Telehealth Results by Tien Nguyen and Mia Singleton

Introduction 

Due to the nationwide pandemic, many countries were affected by the exposure to the coronavirus disease (COVID-19). Individuals worldwide had to self-quarantine to reduce the risk of infection or transmitting the virus unknowingly to a person; this has altered the daily lives of individuals. As a result, at BASICS we began researching alternative avenues to establish how we can better meet the needs of our clients as their environments and daily schedules changed. We realized we needed to pursue telehealth to conduct ABA sessions. We explored the available resources and realized there was a lack of previously published research on this subject. We watched ABA companies quickly pivot but were concerned that services were not meeting our company values of Innovative, Ethical, and Excellent. So, we did as much research as we could, started a telehealth accreditation process with BCHOE, and began a study that evaluated the effectiveness and feasibility of our telehealth interventions for ABA therapy to administer services to our clients and support the parents.

What is the purpose of our study? 

The purpose of this study is to look at how telehealth may change the nature of our work. We wanted to determine whether telehealth was just as effective as in-person. We wanted to look at how telehealth may affect caregivers and therapists’ stress levels and to what extent it empowers them to implement behavioral interventions. To provide telehealth, we also needed to have certain technology in place for video calls. We wanted to look at whether our current technology is sufficient to effectively provide telehealth. Lastly, we wanted to know if the telehealth model would support the health of the company. 

Hypothesis

At BASICS ABA Therapy, one of our goals when designing a behavior intervention plan is to ensure that most, if not all, of the goals can be run in any setting across many situations. When designing goals for telehealth, we kept this goal in mind. That’s why we hypothesized that telehealth would be as effective as in-person therapy sessions. The idea was that telehealth goals would be the same as in-person goals. However, caregivers would play a bigger role in supporting the learner. As caregivers got more involved with the program and played a bigger role in supporting the intervention, they would feel more empowered to consistently provide behavioral intervention. Caregivers would be given more opportunities to practice behavioral intervention to aid the learner. We know from experiences that families that are more involved in the behavior intervention programs see higher successes in behavioral change. With more behavioral changes from the learner, families and therapists would lower their stress levels. This is because behavioral changes may result in more opportunities for play and enjoyment for the learner. This directly impacts the living environment of the learner’s entire relationship circle. As we learned and adapted to the telehealth environment, more variables affected how technology aided in the services being provided. We wondered if the current technology available to our company may not be sufficient in providing telehealth. This was because different households may have different internet connections. Different families may have access to a variety of devices that may not be compatible with our devices to run through the therapy session securely and efficiently. Lastly, telehealth would allow our company to stay open and thus, contribute to the health of the company. 

What did we do to prepare and come up with the criteria? 

To effectively collect our data, we had to compile multiple criteria to ensure that different aspects of telehealth can be measured. We looked at the purposes of our study and determined survey questions that may accurately measure those criteria. Since our questions involve measuring the stress of the caregivers and therapist, we had to come up with a rating scale that can be used across all the criteria. We determined that a rating scale between 1 and 5 would be sufficient and easy to use across all the participants; with 1 being “strongly disagree” and 5 being “strongly agree.” In order to determine the stress level and empowerment across all parties, participants in the study had their own survey. This means that therapists responded to a different survey than the caregivers. Learners that are able to respond to online surveys were also given their own survey to participate in. The different forms of the survey ensure that we tailor the criteria to fit the different relationships the learner may have. 

We had to determine whether telehealth was possible for our participants before they signed up for the study. This is because we were not positive that each insurance plan that our families participated in covered telehealth. Once we were able to determine who was eligible for telehealth, we also had to determine whether it was safe for the caregivers to support the clients for telehealth. For example, clients that display aggression towards their caregivers would not be eligible for telehealth. This is because it would not be ethical to require parents to support these clients. Since the nature of telehealth required the caregivers to be present 100% of the session, it would not be safe for the caregivers if their child displayed aggression towards them. We also had to look at whether the environment in which the child lives is suitable for telehealth. Parents also had to want to receive telehealth. Lastly, we made sure that families can opt in and out of the study any time. 

