Evaluation of a Telehealth Training Package to Remotely Teach Caregivers to Conduct Discrete-Trial Instruction

Method

Response Measurement and Interobserver Agreement

Tact-training task

Caregivers were taught to conduct a tact-training task with a supplemental question (i.e., “What is it?”; Marchese et al., 2012) within the framework of DTI. Each session consisted of the first 12 tact-training trials presented. The primary dependent measure for the caregivers was the percentage of DTI target skills implemented correctly (see Table 1 for operational definitions of individual target skills). The primary dependent measure for the children with ASD was the percentage of trials with independent correct responses during tact-training sessions. All sessions were digitally recorded and scored later.

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Table 1.

Operational Definitions of Caregiver Responses During Discrete-Trial Instruction.

Caregiver response	Definition
1. Establish ready behavior	Waits to present an instruction until the child is not engaging in disruptive movements of the limbs and is oriented toward the therapist (i.e., shoulder facing therapist).
2. Present the picture card correctly	Caregiver presents the picture card directly in front of the child’s visual field.
3. Present correct verbal prompt	Presents the correct verbal prompt (i.e., says, “What is it?”) once and allows the child 5 seconds to respond independently.
4. Present correct model prompt	If the child does not respond or provides an incorrect response within 5 seconds (±2 seconds), the caregiver presents the model prompt (i.e., reads the word on the back of the picture card).
5. Provide the reinforcer immediately following a correct response	A reinforcer (e.g., edible) is handed to or placed in front of the child within 7 seconds of an independent correct or prompted correct response.
6. Reinforcer is made available for designated interval	The reinforcer is made available for at least 15 seconds or until the edible item has been consumed.
7. Remove picture card	Training materials are removed from the child’s view following a correct response or within 7 seconds after the model prompt.
8. Record data	Data are recorded prior to starting the next trial.
9. Ignores/blocks problem behavior	Does not provide verbal or physical attention to problem behavior and continues with the current trial (i.e., minimizes facial expressions, no statements regarding problem behavior). If it is necessary to physically block dangerous behavior, the caregiver rearranges the environment or uses the minimum amount of physical interaction necessary to keep the child safe.

Tact-training sessions were analyzed on a trial-by-trial basis, and the number of correct and incorrect caregiver responses was determined. The percentage of correct caregiver target skills was calculated within each session by dividing the number of correctly conducted skills by the number of opportunities to emit the skills and converting the proportion to a percentage. Caregiver target skills that were not sampled within a trial were marked as not applicable and were excluded from the total number of caregiver target skill opportunities (e.g., a caregiver would only have an opportunity to ignore problem behavior if it occurred).

Child responses included (a) independent correct responses, defined as providing a correct vocal response following the initial prompt (i.e., “What is it?”); (b) prompted correct responses, defined as providing a correct vocal response following the modeled prompt; (c) incorrect responses, defined as providing an incorrect vocal response; and (d) no response, defined as not responding within 5 seconds of the modeled prompt. We calculated the percentage of independent correct child responses within each session by dividing the number of independent correct child responses by the total number of trials (12 trials) and converting the resulting proportion to a percentage.

Interobserver agreement (IOA) was calculated on a trial-by-trial basis using the DTI measure for each teaching component. A second observer, previously trained to 90% IOA, independently collected data for a minimum of 33% of all baseline and treatment sessions. We calculated IOA by determining the number of agreements on the occurrence and nonoccurrence of target behaviors and divided that number by the sum of agreements plus disagreements. We converted the resulting proportion to a percentage. The mean IOA for Dyad 1, Dyad 2, and Dyad 3 was 95% (range, 90%–98%), 95% (range, 90%–98%), and 94% (range, 90%–99%), respectively.

An 8-question social validity survey was adapted from Higgins et al. (2017). Caregivers completed the social validity survey to assess their satisfaction with the equipment, BST procedures, and the use of telehealth for teaching DTI. Participants could respond to the survey anonymously (i.e., the researchers could not identify the participant based on their answers). The survey utilized a Likert Scale with ratings from one to seven; 1 (strongly disagree), 2, 3, 4 (no opinion), 5, 6, and 7 (strongly agree). Each question also included an open-ended response for caregivers to clarify (i.e., “please comment on why or why not.”).

