Telehealth – Clinical Applications to Real Cases

In recent years, telehealth has slowly extended into the world of applied behavior analysis (ABA) services. The COVID-19 pandemic has accelerated demand and adoption of telehealth in ABA therapy services to maintain continuity of care and produce meaningful outcomes for clients. A 2020 BHCOE webinar, Telehealth: Clinical Applications to Real Cases, shares best practice recommendations, highlighting strategies and resources for developing a telehealth model of service provision.

The webinar included in-depth discussions of three real-world cases featuring three ABA telehealth delivery model.

1. Parent training and coaching in which parents carry out the assessment and intervention
2. Supervisor-mediated telehealth in which the Registered Behavior Technician (RBT) is connected with the supervisor via telehealth and delivers in-person ABA treatment to the client
3. Direct therapy in which the RBT provides ABA treatment via telehealth

In this blog post, we’ll focus on the parent training model.

Telehealth Parent Training and Coaching

Parent training and coaching via telehealth is well-supported by research. Essentially, parents are coached to carry out procedures and interventions, such as teaching communication, using speech-generating devices, discrimination training and other interventions. While remote training offers a number of advantages, it also poses some unique challenges.

In the webinar, Jacob, a six-year-old boy with Autism Spectrum Disorder, was highlighted.  Below are some clinical and technology considerations for delivering parent training and coaching to Jacob’s mom:

Risk Assessment

With telehealth parent training and coaching, there are a few additional steps to the intake process. The first is to determine whether the client would be a good fit for telehealth services by conducting a telehealth risk assessment. The risk assessment should uncover behaviors of concern, the caregiver’s ability to participate in sessions, and home technology resources. Jacob engaged in tantrums involving crying, kicking, property destruction and hitting, as well as pre-cursor behaviors. His mom was very motivated to participate and had reliable internet access and a laptop at home.

Informed Consent

Informed consent must be obtained for the client’s participation in telehealth services. The consent document should outline how assessment, parent training, and treatment via telehealth will look so that families can make fully informed decisions about their participation. The consent document should include language consenting to the use of video, audio, and recording.

Equipment Needs

Prior to beginning telehealth services, assess the family’s equipment needs. While many households have a computer or tablet and internet access, it can be helpful to equip them with a web camera for better viewing of the session. In addition, a Bluetooth headset allows you to discretely communicate with the caregiver while he or she implements an intervention. A HIPAA-compliant video conferencing platform is also needed. Also be sure to have an equipment loan agreement that outlines the equipment loaned to the caregiver and what to do if the equipment is lost, stolen, or damaged.

During a pre-intake phone call, help the caregiver install and test equipment and provide checklists on how to use the technology, as well as troubleshooting documentation. Also consider developing criteria for terminating a telehealth session if a problem behavior becomes too intense. With Jacob, the team determined five levels of termination criteria, from level 1, screaming, to level 5, hitting. If Jacob engaged in five or more instances of level 5 problem behavior, the session was terminated.

Telehealth Treatment Intake

The treatment intake begins with a functional assessment interview with the caregiver only to understand the patient’s behaviors. From there, a session with both the caregiver and child takes place to collect ABC data. In Jacob’s case, a trigger analysis was conducted, which involved removing an iPad to evoke a tantrum. During the trigger analysis, his mom was coached to deliver the antecedent and then instructed to do what she normally does to manage the behavior.

Behavior Skills Training

The behavior skills training for a caregiver is similar to the typical BST package, except it is delivered remotely. In Jacob’s case, his problem behavior was found to be maintained by access to tangibles. The team developed a choice intervention plan with tolerance training. The RBT began intervention plan training with mom via telehealth, sending choice intervention instructions a day before the first training. During the training, the RBT reviewed the instructions with mom and then showed a video model of the intervention. Rehearsal and feedback occurred until Jacob’s mom reached mastery.

Over the time, as the client makes progress, caregiver coaching sessions can be faded. Eventually the caregiver may be able to implement sessions on their own and collect and send data to the clinician.

BHCOE’s webinar on Telehealth: Applications to Real Cases also included real cases that illustrated the supervisor-mediated telehealth and direct therapy telehealth models. Watch the full webinar, including illustrative video vignettes, here.