Telehealth-based Systems for Diagnosis, Management and Treatment of Autism Spectrum Disorders: Challenges, Opportunities and Applications

The prevailing system for diagnosis, treatment, and management of Autism Spectrum Disorders (ASDs) in the US-the in-person service delivery-has been unable to address the increase in the demand for services and societal costs for those served, and the unattained societal benefits for those not diagnosed early enough or not offered early and intensive behavioral interventions. The authors discuss new developments in telehealth for diagnostic evaluation and ASD treatment in the US.

Read more: Telehealth-based Systems for Diagnosis- Angjellari-Dajci-Hershey-Dec, 2013-Book Chapter

Behavior Imaging Covered in Handbook of Technology…

Behavior Imaging covered in Handbook of Technology in Psychology, Psychiatry, and Neurology. Dr. Olga Solomon describes the steps of behavior assessment as performed by Behavior Imaging technology as well as the benefits the tech offers to its users. Full article here.


Technologies to Lessen the Distress of Autism

This article explores aspects of autism that make it a potential traumatic stressor for family members, and may put them at risk for Posttraumatic Stress Disorder (PTSD) and/or its sub-syndromal variants.  It also surveys current trends in autism, including the growing number of families affected by autism.

Read more: Technologies to Lessen the-Oberleitner-Binghamton-2006-Journal Article

Adapting Telemonitoring Technology Use for Older Adults

Kristine Williams, PhD, RN, APRN, FNP-BC, FGSA, FAAN; Priya Pennathur, PhD; Ann Bossen, PhD, RN; and Alexander Gloeckner, BBA


Telehealth technologies are increasing health care access for patients in the home and in community, rural, and underserved areas. Older adults may be challenged to use new technologies due to aging- related changes, lack of experience, and different attitudes toward their use. The current pilot study evaluated potential issues in one-on-one training/instructions and use of a telemonitoring application. Older adults may benefit from specific adaptations and training to use new health care technologies, and behavioral coding is an effective way to evaluate the user interface for new technologies. Feedback from the current study will be used to adapt the application and training to support dementia caregivers. [Res Gerontol Nurs. 20XX; x(xx):xx-xx.]

 Read more here: adapting-telemonitoring-technology-use-for-older-adults-a-pilot-study(2)

Tech Innovation Goals

Behavior Imaging is researching how professionals can diagnose and assess individuals with Autism Spectrum Disorders by advancing its technology in the following ways:

Our Goals:

1. Move to a more mobile application of Behavior Capture by utilizing a Smartphone.

Example: A mobile app that can view notes, capture images, send and store data, and review captured data.

Watch the video.
2. Make Behavior Connect state-of-the-art to give doctors and educators the ability to give ‘behavior prescriptions’ remotely.

Example: a practitioner can write a “prescription” for images of a specific behavior that can then be “filled” by the person capturing the data.

3. Provide video data evidence for the assessment process during both diagnosis and treatment.

Example: video data will support goal attainment and identify potential regression.

This is now build into
Behavior Connect the flexible behavior capturing and analyzing tool.
and can be seen on
Watch the video.
4. Improve technology to ensure that prescriptions are ‘appropriately filled.’

Example: “prescriber” can check to see that the correct data was captured and then followup with the appropriate person if further evidence is needed.

This feature is now built into
Behavior Connect the flexible behavior capturing and analyzing tool.
5. Create clinician online tools to accelerate health and education assessments.

Example: diagnostic criteria outlined and described so data is focused for collection efforts.

Apps like NODA now have instructional videos like
and users can use DSM4 and DSM5 criteria as you can see here and read more information here


Current Innovations

4888532947_535c5482aaThe ability to start autism screening and diagnosis the same day – which saves an average of 6 to 9 months in earlier diagnosis and earlier intervention – sets the child miles ahead in development. Telehealth holds this same promise for a huge array of health and behavior issues where time is of the essence.

It’s innovations like that which has won grants and the support of our sponsors.

Here are more features of our current technology that our sponsors and supporters value:

Visual Evidence – “Visual Behavior Specimens” – are a Game-changer

  • Video makes for rich, quality, informative data
  • Multiple reviews/assessments of one set of evidence – Multiple examiners
  • These factors lead to evidence-based practice and less subjective research, diagnosis, and care
  • Unlike observation, video can be stored, archived, and can be revisited later
  • This builds a research subject pool for scientists
  • We’re creating a registry of data, the world’s largest video pool of “Visual Behavior Specimens”

NODA- Naturalistic Observation Diagnostic Assessment

  • Quality of data capture based in natural environments using NODA for direct observation
  • Application to wide array of health and behavior applications from nursing transfer training to PTSD and Alzheimer’s intervention, to medication management