Experimental Conditions

Baseline

Baseline sessions took place in a quiet, well-lighted room within the caregiver’s home. The baseline was constructed to approximate a situation in which caregivers attempted to teach their children to tact a common object (e.g., a chair, boot, fork) without formal training (i.e., without reading published material on the topic or receiving structured practice with feedback). Before conducting baseline sessions, caregivers were provided up to 10 minutes to review written materials describing and defining the caregiver skills (see Table 1) involved in conducting the tact-training task. These materials were displayed electronically on the monitor of the provided laptop computer. Using the three target picture cards, caregivers were instructed to “Do discrete-trial instruction to the best of your ability and present each card four times.” Caregivers were provided blank datasheets that could be used to track the number of times each card had been presented. Each session consisted of 12 trials and lasted between 5 and 12 minutes.

Training

Training consisted of didactic information and video modeling, scripted role-play sessions with immediate feedback, and real-time feedback during practice sessions with their child. First, the caregiver and first author viewed and discussed a 22-slide Microsoft PowerPoint presentation. The presentation introduced basic tact-training programming and the rationale for why it is an important target for EIBI. The presentation described DTI, including trial presentation, data collection, and strategies for managing common problem behavior (e.g., elopement). Caregivers were provided written definitions of the DTI skills, a protocol with explicit instructions for conducting the tact-training task, and instructions for using the tact-training datasheets. The first author and caregiver role-played scripted discrete-trial scenarios following the didactic training. The first author provided trial-by-trial descriptive feedback (i.e., general praise, behavior-specific corrective feedback) on the caregiver’s performance.

Role-playing was conducted to provide an opportunity for immediate, differential consequences to be delivered and ensure that caregivers received exposure to a set of common response exemplars (i.e., correct response, no response, error, approximation, problem behavior) that a child might exhibit. The first author played the role of the confederate child and followed one of three 12-trial scripts. The 12 trials were randomized across the three scripts. They included three independent correct child response trials, three prompted correct child response trials, three incorrect child response trials, and three no child response trials. Independent correct child response trials were ones in which the confederate child (i.e., the first author) provided a correct vocal response within 5 seconds following the initial instruction. Prompted correct child response trials were ones in which the confederate child provided a correct vocal response within 5 seconds following the model prompt. Incorrect child response trials were ones in which the confederate child provided an incorrect vocal response within 5 seconds following the initial instruction or model prompt. No child response trials were ones in which the confederate child did not emit a vocal response.

Caregivers were not informed about the confederate child’s behavior before any trial, nor were they instructed how to respond, but the first author provided a feedback statement after each trial. The order of feedback for each trial involved (a) stating the correct or incorrect responses (i.e., DTI skills, datasheet completion) and (b) obtaining confirmation that a correct or incorrect response was observed (i.e., “Did you see what you did correctly [or incorrectly]”). For correct responses, the first author said, “That was correct because you (correct target responses),” followed by brief praise (e.g., “That was good”). For incorrect responses, the first author said, “That was incorrect because you did not (correct target responses) when (incorrect target responses).”

After role-playing, caregivers were allowed to ask additional questions and practice as needed with the first author. Finally, caregivers conducted one practice tact-training session with their child. The first author provided feedback to the caregiver as described above for role-play sessions. After all the BST components had been completed, training probes were conducted to assess caregiver performance immediately following training with no feedback provided. As in baseline, caregivers were instructed, “Do discrete-trial instruction to the best of your ability and present each card four times.” The training concluded after caregivers correctly performed at least 80% of the DTI target skills in two consecutive training probe sessions. Due to being unable to interpret the data (i.e., failure to capture video of the target skills), Dyad 1 (Mel-David) had to repeat the training procedure and training probes which is indicated by the asterisks in the top panel of Figure 1.

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Figure 1.

Percentage of trials with correct caregiver and child responses. Sessions are listed along the x-axis. Filled circles (caregiver) and filled triangles (child) indicate the percentage of correct responding during sessions conducted with the primary target stimuli. Open circles (caregiver) and open triangles (child) indicate the percentage of correct responding during sessions conducted with the six generalization stimuli. The asterisks (*) indicate sessions that were repeated due to technical difficulties.