         We also ensured we met the requirements for HIPAA for online services. Many requirements were put on hold through emergency legislation, but we got BAAs to ensure our software and communication modes were HIPAA Compliant. We also ensured we had multiple platforms (Zoom and Meet) so it could be accessed from various types of devices. We also found that families were able to access the internet- either through existing technology or through government technology grants. 

How did we train our staff? 

We were able to train our staff through training sessions designed to teach them about the new concepts and procedures of telehealth. We were able to test out our telehealth methods in a few sessions to determine any issues that we may need to troubleshoot. Certain new procedures were put in place in order to successfully have telehealth sessions. For example, we had to come up with procedures on what to do if a learner becomes unsafe during the telehealth session. Staff were given telehealth training by our trainer. We also made sure to go over new procedures with them. Most importantly, the supervisors overlapped with the staff on their first telehealth session with each learner. 

How did we prepare the families for telehealth? 

In order to qualify for telehealth, we must determine whether or not the learner’s behaviors will allow for effective sessions. We also determined whether or not the caregivers were able to support the learner during the telehealth sessions. This was done through a formal meeting between the BCBA 

and the caregiver. During this meeting, we went over concepts and skills that the caregiver may need in order to support the learner. We also discussed safety procedures and other concerns that the caregivers may have. We also determined any barriers that may prevent effective telehealth sessions. These barriers were then addressed. A formal document was filled out in an attempt to address all barriers. Unfortunately, the telehealth model did not work for some families due to unsafe behaviors from the learner and skillset of the caregiver. To effectively apply a behavioral intervention program, we must promote the safety of our staff, the learner, and anyone the learner interacts with during the session. For example, it would be unethical for the caregiver to support a learner that displays high levels of aggression if the caregiver is not properly trained on physical management procedures and de-escalation. We look forward to further training on how we can implement this type of training. 

What did we do to obtain data for the study? 

Our data consisted of surveys answered by the caregivers, learners (if they’re able to), and the staff. Each week, the participants filled out the survey questionnaires. Reminders were sent to families and staff each week to fill out the survey questionnaires. Each family was set into their own groups so data can be compared week after week. This allowed for us to keep track of any concerns that the families may have and address the issue as soon as possible. Only families with 3 or more surveys completed were used in the study. Families that did not meet requirements were omitted at the end of the data collection. However, we still ensure that those families’ concerns are addressed in order to maintain service quality. 

How did we troubleshoot issues? 

When conducting the study, we had therapists fill out a "Technology, Compliant, and Paise" google form at the end of each telehealth session. The therapists could utilize the google form to report the caregiver's experience with ABA Telehealth, any concerns the caregiver or the therapist had, and some technical issues that arose during their online session. 

Were there any technology issues? If so, what were they? What was our initial result? 

The data collected from the "Technology, Compliant, and Paise" have shown a few connectivity issues such as audio delays, the device the individuals were using was not working, or the screen display being delayed. Caregivers and therapists had some speculation about the effectiveness of ABA telehealth and if the number of hours would be adequate for the learner. However, after analyzing the data, the finding suggests caregivers and therapists were pleased with ABA online services and their ability to learn new skills using a new platform in delivering services.  The results also reported that caregivers and therapists were satisfied with their learner's progress. Overall, caregivers and therapists found ABA telehealth suitable and happy with the service being remote from home. 

What was the result of the client-answered survey? 

Clients who were able to answer a short questionnaire survey by themselves were able to do so. The surveys were similar to the ones that caregivers filled out. Data collection began on May 9, 2020 and ended on January 9, 2021. The data collected indicated clients found ABA. online to be beneficial in helping them within their households and were able to learn skills during their telehealth sessions. The data showed clients that participated in telehealth received more structure in their day. As a result, clients express having fewer outbursts and feeling less upset from using online ABA. Clients were asked if their personal schedules made them inaccessible for receiving online ABA. The findings indicated that they were available and open to receiving ABA through Telehealth.

