Evidence-based telehealth practice in the time of COVID-19

I am a BCBA overseeing home-based programs for students with autism. What are some strategies for implementation of evidence-based telehealth practice in the time of COVID-19?

Answered by Sam Blanco PhD, BCBA, LBA, Mordechai Meisels MS, BCBA, LBA, Bryan J. Blair PhD, LABA, BCBA-D, and Laura Leonard MS, BCBA, LBA

As providers of services to people with a diagnosis of an autism spectrum disorder (ASD), we are experiencing an unprecedented situation given the impact of COVID-19 on nearly all service providers. As schools, organizations, and individual practitioners work to shift their practice to a virtual service delivery model, it is essential that we maintain our commitment to evidence-based practice. When faced with so much uncertainty, it can be a relief to turn to the research base and identify how to implement best practices within this new model. Research on telehealth provided to individuals with autism has grown in recent years and demonstrated that effective treatment is possible (e.g., Ferguson, Craig, & Dounavi, 2019; Peterson, Piazza, Luczynski, & Fisher, 2017; Vismara, McCormick, Young, Nadhan, & Monlux, 2013). While the main focus of this article is services provided through insurance, many of the suggestions may also be beneficial for any person providing educational and/or behavioral telehealth services.

When implementing services via telehealth ensure you are using a HIPAA-compliant platform, such as Doxy.me or Vsee. The client should also be kept apprised of privacy risks associated with the platform being used, and signed informed consent for the use of telehealth should also be provided by the parent/caregiver. When we approach evidence-based practice, we must focus on three primary areas of research: the basic principles of ABA and its practical applications, applications of telehealth, and other uses of technology in teaching. The good news is that there is a lot of research-based information available to guide us as we change to a telehealth model.

Current research on telehealth for individuals with ASD primarily focuses on parent training and supervision. In the current crisis, it might be beneficial that direct care be provided through telehealth. In order to effectively provide direct care delivered by a behavior technician through telehealth, we are suggesting the following steps. Some of these steps will be implemented by the BCBA, while others will be implemented by the behavior technician or the parent. The BCBA is responsible for supervising the behavior technician in this process.

Assess prerequisite skills and unique needs of the client.

The citation for an assessment and survey are provided at the end of this article and can be found here. The BCBA should complete this assessment with parents/caregivers in the room with the client. If the results of the assessment demonstrate that the client does not have the prerequisite skills to participate effectively in interventions delivered remotely (i.e., telehealth), then the prerequisite skills will need to be taught and/or a parent/caregiver will be required to be in the room with the client during direct care to be available to implement reinforcement or prompting procedures. It is also possible that with drastic changes in routines and supports, problem behaviors may have increased or topographies of problem behaviors may have changed (e.g., it may be easier to engage in escape behavior such as walking away from the laptop or shutting the screen). If this is the case, the BCBA should also conduct a functional behavior assessment (FBA). An FBA can effectively be conducted through telehealth (Wacker, et al, 2013).

There are many options for how a telehealth session can be conducted and how a display (e.g., computer screen) can be presented to the client. In assessing prerequisite skills of the client, it may also be beneficial to conduct a preference assessment of the general set up for the client. For example, does the client respond better when the screen only shows the practitioner’s face, or does the client respond better when the screen shows the practitioner’s face and a token system? There are many options for how the screen is presented to the client.

Conduct parent training to adequately prepare parents for their supporting role in telehealth.

Prior to any direct care provided by a behavior technician virtually, the BCBA should conduct parent training. There are three goals that should be targeted and met here. First, the BCBA and parent should work together to teach prerequisite skills to the client. If prerequisite skills cannot be taught quickly, then clear protocols should be developed and implemented for how the parent/caregiver will assist with prompting and providing reinforcement during sessions with the behavior technician. The next goal is to identify any potential safety issues and provide guidance on implementation of any interventions. Finally, the parents should be taught what to expect from telehealth and provided with a mechanism for giving feedback to the BCBA throughout the process. These goals should be addressed within the first telehealth meeting with the parents.

Identify reinforcers and how reinforcement will be provided.

