CARD Researchers Develop Instrument to Measure Treatment Integrity of Behavioral Therapy Provided via Telehealth to Patients with Autism

Researchers at the Center for Autism and Related Disorders (CARD) have developed the Telehealth Therapy Treatment Integrity Measure (TTTIM), an instrument designed to measure the treatment integrity of applied behavior analysis (ABA) therapy delivered via telehealth to patients with autism spectrum disorder (ASD). With the closure of many behavioral health clinics at the start of the COVID-19 pandemic, many behavioral treatment services shifted to telehealth, with practitioners conducting behavioral therapy with patients remotely using video conferencing.

For patients with ASD, lapses in treatment can lead to stalls in progress and even skill regression. To ensure continuity of services for patients during the pandemic, many practitioners began using telehealth in the provision of direct ABA therapy, some for the first time.

“The rapid transition to telehealth services was necessary for the health and safety of patients and clinicians,” said Karen Nohelty, M.Ed., BCBA, CARD research director. “Nevertheless, treatment providers who use telehealth are ethically bound to ensure their practitioners are trained to deliver telehealth therapy and that their performance is regularly evaluated to ensure treatment integrity.”

Many challenges and considerations are unique to the delivery of direct therapy via telehealth. Many aspects of effective treatment, such as the caregiver’s role in treatment, building rapport with the patient, managing challenging behaviors, and promoting engagement, must be approached differently when using telehealth services compared to in-person services.

“Very few resources are available to clinicians navigating telehealth for the first time,” said CJ Miyake, M.Ed., BCBA, research manager. “We developed the TTTIM to help clinicians assess the quality of their patients’ telehealth services during this public health crisis.”

The TTTIM is the only published instrument designed to measure the treatment integrity of direct ABA services delivered via telehealth. The TTTIM instrument is comprised of 44 items that may be rated via telehealth. Purposes of the measure include guiding training on telehealth therapy procedures and self-evaluation and ongoing performance measurement. The TTTIM is available at no cost in an open access, peer-reviewed journal article by Nohelty et al. (2021).

The COVID-19 pandemic is having the most significant effect on vulnerable populations, including individuals with ASD. CARD researchers shifted their focus to ensure that patients with ASD would continue to access effective treatment during the crisis. The TTTIM was developed to promote treatment quality assurance, but researchers expect its utility to continue after the health crisis, given that telehealth has so much potential in autism treatment.

Nohelty, K., Hirschfeld, L., & Miyake, C. J., (2021). A measure for supporting implementation of telehealth direct therapy with treatment integrity. Behavior Analysis in Practice.

About Center for Autism and Related Disorders (CARD)
CARD treats individuals of all ages diagnosed with autism spectrum disorder (ASD) at treatment centers around the globe. CARD was founded in 1990 by leading autism expert and clinical psychologist Doreen Granpeesheh, Ph.D., BCBA-D. CARD treats individuals with ASD using the principles of applied behavior analysis (ABA), which is empirically proven to be the most effective method for treating individuals with ASD and recommended by the American Academy of Pediatrics and the US Surgeon General. CARD employs a dedicated team of trained professionals across the nation and internationally. For more information, visit