapy. The urrent analyses foused only on diret treatment osts expended by lini staff, treatment failities, and families, without fatoring in soietal osts. The lini telehealth model inluded salary osts for the family navigators at the regional linis and family travel osts, whereas osts for behavioral onsultants, supervising psyhologists, and data oders remained the same aross models. For the in-home onsultants in the earlier studies, transportation osts (inluding mileage and salaries during trips) were substantial, and these osts made the in-home therapy model signifiantly more expensive than the telehealth models. In terms of family osts, additional equipment and Internet osts were inluded for in-home FIGURE 1 Average weekly FA and FCT treatment osts per hild. telehealth, although these expenses were overed by grant funds in the urrent study. Beause time devoted to treatment by individual parents was not traked, family ost analyses assumed similar time investments for parents in all groups. Although ost analyses for the lini sites inluded expenses for equipment, existing teleonferening equipment was used in the urrent researh. The findings reported by Suess et al 14 demonstrated that parents are able to implement ABA proedures with aeptable fidelity even when a oah is not diretly supervising them. Conerns an be raised about whether weekly ABA oahing sessions are frequent enough to produe optimal behavioral outomes in hildren with ASD, but when parents are taught to use FCT strategies daily with their hildren, the intensity of treatment is atually >1 hour per week. This point has been emphasized in other ASD researh supporting a similar intensity of diret intervention, 23 but we were not able to obtain detailed reords from families regarding S172 LINDGREN et al

7 TABLE 3 Costs of Treatment With FA and FCT When Delivered via Different Servie Models Variables Group 1: In-Home Therapy (n = 44) treatment pratie time ourring outside of telehealth sessions. Potential limitations must be reognized when onsidering the findings from this study. Enrollment riteria were not idential in seleting partiipants, the groups were not randomly assigned, and an untreated ontrol group was not inluded to test these servie models. Although both of the telehealth models used gold standard diagnosti proedures to identify partiipants with ASD, the earlier in-home researh was not limited to ASD. All 3 programs inluded hildren with signifiant behavior problems, but we did not use a fixed utoff sore on a measure of behavioral severity as an inlusion riterion. Intelletual abilities of hildren in the studies ranged from severe ID to above-average ability, and no IQ-based exlusion riteria were used. Although the proportion of hildren with ID was higher in group 1 than in groups 2 and 3, FCT was generally suessful aross IQ ranges, and behavioral outomes were not signifiantly different between groups. Beause the 3 treatment models were not implemented at the same time, it is possible that available servies ould have hanged over time. Group 2: Clini Telehealth (n = 20) Also, additional servies may have been available for group 1 given the proximity to the Children s Hospital. However, the fat that all 3 models ahieved similar positive outomes indiates that any differenes in servies or personnel did not prevent the treatment from ahieving targeted goals for most hildren. Of ourse, it is ritial to reognize that treatment of problem behavior is not suffiient on its own to meet the needs of hildren with ASD, who still need other health are and eduational servies. However, effetive treatment of hallenging behavior an remove a signifiant barrier to benefiting from therapies and skill aquisition programming. CONCLUSIONS Group 3: Home Telehealth (n = 30) Staff osts Mean $ a $ b $ b <.001 (SD) ( ) (371.72) (519.20) Faility osts Mean $99.04 a $ b $97.44 a <.001 (SD) (38.02) (37.80) (42.51) Family osts Mean $ a $ a $ b.002 (SD) (446.46) (264.08) (374.43) Total ost Mean total ost per hild $ a $ b $ b <.001 to omplete treatment (SD) ( ) (673.60) (936.15) Sensitivity analyses based on 25% 50% higher or lower estimates of staff, faility, and family osts produed hanges in total osts for eah treatment, but the pattern of relative osts between groups remained similar. a When there were signifiant between-group differenes, groups with the same supersript in the same row did not differ from eah other. b When there were signifiant between-group differenes, groups with the same supersript in the same row did not differ from eah other. Signifiant differenes were based on ANOVA. This study represents an important step in evaluating the osts and effiieny of alternative models for delivering ABA treatment of hallenging behavior. These findings highlight the importane of studying fators that influene the implementation and sustainability of different methods for delivering are in real-world settings. 24 By reduing the ost of ABA treatment by nearly P half through lini-based telehealth and by almost two-thirds through home telehealth, these strategies fulfill the health are triple aim of enhaning are experienes, improving population health, and reduing osts of are. 25 Beause telehealth an provide researh-based ABA treatment to any family with aess to the Internet, barriers to providing aess to ABA an be redued, espeially for rural and underserved families. There is a rapidly growing literature on the use of telehealth to deliver a range of ASD interventions, and future issues regarding the delivery of ABA servies via telehealth will need to fous on when to provide servies and at what intensity to deliver them in relation to other interventions. These timing and dose issues warrant areful study, as will issues suh as the effets of ABA treatment on aregiver stress and parenting and the best ways to ensure generalization of hildren s and parents newly learned skills. The results of these studies are ruial for informing future deisions about the optimal use of telehealth in delivering ABA servies for hildren with autism. ACKNOWLEDGMENTS We thank the researh assistants and the staff of the University of Iowa Child Health Speialty Clinis for their invaluable ontributions to these studies. We appreiate the assistane of Bridget Zimmerman and George Wehby with seleted aspets of the data analysis. We are espeially grateful to all of the families who have shared their lives with us. ABBREVIATIONS ABA: applied behavior analysis ANOVA: analysis of variane ASD: autism spetrum disorder DD: developmental disability FA: funtional analysis FCT: funtional ommuniation training ID: intelletual disability PEDIATRICS Volume 137, number S2, February 2016 S173