Technology Lowers Connection Barriers

  • Accessible and Portable to overcome 5 barriers – Time, Geography, Professional expertise, Cost, Communication
  • Flexibility among Dx systems; Ease of transfer for Dx results
  • Quickly switch between DSM4 and DSM5 – debates may rage on but the video data never change
  • Access to specialists improves quality and speed of diagnosis and care


Problems We’re Tackling

The Critical Need For Telehealth Research

5-31-2013-7-49-56-PM-150x150There is a pressing need for diagnostic and intervention services to support the rapidly growing population of children with Autism Spectrum Disorders (Autism and Developmental Disabilities Monitoring (ADDM) Network, 2009). Direct observation of the child remains the gold standard practice in diagnosis, assessment, and treatment planning for children with autism and related developmental disabilities (Filipek, Accardo, Barnek, Cook, Dawson, Gordon, et al.,1999; National Research Council, 2001; Ozonoff, Goodlin-Jones & Solomon, 2005). Moreover, the literature supports early screening to ensure that children are referred for diagnostic assessments sooner, and that timely evaluations of eligibility for services result in immediate implementation of appropriate early intervention (American Academy of Pediatrics Council on Children With Disabilities, 2007; Johnson, Myers).

Despite this literature, many rural communities that are also characterized by low socio-economic status (SES) are marked by lack of access to autism-specific expertise among professionals in mental health, primary care, and education (Belfer & Saxena, 2006; Marcin, Ellis, Mawis, et al., 2004; Nesbitt, Rogers, Rich, et al., 2006). Even in urban communities where services are more widely available, timely access to diagnostic and intervention services is often hampered by long waiting lists at centers focused on diagnosis and treatment (Hayden, 2011).

Telehealth Practices Promising and in Need of More Research

Despite gvlcsnap-2013-02-18-18h44m59s235-e1379549601825-150x150rowing recognition of the potential for telehealth to improve access to care for individuals with ASDs (Karp, Grigsby, McSwiggan-Hardin, Pursley-Crotteau, Adams, Bell, W., et al., 2000; Saint-André, Zalentein, Robin, & Lazartigues, 2011; Terry, 2009; Baharav & Reiser, 2010), few peer-reviewed evaluations of telehealth technologies applied to autism have been published (Boisvert, Lang, Andrianopoulus & Boscardin, 2010). Boisvert and colleagues (2010) found that 7 of the 8 studies reviewed reported successful implementation and positive outcomes of services delivered via telepractice. However, the total number of participants across these studies was extremely small (n=46), most lacked a true experimental design, and only a single study directly compared the effectiveness of services delivered via telepractice to the same services delivered in person.

The authors concluded that telepractice is a promising service delivery approach for individuals with ASD that warrants additional research, particularly with respect to technological requirements to support diagnostic protocols and intervention procedures, analysis of clinical efficacy and effectiveness, and cost-benefit analyses. Based on these identified areas of need, our system for approaching both diagnostic assessment and treatment planning will address these shortcomings and the effectiveness and efficacy of the system will be tested in two separate clinical settings using rigorous scientific methods.

Shortening Wait Lists, Providing Care to Remote Areas

vlcsnap-2013-04-23-12h17m29s122-150x150Asynchronous (store-and-forward) telehealth technology, such as our own Behavior Imaging technology, demonstrates how contextual video capture and a complementary online consultation platform effectively address the need for observation of the child by a professional who can make more timely clinical decisions regarding diagnosis and treatment. Beyond the potential for such technology to improve access to care for remotely located children (i.e., rural areas, military bases, etc.), it can also enable clinical centers around the country to shorten their wait-lists by facilitating more timely communication with families about the nature and range of the child’s symptoms and needs. There is great potential for enabling these centers to quickly gather initial clinical impressions of the child by reviewing videos collected by caregivers in the home, and then to more effectively triage cases into those that are clear cut and those that require more extensive in-person assessment.

In addition, the system allows for multiple raters to view evidence thus providing a format for documenting inter-rater reliability. In cases where raters are not in full agreement as to a specific diagnosis or plan for treatment, this system also allows for a third rater to view the evidence and weigh in on the decision. This capability further allows clinicians and educational professionals to make more informed decisions based on visual evidence.