Moreover, we wanted to see if the learners felt they were being supported at home with their guardians, and reports have shown that they were satisfied with the assistance they were receiving in coping with their challenging behaviors. Similar clients were pleased with the number of hours they were receiving for ABA Telehealth. At the end of the survey, clients were asked, "if the COVID-19 crisis were not happening, I would want to do online ABA," and the data showed clients would remain interested in online ABA as an alternative way of receiving services.

What was our result at the end of the study? 

The data shows that 83% of all the kids showed positive change and became more engaged. We also researched what the parents were feeling and 33% of parents felt more empowered. However, 33% remain the same with being empowered. The rest felt less empowered. 20% of the therapists would not do telehealth if there were no pandemic and 80% of therapists would continue to do telehealth if there were no pandemic. 100% of the therapists felt that they were being supported.  100% of the therapists felt like they were gaining new skills to provide therapy. 

Were there any differences in the ages of the clients?

We had a variety of ages for this study. The majority of the participants were teenagers ages 13 to 17. We had one preteen aged 9. Lastly, we had 2 children ages 4. Our data showed that the preteen did not benefit from telehealth throughout the data collection of this study. Even though the parents felt more supported as the study progressed, the participant’s behaviors appeared to have deteriorated. We had more success with clients that were teenagers at the time of the study; ages 13 to 17 years old. These participants were able to add more structure to their day and gained new skills. The parents also felt more empowered to work on more skills with their children outside of telehealth. For our participants that were 4 years old at the time of the study, telehealth also appeared to support the participants and their behaviors. Parents felt more empowered to work on skills outside of the session and the program provided more structure for the families. One of these participants had increased high magnitude behaviors that were ineffective. However, the family felt that they were being supported. 

What is our conclusion? 

Majority of participants showed positive behavioral change and became more engaged. The overall data did not support that telehealth allows families to feel more empowered. However, families did feel more empowered to work on skills outside of the sessions and to try new methods. 

Therapists and families were pleased with the technology used to provide the service. They also were pleased with the services. 

For the therapists that worked with the participants during telehealth, they were being supported by admin and supervisors throughout the whole process. The majority of the therapists did not have an increase in the level of support by the supervisor. However, they all felt adequately supported. They also felt less stress during telehealth. However, it should be noted that this criteria did not change throughout the data collection process. This means that the therapist’s stress levels were consistently the same throughout the data collection process. The majority of therapists consistently said that they would still want to do telehealth if there were not pandemic. 

How does our conclusion be applied to the real world? 

The data suggests that telehealth can be used for children and teenagers to supplement their ABA services. During a world pandemic, this is an alternative option to receiving in-person therapy since the alternative would be to not receive any ABA Therapy at all. Telehealth also supports an ABA company since our company was able to remain open throughout the entire pandemic. We must also note that some clients that did not receive telehealth were able to continue to receive in-person ABA Therapy. This means that telehealth is a great way to supplement the number of hours lost from the pandemic. However, not every client is going to benefit. Precautions should be made individualized for each client. Even though telehealth is new, we still have to make sure that our ethical guidelines are followed. 

What were our limitations? 

There were several limitations we ran into during the study and from analyzing the result of our findings. In the study, we had two participants who were able to fill out the short questionnaires on their own instead of their caregiver filling out the survey. The participants’ experience may have been vastly different from their caregivers’. However, we utilized these 2 forms of the surveys to come up with our conclusions about the results of the study. This may have affected our results. Due to the low number of participants, the findings of the results may not reflect the entire company or real-world settings. In addition, the surveys were self-reporting. This means that they may not have captured the true intent of the person filling out the survey. Another limitation was the data could have been skewed from the participant's internal or external conflict, such as having a difficult day or not feeling well. Those that filled out the survey may have interpreted the questions differently since we did not go over the survey questions with the participants. More data are needed in order to fully support our findings and our hypothesis. 

“I should change the topic” by Jordan Hoskinson

We all have things that we are passionate about. Maybe it’s something that we are studying, a comic book, a game we love, a book we read, or a TV show that we watch regularly. Most of us have a topic that we know a weird amount about, and we love to discuss it with others! For example, I could probably discuss Harry Potter or the Marvel Universe with someone all day. I would love to share theories, favorite characters, and random facts with other people. I am able to refrain from doing this though because I have learned how to be open to having a conversation about a different topic.