Posttraining

Post-training sessions were conducted to assess caregiver DTI performance with the child without training materials and feedback from the first author. Caregivers were instructed to conduct daily DTI sessions targeting the three primary stimulus cards and six additional generalization stimulus cards. Caregivers set up the telehealth technology and were instructed, “Do discrete-trial instruction to the best of your ability and present each card four times.” Caregivers conducted a block of four 12-trial DTI probe sessions. Posttraining was complete when a caregiver met mastery criteria (i.e., 80% of target skills conducted correctly) on three of four tact-training sessions.

Maintenance

One-month follow-up meetings were scheduled after post-training to assess maintenance of caregiver skills and were conducted as described above in baseline. Caregivers conducted one 12-trial DTI session targeting the three primary stimulus cards.

Generalization

Generalization sessions were the same as described in baseline to assess how the caregiver skills generalized when presenting stimulus cards not included in the BST package. Caregivers conducted one 12-trial DTI probe session targeting the six generalization stimulus cards.

Social validity questionnaire

We asked caregivers to complete a social validity questionnaire with open-ended and closed-ended questions. The questionnaire allowed caregivers to provide qualitative and quantitative information about their remote training experience. Caregivers responded to eight items by circling a number on a Likert scale from 1 to 7, where 1 = “I am not satisfied at all” to 7 = “I am extremely satisfied.” Three questions asked whether caregivers were satisfied with setting up the materials and transferring the data files electronically. Several questions addressed the quality of the audio and video communications. Finally, caregivers were asked if they would recommend these remote methods to others.

Results

Figure 1 displays the percentage of correct caregiver DTI skills (circles) and independent correct child responses (triangles) across all tact-training sessions. The number of baseline sessions was staggered across the three caregiver-child dyads (three to five sessions). All three caregivers emitted few correct DTI target skills during baseline, and low and stable responses characterized performance. Across baseline, the average percentage of correct caregiver DTI skills for Dyad 1, Dyad 2, and Dyad 3 was 30% (range, 26%–32%), 48% (range, 44%–52%), and 36% (range, 31%–39%), respectively. When provided written instructions and no feedback, all caregivers performed the DTI skills inadequately. Similarly, child participants emitted few independent correct responses during baseline. The average percentage of child independent correct responses during baseline was 28% (range, 25%–33%), 52% (range, 0%–83%), and 25% (no range) for Dyad 1, Dyad 2, and Dyad 3, respectively.

After introducing the remote BST package, we observed a robust improvement in caregivers’ correct implementation of the DTI skills across all three caregivers. Caregiver performance conducting the DTI skills following training increased by an average of 59%, 38%, and 57% for Dyad 1, Dyad 2, and Dyad 3, respectively. Following training, the average percentage of correct caregiver DTI skills was 89% (range, 80%–98%), 86% (range, 80%–92%), and 93% (range, 92%–94%), for Dyad 1, Dyad 2, and Dyad 3, respectively. Child independent correct responses following caregiver training increased by an average of 56%, 11%, and 38% for Dyad 1, Dyad 2, and Dyad 3, respectively. The average percentage of child independent correct responses was 84% (range, 75%–92%), 63% (range, 58%–67%), and 63% (range, 58%–67%), for Dyad 1, Dyad 2, and Dyad 3, respectively. Due to technical difficulties described earlier, training data for Dyad 1 (Mel/David, shown in the top panel) depict caregiver and child performance in the second set of training probes.

For David and Alice, the improvements in child’s correct responses occurred concurrently with improvements in their caregivers’ correct implementation of the DTI skills. For Eric, it is unclear whether improvements in his correct response corresponded to progress in his caregiver’s correct implementation of DTI skills because Eric’s baseline response was highly variable. Nevertheless, Eric’s levels of correct responding showed a consistently increasing trend as his caregiver’s correct implementation of DTI skills improved during training and post-training.

All three caregivers maintained increased caregiver performance across post-training. The average percentage of correct caregiver DTI skills was 92% (range, 89%–94%), 88% (range, 78%–94%), and 98% (range, 94%–100%), for Dyad 1, Dyad 2, and Dyad 3, respectively. The average percentage of child-independent correct responses during post-training was 88% (range, 75%–96%), 56% (range, 17%–83%), and 63% (range, 50%–83%), for Dyad 1, Dyad 2, and Dyad 3, respectively. After 1 month, all three caregivers demonstrated that their DTI skills were maintained over time. The percentage of correct caregiver DTI skills during maintenance was 95%, 82%, and 99% for Dyad 1, Dyad 2, and Dyad 3, respectively. For Dyad 1, Dyad 2, and Dyad 3, the percentage of child-independent correct responses during maintenance was 67%, 83%, and 83%, respectively. The generalization probe suggested that caregivers could perform the DTI skills when presenting stimulus cards that were not targeted during BST. The percentage of correct caregiver DTI skills during generalization was 95%, 82%, and 99% for Dyad 1, Dyad 2, and Dyad 3, respectively. The percentage of independent correct child responses during generalization was 78%, 92%, and 42% for Dyad 1, Dyad 2, and Dyad 3, respectively, well above baseline performance levels for all three children.