Capturing Behavior in a Natural Setting for More Efficient and Accurate Assessments

Behavior Imaging technology facilitates clinical decisions based on child behaviors captured as they occur in natural settings. In contrast, the current practice of observing the child in a specialized room at a clinic may produce reactivity effects in the child, both those introduced by a novel environment and unfamiliar observer (Gardner, 2000; Kazdin, 1982). Moreover, for many interventions like those targeting challenging behaviors, a key component of treatment planning involves understanding the function of the behavior. However, the stimuli that evoke the behavior as well as consequences that maintain it in the natural environment may not be observed in an artificial setting like a clinic.

parentconcern_psd-e1379549490516-150x150Thus, Behavior Imaging technology allows for families and caregivers to capture not only the behavior, but what happened right before it (i.e., antecedent) and what happened right after (i.e., consequence). With this knowledge, practitioners are able to further understand potential triggers for problem behaviors and actions that may be maintaining its occurrence. Results of a multi-site (Oberleitner et al., 2007) user study identified a need for this technology in the process of behavior assessment, supporting teaching practices, increasing administrative support, and the ability to gain input from experts in the field.

Enabling Collaboration between Families and Professionals

Behavior Imaging technology will further enable collaboration and consultation between families and professionals through a secure health record application that allows users to store, share, and annotate captured video. Our long-term vision is that this telehealth system will to a great extent replace current practices to provide patients with diagnoses and treatment plans based on information that is collected in natural environments, and is thus more ecologically valid. At the same time, our system will make more efficient use of professionals’ time and reduce office visit times for patients and their families. By providing a format for collecting and analyzing visual evidence, both diagnosis and treatment efforts will translate into a streamlined approach that is ultimately more reliable and cost effective for practitioners and families.

Active Conference Schedule for 2015


International Autism Research Meeting 2015 (IMFAR) May 13 – May 16 at the Grand America Hotel in Salt Lake City, Utah. Behavior Imaging presentations include:

  • NODA-clinical-study-parent-feedback-IMFAR-poster-May2015Analysis of Parent Responses to Using a Remote Autism Diagnostic Assessment System (NODA): A remote autism diagnostic assessment system was designed through a series of research studies conducted with clinicians and parents of children with autism. Through In-home evaluation parents confirmed that capture system facilitated a simplified capture experience. Currently through a systematic study, diagnostic assessments conferred through the proposed system are being compared with in-person diagnostic assessments.

  • IMFAR 2015 NODA FinalComparing Remote Diagnosis of ASD (NODA) to In-Person Assessment: Study – To compare a novel telehealth approach to diagnosing ASD to the gold standard, in-person assessment. Conclusion to the study provided that raters can accurately diagnose ASD with NODA for most cases. A small percentage of participants, particularly high functioning children with few observable behaviors may require an IPA.

  • IMFAR Pharma Trial Poster, - 051112015NODA to Improve Pharmaceutical Trials: Study – To provide a method for centralized assessment of inter-rater reliability for key assessments in a multi-site pharmaceutical trial. Conclusion: Study demonstrated practicality and ease of the BI technology to facilitate and document inter-rater reliability in pharmaceutical trials. Study also provided that use of this platform can help to improve the integrity of data collected at sites in a more efficient manner than is currently applied.

CCSSO Council of Chief State School Officers: National Conference on Student Assessment (NCSA 2015) June 22 – 24, Manchester Grand Hyatt, San Diego, CA.

  • The primary objective of the NCSA is to promote sharing of information and best practices that will help states achieve their educational purposes through having the strongest assessment systems possible. This year the conference theme is “Implementing High-Quality Assessments for ALL Students.” The goal of the 2015 conference is to provide a forum for states to share the best practices, strategies, lessons learned, and available resources relative to their implementation of high-quality assessments for all students.

Association for Behavior Analysis International: 41st Annual Convention – San Antonio, TX (ABAI) Poster (Marcus Autism Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Center for Leadership and Disability, Behavior Imaging):

  • ABAI-Autism-Poster-SBIR-final111111Feasibility of Conducting FBA’s in the Schools with Web-Based Video Recording Technology: Purpose of Current Study: To determine the efficacy of using web-based video recording technology to conduct functional behavioral assessments (FBA’s) in the schools for children with ASD or related disorders, in addition to exploring the cost-benefit )i.e., time and money) of using telehealth for FBA’s in the schools when compared to archival records of FBA’s conducted in person (I.e., traditional approach). Download

Applied Human Factors and Ergonomics 2015 (AHFE):

  • Use of a Novel Imaging Technology for Remote Autism Diagnosis: Applied Human Factors and Ergonomics Conference 2015 (AHFE International)July 26th – 30th, Caesars Palace Hotel, Las Vegas, Nevada, USA. Prevalence of Autism Spectrum Disorder (ASD), in children in the United States has significantly increased form 1 in 150 in 2000 to 1 in 68 in 2010. While the cause of this neurodevelopmental condition is unknown, clinical evidence has shown that early diagnosis and early intervention are critical to improving the long term functioning of a child with ASD. However, a major challenge facing parents is difficulty in obtaining on-time access to appropriate diagnostic services. To address this need, an imaging technology, NODA ® (Naturalistic Observation Diagnostic Assessment), has been successfully developed and field-tested.