A skill that is typically worked on in ABA is learning how to change the topic. As the client chats away about their passion, therapists may feign boredom by sighing, glancing around the room, or they may even tell the client that they are bored. Think about that for a second - imagine sharing your joy and passion with someone and their response is to tell you that they are bored. Wouldn’t that make you question if someone is bored whenever you are having a conversation with them? 

My son is autistic and his favorite thing in the world is Pokémon. He plays the games, he collects the plush toys, he watches the different shows and movies, and he absolutely loves to keep me updated about all things Pokémon. When Gabriel meets other people, he has a solid and sure base on which to begin conversations. He may use facts about Pokémon as an icebreaker because it’s something that he knows a lot about, so he feels comfortable chatting about it. Pokémon gives him a sense of order and predictability in a world that is often too loud and always changing. Sometimes Gabriel has a hard time disengaging from a topic about Pokémon, so I may tell him, “I just do not know as much about Pokémon as you do, so I have a hard time having a conversation about it. Can we talk about something else?”

As a clinician it is important to teach these skills in a way that doesn’t do harm. At BASICS ABA Therapy it is incredibly important to us that we are creating programs that are kind and showcase how awesome our clients are! We do not want our clients to be afraid that they, or their interests, are boring - it could cause additional stress when they are engaged in a conversation and damage their self-esteem. Instead of showing the client how disinterested we are, the listener should instead ask the client to change the topic - if the client struggles to come up with a different topic, then we can assist them by suggesting some other things to talk about. For example, “I love when you share facts about Pokémon with me, but right now I’d really like to know more about how your school day went! Let’s talk about school for a little bit!” This encourages the client to have a different conversation without having to worry that someone is bored whenever they speak. It also ensures that we are not discouraging clients from loving what they love. Like all children, autistic children need their interests to be encouraged, praised, and streamlined into skills that will help them throughout the rest of their life.  

Why Do We Run Natural Environment Goals By Ashiee Best

Why do we run natural environment goals?

 Natural environment goals, or a natural environment teaching (NET), describes the method of providing ABA therapy by using in real life situations as teaching moments. This method of teaching is often used for individuals on the spectrum to help them generalize skills and behaviors.

 Why is NET important?

 This method often helps with teaching generalization of skills! It can help with social skills, language, and even motor skills. During NET, the child is engaged in a preferred activity and because the activity is preferred, it doesn’t even feel like work! The child is more likely to stay engaged. Also with NET, the environment is already reinforcing so the child stays motivated.

 What does NET look like?

 An example of NET could be if a therapist (Tx) was working on self advocating with a client. Instead of saying "I want that", the client may just take it. The Tx would first teach the child how to advocate with people they are comfortable with (parents, siblings, therapist). After being comfortable with some self advocacy language, the Tx can practice the skill in a natural environment (like the playground). 

The client is playing, but Tx noticed their client watching other children play with their toys. The Tx could prompt or guide the client to ask to have a turn. The client can get 1 of 2 reactions.

 If the client just takes it, he won't get the reaction he wants, but if he gives the correct response, the kids allow the client to play with their toys. Both of these outcomes would be the natural consequence. Positive reinforcement; he gets to play with the toys, that feels good! Or punishment; the other children don't share or play with him. This is a step in generalization because this reinforcement would occur more often as the client begins to retain the skill and more like it. The client is being reinforced by their environment, not the therapist. 

Another Example of this could be done in a classroom if you are teaching a client to tact (label) colors, this could be done while playing with paint. As the client continues to need more colors, the behavior technician could use that as an opportunity to get the client to label the colors they are reaching for before or as they are receiving them. The therapist can give extra reinforcement, but the client is naturally reinforced by receiving the color they want. The activity is fun, rewarding, and the client is still getting their therapy!

Parent Involvement in Education

Education in society is an essential need and begins as young as two years old and can continue for many decades. During the early years of education through college, parent involvement is key to the success of all students. However, that is not always the case for some students  in elementary school  who are left alone to figure out their next steps in their educational path.

