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 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 a 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 (Ferguson, Craig, & Dounavi, 2019; Peterson, Piazza, Luczynski, & Fisher, 2017; Vismara, McCormick, Young, Nadhan, & Monlux, 2013; Ferguson et al, 2019).
The first priority when implementing services via telehealth is to ensure you are using a HIPAA-compliant platform, such as Doxy.me or WhatsApp. 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. However, in the current crisis, it is necessary that direct care be provided through telehealth. In order to effectively provide direct care, we are suggesting the following steps in order to appropriately implement telehealth services.
(1) Assess prerequisite skills and unique needs of the client. An assessment and survey is provided at the end of this article (Appendix A). 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. 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. 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, etc. There are many options for how the screen is presented to the client.
(2) Conduct parent training to adequately prepare for telehealth. Prior to any direct care provided by a behavior technician, 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 a clear plan should be developed and implemented for how the parent/caregiver will assist with prompting and providing reinforcement during sessions with the BT. 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 clear plan for giving feedback to the BCBA throughout the process.
(3) Identify reinforcers and how reinforcement will be provided. A preference assessment should 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, you can remotely split the computer screen to show a token system on one side of the screen, use built-in capabilities of platforms such as Microsoft Teams 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 BT should not begin until the previous steps have been completed and the BT has been trained on both the platform for delivering services and the steps for implementing programs and delivering reinforcement.
(4) Train the BT on 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 is essential that any technology components that you introduce are clearly understood by the BCBAs and the BTs. 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 practitioners 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 BT to implement services through telehealth, the parents should be trained on implementing discrete trials. Hay-Hansson & Eldevik (2013) outlined a procedure for using videoconferencing to train discrete-trial instruction teaching.
(5) 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.
(6) Consider how to implement Active Student Responding (ASR). Drevno, Kimball, Possi, Heward, Gardner, & Barbetta (1994) identify a 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.
Download Appendix A: Telehealth Clinical Effectiveness Survey here.
Mordechai Meisels is the Founder and Chief Clinical Officer of Encore Support Services, a leading provider in special education and ABA therapy services. Under his leadership, Encore quickly expanded across state lines, servicing thousands of children in the Tri-State area. Mordechai’s vast expertise in the behavioral health industry inspired him to fill a critical void with the founding of Hadran Academy, a high school for high functioning autistic youth. In true visionary form, Mordechai combined his background as an expert clinician and passion for technology with the creation of Chorus Software Solutions. As the Founder and CEO of Chorus, Mordechai is committed to creating innovative technology to empower care teams, increase operational efficiency, and ultimately impacting quality of care.
Dr. Bryan J. Blair is a licensed behavior analyst (MA), Board Certified Behavior Analyst, and is currently an Assistant Professor at Long Island University – Brooklyn where he is also the coordinator of the Applied Behavior Analysis graduate certificate and supervised fieldwork programs. He has worked with children and adults with developmental disabilities and other clinical disorders for over 15 years in a variety of settings. For more information or to contact Dr. Blair please see his website: https://www.bryanjblair.com.
Laura Leonard MS BCBA LBA is the owner and clinical director of ABA TREE, a behavioral health agency in NYC, former ABA director of an early intervention program and current Director of Behavioral Services at a private school in Brooklyn. Laura provides supervision to BACB candidates and is primarily focused on reduction of maladaptive behaviors. www.abatree.org
Sam Blanco, PhD, LBA, BCBA is an ABA provider for students ages 3-15 in NYC. Working in education for sixteen years with students with Autism Spectrum Disorders and other developmental delays, Sam utilizes strategies for achieving a multitude of academic, behavior, and social goals. She is also an assistant professor in the ABA program at The Sage Colleges, and she is the Senior Clinical Strategist at Chorus Software Solutions