20th Annual Telemedicine Meeting & Trade Show (ATA 2015) May 2 – 5, Los Angeles, Booth # 1430.

  • Telemedicine for Autism Collaborators: Treatment – Behavior Connect is an online portal that enables health and education professionals and their organizations to remotely interact with clients, specialists and other staff members, while building a library of shareable assets and a continuous health record. Better manage your: Records (a video record annotated for assessment, communication between users/clients, Functional Behavior Analysis, training or second opinions), Therapy and In-office Visit Intervals, Treatment Options and Capacity, Treatment Gaps, & Remote Technology – Distance and Time Gaps.
  • Southwest Autism Research & Resource Center (SARRC) hosted its 17th Annual Community Breakfast “Take The Next Step” on Friday, April 24th, 2015 at the Arizona Biltmore’s Frank Lloyd Wright Ballroom. The goal of the Breakfast was to raise funds for SARRC’s outreach, education and research programs and inform individuals about autism, which is now the most prevalent children developmental disorder in the United States, affecting one in every 68 children born today.

SARRC Outreach Magazine (Spring 2015) NODA:

Looking to Telehealth Care to Cap Economic Costs and Reach Autism Community

Summary of “Economic Evaluations for Service Delivery in Autism Spectrum Disorders: Benefit-Cost Analysis for Emerging Telehealth Systems,” (2013), Angjellari-Dajci F., Stachura, M. E., Lawless, W. F., Wood, E. A., and DiBattistto, C. In  I. M. Miranda and M. M. Cruz-Cunha eds. Handbook of Research on ICTs for Healthcare and Social Services: Developments and Applications, Hershey, PA: IGI

Can telehealth medicine, including Behavior Imaging, be the answer to problems millions of Americans are facing? Authors of a new IGI book on autism seem to think so. Traditional in-person interventions—which includes everything from the diagnostic assessment to the supervision of treatments—for those on the autism spectrum have so far been incapable of meeting the growing demand for services and support. With so many people in need of care and unable to get it, telehealth intervention programs have the potential to be the solution we are looking for.

Authors Fiorentina Angjellari-Dajci, Max Stachura, William Lawless, Elena Astapova Wood, and Caroline DiBattisto did an extensive analysis on the subject with the conclusion that telehealth interventions can be immensely more economically beneficial than in-person interventions, especially from the perspective of patients/caregivers. The team of researchers also looked into the economic costs and benefits of a systematic change towards telehealth interventions.

Recent Research Presentations and Conferences

Behavior Imaging’s main purpose is to develop solutions to facilitate the observational, analytical and collaborative needs of behavior health care and special education professionals. By enabling collaboration and consultation between patients and professionals through the use of video capture and a secure health record, clients like the Department of Defense, State Departments of Education, universities, and other behavior health service providers now have the ability to store, share and annotate video files as a means of increasing disabled people’s access to care via technology.

Innovative Technology Demonstration at IMFAR Autism Research Conference

Recently on May 16th, 2014 our clinical partners from Georgia Tech spoke at the International Meeting for Autism Research (IMFAR) about their research using Behavior Imaging via the iterative design of a system to support diagnostic assessments for autism using home videos. IMFAR is an annual conference by the International Society for Autism Research (INSAR) to provide ASD researchers from around the world with a focused opportunity to share the rapidly moving scientific investigation of ASD.

With the understanding that direct observation in the natural environment is the key in diagnosing ASD, clinical professionals agree that while such observations are crucial at obtaining accurate and comprehensive assessments, such observations are currently not feasible to implement into clinical practices on a larger scale.

Georgia Tech then spoke of their objective and partnership with Behavior Imaging to iteratively design a system that would enable parents to record video examples of their child’s behavior at home under the guidance of a clinician in order to share these recordings for the purpose of diagnosing autism. Included with this system is a set of reordered instructions embedded within the capture application that would help guide parents while maximizing the clinical utility of the recordings as well. Currently a study is being conducted in which families of children recently diagnosed with autism will use this system in their homes, under the guidance of a remotely-located clinician in order to complete a diagnostic checklist for autism, which will then be compared to the child’s current diagnosis.

Recent Presentation on Innovation and Technology

In addition, Behavior Imaging was also proud to speak as one of the leading experts in healthcare technologies innovation at the 12th Annual 2014 Front End of Innovation Conference that is the #1 industry event for provoking change, and exchanging best practices for real world, best-in-class presentations by true visionaries that are passionate about innovation and deliver measureable results.