• What we know: Parents tend to lack involvement in their children's educational needs after elementary school. This happens for many reasons such as divorce, a struggling single family, families being embarrassed because of a lack of understanding about school related topics and an uncertainty about commitment to the student and the school for each child (LaBahn, 1995). 

• What we don’t know: The current research shows why parents may be less involved. What we don’t know is how soon they become less involved, and do they resurface with involvement or is it a drastic halt? 

• Need for further study: Most of the studies that are completed are for early education. However there needs to be more research about the  high level of parental involvement in their child’s education from middle school to post-secondary avenues. This could possibly explain why parents lose interest as the child goes further into their education. (Dwyer. and Hecht., 1992. P. 282).

• The involvement of the family unit is key to our children's success in school at all levels.  Helping that child stay focused and providing a sense of protection for children who may struggle in their academics and can be left behind if the parent is not aware or paying attention.

• The list below offers  a few tips for family involvement that may improve the child’s education interaction. 

  • Making sure the child is present for school and on-time. 

  • Attending open houses, parent teacher conferences, and school activities.

  • Checking in with teachers at least once a month, if you notice your child is not improving check in more frequently.

  • Join the PTA or committees.

  • Track daily agenda checks on your personal calendar, google classroom, or outlook.

  • Create a goals board in the house to check off school assignments that were completed for that week to be tallied for a reward. 

  • Ask your child what they learned in school and what their emotions are about school every other day or weekly.

• Education can be a learning experience for the whole family don’t miss out on the adventure!

References: 

LaBahn, J. (1995). Education and parental involvement in secondary schools: Problems, solutions, and effects. Educational Psychology Interactive. Valdosta, GA: Valdosta State University.

Dwyer, D., & Hecht, J.B. (1992). Minimal Parental Involvement. School Community Journal, 2, 53-66.

By: Kelli R. Matthews 

Interview with Saundra Bishop, CEO and Clinical Director of BASICS ABA Therapy, LLC by Kristin Thomas.

1. What is your definition of equity, diversity, cultural humility here?

I guess to me it means that this company attempts to give equal voice to all stakeholders. That everyone has the ability to be a stakeholder regardless of demographic (anyone can be a client, RBT, BCBA). It means that we are constantly learning about equity, diversity, and cultural humility and applying that knowledge. It means we treat everyone with respect and do our best to educate people to challenge bias.

2. What is your goal of equity within BASICS?

I want to be sure to provide access to our services to as many people as possible and provide opportunities for employment without excluding people of diverse populations. Before COVID we had a lot of initiatives in place that supported this mission- we allowed staff to send their kids to aftercare for free, we accept vouchers, we accept Medicaid, we hire staff brand new to the field with high school diplomas and coach them up. However, when COVID happened the aftercare closed and so childcare and vouchers went away too. Our families that had Medicaid were more likely to live in multi-generational homes and so they stopped services and when training went remote the staff had a harder time with it because they were not used to a college like training environment since it wasn't hands on like it used to be. So, I really want to work on making this new normal more equitable. I also want to continue to grow and challenge myself and the entire team to do better.

3. Your BCBAs and RBTs provide ABA services to families from diverse populations how are they equipped in cultural competence?

Each of our staff take several different webinars through various companies in cultural humility. Also, we are members of the ABA taskforce and the Black Applied Behavior Analysts. All of our programs are assessed to make sure that they meet a cultural competence standard such as pictures of materials that match the skin color of the students and programming that is culturally relevant. Our intakes also include questions which ask parents about cultural needs and barriers so that we can ensure that we aren’t making assumptions about the cultural factors that the specific clients need in their programming.

4. Why is equity, diversity, cultural humility important?

This is a field predominantly dominated by middle-aged white women and particularly in the District of Columbia most of our clients are boys and young men of color. It’s important that we’re teaching social skills and communication skills that are appropriate for the communities our students live in and we’re not teaching them to act like white women. We also want to ensure that RBTs and BCBAs are trained in a way that makes them feel comfortable to be in this field. If people feel like they can only run programming in a certain way, then we will not be able to grow and change. Our field can only get better if we have a variety of voices.