The total number of remote caregiver meetings for Dyad 1, Dyad 2, and Dyad 3 was 5, 4, and 4, respectively, and were conducted over a period of 29, 15, and 13 days. The average duration of the remote baseline meetings was 64 minutes (range, 49–85 minutes), although the number of sessions conducted across caregivers was staggered within the multiple-baseline-across-participants design. Remote BST meetings lasted an average of 122 minutes (range, 107–145 minutes). The average duration of post-training and follow-up meetings was 51 minutes (42–56) and 36 minutes (29–46), respectively.

The results of the social validity questionnaire are summarized in Table 2. In general, the caregivers rated their remote training experience highly. They were highly satisfied with the technical setup, as indicated by a mean rating of 6.9 out of a possible 7 and no rating below 6, with 7 indicating highly satisfied. All three caregivers rated their video conferencing experience as positive and reported that they would recommend this remote training to others. Together, the acquisition data and the results from the social validity questionnaire demonstrate that remote BST was effective for all three caregivers who rated their remote training experience positively.

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Table 2.

Social Validity Questionnaire: Caregiver responses.

Caregiver	Mel	Ana	Tammy	M
1. Prior to interacting with the therapist and conducting sessions, you were required to set up several pieces of technology. Were you satisfied with the technology setup, which involved starting the webcams and accessing the Adobe Connect and webcam software?	7	7	7	7
2. In order for us to evaluate your performance, you were video recorded while conducting sessions. Were you satisfied with the process of recording the sessions?	6	7	6	6.33
3. Were you satisfied with the audio and video quality of the remote interactions (i.e., via Adobe Connect)?	7	7	7	7
4. Were you satisfied with the quality and organization of the PowerPoint presentation?	7	7	7	7
5. Were you satisfied with the process in which feedback was provided during role play sessions?	7	7	6	6.67
6. Do you think this process of remote instruction would be acceptable for teaching other skills relevant to your child’s treatment?	7	7	7	7
7. Would you recommend remote instruction to other caregivers who are not able to receive onsite training?	7	7	7	7

Note. 1 = Highly unsatisfied; 4 = no opinion; and 7 = highly satisfied.

Discussion

This study evaluated the effectiveness of telehealth technologies in delivering a multi-component BST package for caregivers in their own homes. We conducted the telehealth training using inexpensive hardware and widely available software. The BST package consisted of didactic information and video modeling, scripted role-play sessions with immediate feedback, and real-time feedback during practice sessions with a child. Three caregivers were taught to teach their respective children to tact common objects within a non-concurrent, multiple-baseline design. During baseline, few correct responses were emitted by either caregiver (DTI target skills) or child (tact target skills) participants. All three caregivers quickly acquired the DTI target skills following exposure to the remote BST package. All three caregivers continued to conduct the DTI target skills with high integrity during post-training and follow-up probe sessions. The caregiver’s target skills were generalized to novel stimuli. In addition to the improvements in caregiver performance, we observed a concurrent increase in child independent correct responding for two of the three children. The third child showed an increasing trend in correct responding as his caregiver’s implementation of DTI skills improved. He showed mastery performance by the end of training and during the follow-up and generalization probes.

The current findings are consistent with previous evaluations of the BST approach when used to teach caregivers to conduct DTI (Lafasakis & Sturmey, 2007; Sarokoff & Sturmey, 2008). More broadly, these findings add to the growing body of research supporting the effectiveness of the BST approach for teaching a variety of skills to a variety of individuals (Dib & Sturmey, 2007; Reid & Parsons, 2006). The strength of the BST approach is in the careful observation of clearly defined target skills. This approach facilitates learning through differential reinforcement and shaping using instruction, modeling, role-play, and feedback. Also, the results of the current study provide additional support for the systematic presentation of discrete trials by caregivers when teaching children diagnosed with ASD to tact common objects in the environment (Devlin & Harber, 2004; Taylor & McDonough, 1996). Together, these findings suggest caregiver training is a viable option for increasing the use of evidence-based strategies to treat children diagnosed with ASD.