First, the treatment team and parents should identify which reinforcers provided during in-person treatment are still available during telehealth services. A preference assessment should then be conducted with the client utilizing any new options presented through the use of technology as well as identifying any barriers resulting from the use of telehealth. For example, a potential new option might be sharing your screen to show clips of a client’s favorite show on YouTube. A potential barrier might be that a highly reinforcing activity might include social mediation and/or interaction with another person that is not possible unless you’re physically in the room or that the client is unwilling to relinquish a reinforcer when the BT is not physically present in the room.

Speak with the parents (and the client if he/she is capable of participating in the conversation) about specific reinforcers to include in the preference assessment. After the preference assessment is conducted, you should create a clear plan for how reinforcement will be provided.

One potential option here is the use of a token system. The research-base on using token systems with telehealth is primarily focused on teaching parents how to utilize the token system correctly (Hall, 2018; Machalicek, Lequia, Pinkelman, Knowles, Raulston, Davis, & Alresheed, 2016). If a token system is currently in place, it may be beneficial to continue with the existing system as long as the necessary materials are in the room with the client and either the client can provide his/her own tokens upon being told to do so by the BT or a person in the room can provide the tokens. Another option is to use existing technology to provide tokens. If you elect to use technology, there are several options available for delivering tokens. You can remotely split the computer screen to show a token system on one side of the screen, use built-in capabilities of platforms to switch control of the screen to the client so he/she can give the token upon correct responding, or use built-in capabilities of platforms to share the screen of an existing token system app. If a token system is being used and earning the requisite number of tokens results in an activity within the client’s room (i.e., access to a preferred toy) you must assess the client’s ability to relinquish the reinforcer. A final possibility here is to incorporate access to preferred videos or songs through the shared screen.

If a token system is not being utilized, a clear plan and schedule of reinforcement should be defined. The plan could include delivery of reinforcement in the form of videos, online games, or apps through the telehealth platform by the BT. If reinforcement includes items that are present in the room with the client (such as edibles or favored toys) then an additional person (such as a parent or older sibling) will be required to be present in the room with the client during sessions.

If the client responds to vocal praise as a reinforcer during in-person sessions, then it should be determined if vocal praise through the screen is also reinforcing for the client. If it is not, a response-stimulus pairing procedure (Dozier, Iwata, Thomason-Sassi, Worsdell, & Wilson, 2012) should be utilized.

Sessions with the behavior technicians or other team members should not begin until the previous steps have been completed and they have been trained on both the platform for delivering services and the steps for implementing programs and delivering reinforcement.

Train the behavior technician how to implement discrete trial instruction through telehealth.

Discrete trials training can be implemented as it typically is, though technology can be utilized to streamline the process when images, text, or videos are used. Cummings & Saunders (2019) utilized PowerPoint 2016 to create matching-to-sample trials for use in discrete trial instruction. Blair & Shawler (2019) identified best practices and provided a tutorial for developing and implementing emergent responding through computer-based learning tools. In addition, there are apps such as Kahoot or Quizlet Learn that can be utilized. It’s also possible to run trials with materials in the room with the client and have the parent/caregiver help set up materials appropriately. For example, the parent can put five items on the table, and the behavior technician can say “hold up the frog.” The client would then hold up the named item.

It is essential that any technology components that you introduce are clearly understood by the BCBAs and the behavior technicians. Our recommendation is that brief video models be provided (i.e., video-supported task analyses) so that the steps of implementation are clear to all team members implementing services. After video models have been viewed, the BT should practice implementing the technology with the parent or the BCBA prior to conducting a direct care session.

If it has been determined that the client does not yet have the prerequisite skills for the behavior technician to implement services through telehealth, the BCBA should train parents to implement discrete trials as well as any other interventions (Ward‐Horner & Sturmey, 2008). Hay-Hansson & Eldevik (2013) outlined a procedure for using videoconferencing to train discrete-trial instruction teaching.

Consider how visual schedules and supports may be used.

Visual schedules and supports can be presented on the screen, utilized through a separate app (such as Todo Visual Schedule or Choiceworks), or made with pre-existing materials that are in the home. If you elect to use a separate app for the visual schedule, ensure that the BT has mastered the platform for providing instruction before implementing additional technologies.

Consider how to implement Active Student Responding (ASR).