5. What qualification does the teacher have to provide social and communication skills in communities of color?

It's a good question and something constantly evolving. Right now, we review social and communication goals through the lens of social justice movement writings, training and writings written by Autistic people and clinicians that are BIPOC. We also are very lucky to have a diverse staff, leadership team, and BCBA team and are able to run goals through the team as needed. However, the primary thing we do before starting an actual program is to check with the parent that the goal is being taught the way they want it taught.

6. Does your company, including leadership, receive and implement training on diversity, equity and inclusion?

Yes- All new hires and staff take an online training on diversity and humility. New hires also have an orientation with the CEO where we review cultural acceptance policies relating to disability, LGBTQ and race and ethnicity. We do continuous refreshers at team meetings. All our programming has a focus on cultural competency and diversity which is reviewed with the staff during their supervision sessions. Cultural competency is a key component of lesson planning in the Beyond the BASICS program as well.

7. How does equity, diversity and inclusion improve the quality of the work of all of BASICS’ staff as well as employee engagement?

Staff have said it makes them feel heard and more likely to go to HR with concerns or bring ideas and initiatives to leadership. Because these policies are in place it makes our programming more clinically appropriate. It also means that we have an amazing diverse team that can create our clinically appropriate programming.

8. You work with colleagues and clients from diverse populations. How important is cultural competence to you?

It is one of our most essential values. When we talk about our company being innovative, ethical or excellent, cultural competence falls within that ethical paradigm. I talk about this in every training I do. It applies to every area of our work whether it is trauma or training on mask wearing or COVID safety. Every single program you write needs to take into account cultural factors.

Do you offer ABA during the school day?

Yes! 

If your insurance allows it, we can support during the school day. Some programs prohibit us from working during the class schedules but we may be able to work when the ;synchronous classes are not in session

This is what it looks like 

During virtual learning, the kiddos can be logged in to their virtual class. Their therapist will be next to them. When the therapist needs to prompt the student or remind them of something, they will do so. However, the main focus for us during virtual learning is to have your kiddo focused on the directions of their teachers, and do what they are supposed to be doing during virtual class. The focus is on self advocacy, social skills, self help, and communication. 

For example, a student is having a hard time with his virtual classroom, and is not looking at the screen. The therapist will remind the student to look at the screen or ask for a break. The therapist may vocally remind the student or will be there to physically remind the student. This can be done with a shoulder tap or gesturing at the screen. During virtual learning time, we may record data on natural environment success for the medically necessary procedures. 

For students only getting services outside of synchronous times, we will work on goals just like in regular ABA sessions focusing on the natural environment and appropriate goals for the setting.  

We can support with 

• Paying attention to the screen

• Following teacher’s directions

• Communicating with peers or teachers

• Sitting in one spot

• Classroom activities

• Motor Skills

• Helping the student do an activity directed by the teacher

• Soothing behaviors

• De-escalation

• Self advocacy

• Executive Functioning (organizing)

Can my kid sit through all their classes?

This is hard for almost all children right now! This is a skill that many of our kiddos are currently working on in their ABA program and throughout their daily routines. So it will be a challenge to get them to suddenly sit through a longer classroom session. That’s why we are also practicing other strategies with the students in order to prevent escalation. For example, taking breaks throughout the virtual learning session. 

Why are they taking so many breaks? 

Breaks are there to help to prevent the student from getting too stressed out and needing to use ineffective behaviors. We want to ensure that students are relying on more effective methods to escape from the virtual learning environment instead of using ineffective ways if they need a break to stretch, rest their bodies, or clear their heads. This way, the student is able to practice more functional and effective skills. 

Are you actually running goals?

Yes, goals will be different based on the student. However, we have put in place goals that can be run during the virtual learning environment as well as out of this time. For most of our kiddos, the goals are often more subtle and embedded into the online school environment. 

Can my kid do school with a mask on? 

For kids wearing masks, they definitely can wear their mask for the entire session and during their virtual learning session. As part of our COVID-19 safety precautions, kids, their family members, and therapist are wearing masks during the entire ABA Therapy session. For our kiddos that are working on wearing their masks during their ABA time, wearing a mask may be worked on during virtual learning if appropriate.