The current study replicates and extends previous telehealth research in several potentially important ways. First, these findings demonstrate the effective use of telehealth technologies when conducting remote BST to teach caregivers to conduct DTI in the home with no onsite assistance. In particular, we used the Internet and a secure videoconferencing platform (i.e., Adobe Connect) to establish a virtual operant space in which training materials and live, real-time feedback could be provided. Second, the use of a widely available remote desktop application (i.e., LogMeIn) dramatically reduced the response effort of caregivers in the home. The remote application allowed the first author to create a digital video of caregiver skills in the home during baseline, training, post-training, and 1-month follow-up probe sessions. The remote desktop application allowed the first author to securely transmit the digital videos from the caregiver’s home to the university-based medical center using a virtual private network.

The findings from the current study are important because telehealth may be a viable option to address the shortage of qualified people (e.g., board certified behavior analysts) to implement ASD treatment strategies. In addition, the procedures used in this investigation allow parents to continue their child’s ABA programming and progress at home when the child cannot receive services from a behavior therapist (at home or in a clinic) due to health issues like the COVID-19 Pandemic. Moreover, telehealth technologies can provide effective training to various individuals (e.g., caregivers, teachers, and staff) involved in the treatment of children with ASD. This remote training approach may be ideal for individuals who face a variety of barriers (e.g., distance, a limited number of providers; health concerns) to training, feedback, oversight, and follow-up (McGee & Morrier, 2005; Smith, 2001). Using telehealth technologies in this way may extend the reach of specialized training and allow caregivers of children with ASD to learn evidence-based treatment strategies (e.g., DTI) and become actively involved in their child’s treatment.

Since the onset of the COVID-19 pandemic, there has been a temporary waiver of face-to-face requirements for nearly all of the ABA therapy codes, and it is not clear if there will be reimbursement for these service codes moving forward. The current study adds to a growing number of studies demonstrating the effectiveness of providing remote services.

It is not always clear when telehealth is an appropriate option. This is not to suggest that telehealth is always appropriate, and that telehealth will solve the provider shortage problem. As a field, we need continued efforts in the development and maintenance of effective training programs so that we can build capacity and meet the demand for behavior analysts.

Third, many previous studies used telehealth to implement assessments and treatments using telehealth and onsite assistance, whereas we conducted all caregiver training using telehealth alone in the current study. Caregivers independently acquire skills relevant to their child’s individual needs, and these skills were maintained over time and generalized to novel stimuli. This was accomplished without the aid of onsite assistants, and caregivers participated in the remote training program without leaving the comfort of their own homes.

Caregiver involvement is an important treatment component for children with ASD (Strauss et al., 2013), particularly those who cannot access the recommended intensity of EIBI (i.e., 25 hours or more per week). Teaching caregivers to present more frequent, reliably, and consistent learning opportunities may significantly impact the pace with which their children acquire skills commonly targeted in EIBI. The current study also adds to the limited published data on the social acceptability of ABA services delivered using telehealth. All three caregivers reported high satisfaction with their BST experience, stating that they would recommend this type of remote training to other caregivers. These findings are consistent with the evidence of high patient satisfaction with telehealth services in various fields (e.g., psychiatry, psychology, mental health; Frueh et al., 2000).

Despite the effectiveness of the telehealth training provided in the current study, several study limitations should be noted. First, due to technical difficulties described earlier, the first participant (top panel of Figure 1) was exposed to the full teaching package twice before conducting the training probes presented in this paper. This variation in the treatment protocol may have influenced the observed change in caregiver performance differently than the other participants. However, given the similar change in performance across the other two caregivers, it is unlikely that this unexpected variation had significant effects on the caregiver’s acquisition. Systematic replications of the current study will help to resolve this limitation.