8 Copyright 2016 by the Amerian Aademy of Pediatris FINANCIAL DISCLOSURE: The authors have indiated they have no finanial relationships relevant to this artile to dislose. FUNDING: Supported by grants R40 MC22644 from the Maternal and Child Health Bureau of the Health Resoures and Servies Administration, R01 MH89607 from the National Institute of Mental Health of the National Institutes of Health, and R01 HD from the National Institute of Child Health and Human Development of the National Institutes of Health. The authors have no other finanial relationships relevant to this researh to dislose. Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: The authors have indiated they have no potential onflits of interest to dislose. REFERENCES 1. Wong C, Odom SL, Hume K, et al. Evidene-Based Praties for Children, Youth, and Young Adults With Autism Spetrum Disorder. Chapel Hill, NC: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidene-Based Pratie Review Group; Lovaas OI. Behavioral treatment and normal eduational and intelletual funtioning in young autisti hildren. J Consult Clin Psyhol. 1987;55(1): Koegel RL, Koegel LK. Generalized responsivity and pivotal behavior. In: Horner R, Koegel R, Dunlap G, eds. Generalization and Maintenane: Lifestyle Changes in Applied Settings. Baltimore, MD: Paul H. Brookes; Dawson G, Rogers S, Munson J, et al. Randomized, ontrolled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatris. 2010;125(1). Available at: 125/1/e17 5. Waker DP, Lee JF, Padilla Dalmau YC, et al. Conduting funtional ommuniation training via telehealth to redue the problem behavior of young hildren with autism. J Dev Phys Disabil. 2013;25(1): Carr EG, Durand VM. Reduing behavior problems through funtional ommuniation training. J Appl Behav Anal. 1985;18(2): Tiger JH, Hanley GP, Bruzek J. Funtional ommuniation training: a review and pratial guide. Behav Anal Prat. 2008;1(1): Iwata BA, Dorsey MF, Slifer KJ, Bauman KE, Rihman GS. Toward a funtional analysis of self-injury. J Appl Behav Anal. 1994;27(2): Durand VM, Carr EG. Self-injurious behavior: motivating onditions and guidelines for treatment. Shool Psyh Rev. 1985;14: Carr EG. Funtional equivalene as a mehanism of response generalization. In: Horner R, Koegel R, Dunlap G, eds. Generalization and Maintenane: Lifestyle Changes in Applied Settings. Baltimore, MD: Paul H. Brookes; Waker DP, Lee JF, Dalmau YC, et al. Conduting funtional analyses of problem behavior via telehealth. J Appl Behav Anal. 2013;46(1): Waker DP, Harding JW, Berg WK, et al. An evaluation of persistene of treatment effets during long-term treatment of destrutive behavior. J Exp Anal Behav. 2011;96(2): Waker DP, Berg WK, Harding JW, Derby KM, Asmus JM, Healy A. Evaluation and long-term treatment of aberrant behavior displayed by young hildren with disabilities. J Dev Behav Pediatr. 1998;19(4): Suess AN, Romani PW, Waker DP, et al. Evaluating the treatment fidelity of parents who ondut in-home funtional ommuniation training with oahing via telehealth. J Behav Edu. 2014;23: Rutter M, Le Couteur A, Lord C. ADI-R: Autism Diagnosti Interview Revised (ADI-R). Los Angeles, CA: Western Psyhologial Servies; Lord C, Rutter M, DiLavore P, Risi S. Autism Diagnosti Observation Shedule (ADOS) Manual. Los Angeles, CA: Western Psyhologial Servies; Amerian Psyhiatri Assoiation. Diagnosti and Statistial Manual of Mental Disorders. 4th ed. Washington, DC: Amerian Psyhiatri Assoiation; Harding JW, Waker DP, Berg WK, Lee JF, Dolezal D. Conduting funtional ommuniation training in home settings: a ase study and reommendations for pratitioners. Behav Anal Prat. 2009;2(1): Roane HS, Vollmer TR, Ringdahl JE, Marus BA. Evaluation of a brief stimulus preferene assessment. J Appl Behav Anal. 1998;31(4): Reimers T, Waker D, Cooper L. Evaluation of the aeptability of treatments for hildren s behavioral diffiulties: ratings by parents reeiving servies in an outpatient lini. Child Fam Behav Ther. 1991;13(2): Lee JF, Shieltz KM, Suess AN, et al. Guidelines for developing telehealth servies and troubleshooting problems with telehealth tehnology when oahing parents to ondut funtional analyses and funtional ommuniation training in their homes. Behav Anal Prat /s Bureau of Labor Statistis. Table B-3: average hourly and weekly earnings of all employees. Deember US Department of Labor. Available at: esbtab3. htm. Aessed February 15, Vismara LA, Colombi C, Rogers SJ. Can one hour per week of therapy lead to lasting hanges in young hildren with autism? Autism. 2009;13(1): Protor E, Silmere H, Raghavan R, et al. Outomes for implementation researh: oneptual distintions, S174 LINDGREN et al