Drevno, Kimball, Possi, Heward, Gardner, & Barbetta (1994) identified clear procedure for implementing error corrections during ASRs. With the use of technology as described previously (such as Microsoft PowerPoint), error corrections can be made quickly because they can be built directly into the presentation.

Ultimately, as you review the suggestions, two things become very clear. First, we must consider the training needs of the client to effectively participate in treatment through telehealth. Second, we must consider the training needs of the practitioners who will be implementing treatment to ensure they can effectively put these practices in place. More than ever, we must assist each other in providing resources: sharing video tutorials for how to implement specific technologies, identifying technologies that will allow us to better implement services, and identifying platforms that reduce response effort and training needs for BCBAs and BTs.

Helpful Links

References

Blair, B. J., & Shawler, L. A. (2019). Developing and implementing emergent responding training systems with available and low-cost computer-based learning tools: Some best practices and a tutorial. Behavior Analysis in Practice, 1-12.

Cummings, C., & Saunders, K. J. (2019). Using PowerPoint 2016 to create individualized matching to sample sessions. Behavior Analysis in Practice, 12(2), 483-490.

Dozier, C. L., Iwata, B. A., Thomason‐Sassi, J., Worsdell, A. S., & Wilson, D. M. (2012). A comparison of two pairing procedures to establish praise as a reinforcer. Journal of Applied Behavior Analysis, 45(4), 721-735.

Drevno, G. E., Kimball, J. W., Possi, M. K., Heward, W. L., Gardner III, R., & Barbetta, P. M. (1994). Effects of active student response during error correction on the acquisition, maintenance, and generalization of science vocabulary by elementary students: A systematic replication. Journal of Applied Behavior Analysis, 27(1), 179-180.

Ferguson, J., Craig, E. A., & Dounavi, K. (2019). Telehealth as a model for providing behaviour analytic interventions to individuals with autism spectrum disorder: A systematic review. Journal of Autism and Developmental Disorders, 49(2), 582-616.

Hall, C. M. (2018). Parent consultation and transitional care for military families of children with autism: A teleconsultation implementation project. Journal of Educational and Psychological Consultation, 28(3), 368-381.

Hay-Hansson, A. W., & Eldevik, S. (2013). Training discrete trials teaching skills using videoconference. Research in Autism Spectrum Disorders, 7(11), 1300-1309.

Machalicek, W., Lequia, J., Pinkelman, S., Knowles, C., Raulston, T., Davis, T., & Alresheed, F. (2016). Behavioral telehealth consultation with families of children with autism spectrum disorder. Behavioral Interventions, 31(3), 223-250.

Peterson, K. M., Piazza, C. C., Luczynski, K. C., & Fisher, W. W. (2017). Virtual-care delivery of applied-behavior-analysis services to children with autism spectrum disorder and related conditions. Behavior Analysis: Research and Practice, 17(4), 286.

Vismara, L. A., McCormick, C., Young, G. S., Nadhan, A., & Monlux, K. (2013). Preliminary findings of a telehealth approach to parent training in autism. Journal of Autism and Developmental Disorders, 43(12), 2953-2969.

Wacker, D. P., Lee, J. F., Dalmau, Y. C. P., Kopelman, T. G., Lindgren, S. D., Kuhle, J., … & Waldron, D. B. (2013). Conducting functional communication training via telehealth to reduce the problem behavior of young children with autism. Journal of Developmental and Physical Disabilities, 25(1), 35-48.

Ward‐Horner, J., & Sturmey, P. (2008). The effects of general‐case training and behavioral skills training on the generalization of parents’ use of discrete‐trial teaching, child correct responses, and child maladaptive behavior. Behavioral Interventions: Theory & Practice in Residential & Community‐Based Clinical Programs, 23(4), 271-284.

Citation for this article and for survey:

Blanco, S., Meisels, M., Blair, B., & Leonard, L. (2020). What are some strategies for implementation of evidence-based telehealth practice in the time of COVID-19? Science in Autism Treatment, 17(4).

Blanco, S., Meisels, M., Blair, B., & Leonard, L. (2020). Telehealth Preparedness Survey. Science in Autism Treatment, 17(4).

Note: The survey can be accessed here.

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