A second potential limitation was that two of the three child participants were receiving ongoing EIBI services within a center for ASDs, and these services included the use of DTI. To address this issue, participating caregivers agreed not to observe DTI sessions conducted in the clinic until they completed their involvement in the current study. In addition, each child’s EIBI team was informed of the targets of the current study, and tact targets were not targeted for acquisition in the EIBI clinic until the caregiver-child dyad had concluded participation in this study. Future research should evaluate the effectiveness of remote BST for caregivers of children with ASD who are not currently receiving any EIBI services and determine the training effects on child acquisition.

Third, no data were collected during role-play training; thus, detailed information regarding the rate of acquisition for each caregiver could not be determined. Additionally, changes in responding following the implementation of each treatment component also could not be determined.

Despite these limitations, the current study results suggest several other areas for future research. First, investigators observed considerable variability in independent correct responding during baseline for child participant Eric (middle panel of Figure 1). Anecdotal observations and caregiver and therapist reports indicated that this variability may have been due to frequent but episodic noncompliant behavior when presented with pre-academic tasks. Thus, teaching caregivers to conduct compliance training may be an important prerequisite to teaching caregivers to conduct DTI. Teaching caregivers to conduct compliance training will likely increase the effectiveness of EIBI programming in general. Future research should evaluate the effectiveness of remote BST when teaching caregivers to conduct compliance training with their children with ASD.

Future research should also evaluate telehealth technologies in pyramidal training procedures, which involve teaching one person to implement a behavioral intervention and then training others. These same remote training techniques could be applied to teach individuals in remote communities and provide them with the tools to teach others that would benefit from acquiring particular skills. For example, previous research on pyramidal training has produced successful outcomes for caregivers and professionals in clinical and residential settings (Page et al., 1982).

Although the BST approach can be conducted effectively using telehealth technologies, questions remain about which procedures are appropriate to be targeted for remote caregiver training. For example, in the current study, we taught caregivers to implement a relatively simple tact-training task. We designed the target skills to be relatively easy for the caregivers to learn and implement. Thus, future research should evaluate the effectiveness of telehealth-delivered caregiver training with more complex DTI procedures, such as those used to establish initial auditory-visual conditional discriminations (e.g., Fisher et al., 2014).

Regardless of the complexity of the skills taught, future research is needed to identify the level of treatment integrity necessary when caregivers are taught to implement specific components of a child’s EIBI program. The present study is a good example of how advances in telecommunication technologies provide unique and alternative approaches to addressing important research questions. Perhaps the same telehealth technologies can be used to improve treatment integrity while also facilitating necessary supervision and follow-up. For example, video self-modeling has shown emergent evidence as an effective means to increase staff performance in implementing DTI (Belfiore et al., 2008). Combining video self-modeling with the remote BST approach may increase the efficiency of BST, as caregivers could be trained to self-identify and self-correct their errors, thereby reducing the time and resources required from behavioral specialists. This method would also address the noted challenge of providing follow-up sessions in the home post-DTI implementation.

Similarly, it is possible for caregivers to video record themselves while conducting a particular skill and forward the digital file to a behavioral specialist across the Internet. The behavioral specialist could review the caregivers’ video-recorded performance at a convenient time and then prepare and deliver the necessary feedback to the caregiver during the next remote meeting. A behavioral specialist in one location could provide real-time feedback while caregivers watch their own recorded performance. Additional research is needed to assess the utility of telehealth technologies for this form of follow-up training.

The current study did not explicitly focus on the relative efficiency of telehealth technologies in conducting remote BST. However, there is little doubt that this remote BST approach is a less expensive alternative for caregivers who travel long distances to access behavioral specialists. Previous research suggests significant cost savings when mental healthcare patients from outlying communities are seen remotely using a secure videoconferencing platform (Jong, 2004). These findings will likely become more significant with the reduced cost and availability of portable devices that can securely access the Internet and support videoconferencing technology (Cluver et al., 2005). Future research should evaluate the relative time and cost savings for training conducted remotely compared to more traditional in-person arrangements.

Overall, the current study results support telehealth technologies to create a remote operant space in which caregivers can be taught important skills relevant to child development. The results are important because they provide further evidence that telehealth may be useful in increasing the accessibility of specialized training to underserved populations. The implications of this remote BST approach are exciting and suggest several fruitful lines of research. Behavior analysis is uniquely suited to evaluate the effectiveness of well-established applied techniques when conducted via telehealth. Additional research is needed to evaluate telehealth technologies’ clinical utility and establish a standard behavioral technology of telehealth that could broadly affect learning across various healthcare and educational fields.