9 measurement hallenges, and researh agenda. Adm Poliy Ment Health. 2011;38(2): Berwik DM, Nolan TW, Whittington J. The triple aim: are, health, and ost. Health Aff (Millwood). 2008;27(3): Vismara LA, Young GS, Stahmer AC, Griffith EM, Rogers SJ. Dissemination of evidene-based pratie: an we train therapists from a distane? J Autism Dev Disord. 2009;39(12): Vismara LA, Young GS, Rogers SJ. Telehealth for expanding the reah of early autism training to parents. Autism Res Treat. 2012;2012: Wainer AL, Ingersoll BR. Inreasing aess to an ASD imitation intervention via a telehealth parent training program. J Autism Dev Disord. 2015;45(12): Mahaliek W, O Reilly MF, Rispoli M, et al. Training teahers to assess the hallenging behaviors of students with autism using video tele-onferening. Edu Train Autism Dev Disabil. 2010;45(2): Heitzman-Powell LS, Buzhardt J, Rusinko L, Miller T. Formative evaluation of an ABA outreah program for parents of hildren with autism in remote areas. Fous Autism Other Dev Disabil. 2013;20:1 16 PEDIATRICS Volume 137, number S2, February 2016 S175

10 Telehealth and Autism: Treating Challenging Behavior at Lower Cost Sott Lindgren, David Waker, Alyssa Suess, Kelly Shieltz, Kelly Pelzel, Todd Kopelman, John Lee, Patrik Romani and Debra Waldron Pediatris 2016;137;S167 DOI: /peds O Updated Information & Servies Referenes Permissions & Liensing Reprints inluding high resolution figures, an be found at: /ontent/137/supplement_2/s167.full.html This artile ites 23 artiles, 3 of whih an be aessed free at: /ontent/137/supplement_2/s167.full.html#ref-list-1 Information about reproduing this artile in parts (figures, tables) or in its entirety an be found online at: /site/mis/permissions.xhtml Information about ordering reprints an be found online: /site/mis/reprints.xhtml PEDIATRICS is the offiial journal of the Amerian Aademy of Pediatris. A monthly publiation, it has been published ontinuously sine PEDIATRICS is owned, published, and trademarked by the Amerian Aademy of Pediatris, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2016 by the Amerian Aademy of Pediatris. All rights reserved. Print ISSN: Online ISSN:

11 Telehealth and Autism: Treating Challenging Behavior at Lower Cost Sott Lindgren, David Waker, Alyssa Suess, Kelly Shieltz, Kelly Pelzel, Todd Kopelman, John Lee, Patrik Romani and Debra Waldron Pediatris 2016;137;S167 DOI: /peds O The online version of this artile, along with updated information and servies, is loated on the World Wide Web at: /ontent/137/supplement_2/s167.full.html PEDIATRICS is the offiial journal of the Amerian Aademy of Pediatris. A monthly publiation, it has been published ontinuously sine PEDIATRICS is owned, published, and trademarked by the Amerian Aademy of Pediatris, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2016 by the Amerian Aademy of Pediatris. All rights reserved. Print ISSN: Online ISSN: