Teaching Functional Skills via Telehealth

Emma A. Craig, Katerina Dounavi,Jenny Ferguson, “Telehealth to train interventionists teaching functional living skills to children with Autism spectrum disorder”, Journal of Applied Behavior Analysis,2021,54,511-529.

This study has been conducted regarding the effectiveness of telehealth on children with ASD (Autism Spectrum Disorder). ASD is known as a development disorder associated with limited socializing, impairment in communication skills and restrictive behaviors (American Psychiatric Association, 2020).The Board Certified Behaviour Analysts (BCBA’s) are less in number as compared to the prevalence of Autism outside United States. In order to increase the accessibility to professional individuals the need of effective interventions should be made through the science of Applied Behaviour Analysis (ABA) (EBP;Dillenburger,2011; Reichow ,2012;Reichow et al.,2018;Steinbrenner et al,2020; Wong et al,2015).

The accessibility to ABA is much smoother in the US as compared to the countries other than United States. In other countries it is not only difficult to access ABA professional but ABA itself is surrounded by misconceptions. For instance in many European countries ABA is not covered by the Government insurance so many individuals have to seek ABA by paying themselves (Dillenburger et al., 2006; Fennel & Dillenburger, 2018; Keenan et al., 2015). It has been observed that a large majority of practitioners obtaining BCBA certifications were US based whereas despite being higher Autism prevelance rate in other countries such as UK, UAE ,Serbia,Greece and Pakistan trained professionals are less in numbers.

To cope-up with this issue and to provide accurate training to the designated professionals BACB came up with an idea to use Telehealth in order to provide health services digitally via laptops, video conferencing, mobile phones etc. As per the author’s information only one study has been conducted to demonstrate the effectiveness of telehealth to teach functional living skills to the individuals with Autism (Boutain et al., 2020). Functional living skills include skills that are required to manage daily life tasks independently. The purpose of the following study was to train professionals who deal with Autistic individuals and resided outside the premises of United States through Telehealth. Principles of behaviour analysis and certain interventions that focus on functional living skills were taught to the professionals.The professionals also known as interventionists received live coaching sessions and they taught children three complex behaviour chains . Similarly effectiveness of online didactic training was also evaluated.

Further more in this study it was also assessed whether the interventionists conducted teaching sessions as intended with high adherence especially in the absence of the coach. A recruitement call was circulated among the professional contacts and social media. There were four eligibility criteria to participate in this study (a)Interventionist should have worked with the child with ASD (b) should be a professional relationship (c) had no prior training in behavior analysis (d) should be fluent in English. Whereas the eligibility criteria for children were (a)if they have been officially diagnosed with ASD and were assessed with certain tools like Autism Diagnostic Observation Schedule, Second Edition (ADOS™-2; Lord et al., 2012) (b) they were between the ages of 2-8 years (c) showed development delays in certain age appropriate behaviors. The participant who conducted sessions in their native language were provided with the second author who translated these languages. School based participants were made sure to conduct study in well-equipped classrooms with table, chair and sink for hand-washing whereas participants in clinical settings were required a room with tables chairs and a bathroom. The following study was conducted by the English speaking behavior consultant first author. This study was further conducted by using nine didactic training PDF documents that were designed on canva. Other materials that were required by the participants were laptops with built in cameras used for video conferencing. Additionally, smart phone was required to record the video footages of the sessions conducted.

To prevent child from distraction interventionists were required to use a wireless bug in ear head phones. Training sessions were conducted by the behavior consultant using laptops with built in microphones. Interventionists without certain materials were loaned a bug in wireless ear phone and a web camera. Videoconferencing software included Zoom™ and Skype™, with QuickTime Player for the purpose of screen recording. In order to send and receive large video files Dropbox and WeTransfer were used. To evaluate the effect of independent variables on dependent variables multiple probe design was used. Dependent variables included interventionists and children. Interventionists were scored negative if they didn’t provide child with a probe and the child couldn’t keep up with the sequence. As for the children they were assessed on three tasks such as getting dressed, making snack and hand-washing.

Baseline skill level was assessed using VB-MAPP and AFLS some how all four children showed shortfall in above required skills. All children were taught with total task chaining procedure. If a child completed 80% of the task list he or she was considered successful. An individualized approach was considered for the completion of tasks and to avoid breach of privacy especially for getting dressed children were taught all the steps in order to get dressed and it was made sure that they wore vests underneath. A cost analysis was done in order to
compare behavior therapy provided onsite versus behvior therapy provided through Telehealth.

The procedure was carried out in five levels such as Baseline in which interventionists were asked to teach the child three target behaviors and upload the footage on the Dropbox. The second step was Didactic Training in which interventionists were provided with one training document further a time was set to meet the experimenter through video conferencing. After the meeting a quiz was carried on to assess the interventionist if a score of 80% was obtained by the interventionist he or she was provided with another training document. If the interventionist scored less in quiz another video session was arranged. The purpose of Didactic Training was to see its effectiveness whether the tasks provided on the document were delivered to the children properly. A total of 9 training sessions were received by the interventionists.

After the completion of all nine didactic sessions interventionists were able to receive live coaching sessions through video-conferencing. In these sessions feedback on treatment fidelity checklist was provided to the interventionists and they were given the opportunity to ask any questions to avoid mistakes and shortcomings. The experimenter would carry live sessions to demonstrate how to carry out a particular skills. Interventionists were required to obtain 80% on treatment fidelity checklist. Follow up probes were collected for three children as one child left the study and changed her class. Intro observer agreement was carried by third and first author.

Intro observer agreement is a term referred to assess the percentage of steps performed correctly on the treatment fidelity checklist and percentage of steps performed independently on the task analyses, for interventionist and child, respectively). Treatment integrity data was collected by the third author. Data was calculated by the percentage of steps performed correctly and it was scored as 100%. Social Validity Questionnaire was designed by the first author and interventionists were required to fill the questionnaire. In this article results were discussed separately for all the skills for instance in case of dressing, children were evaluated independently as all children showed no progress for the baseline, but their progress increased after fifth didactic session. Similarly, almost same results were shown by both the children and interventionists for hand-washing. Interventionists proficiency increased after live coaching whereas treatment fidelity also increased after live coaching sessions. Independent responding increased further for two children and maintained for all children during the follow-up probes. Whereas, for making the snack, an increase in performance by the children was observed during didactic training sessions.

After the introduction of live coaching, the interventionists’ responded correctly and scored 100%. The children’s responding either increased or remained at similar levels during the live coaching and follow-up probe. Almost all the interventionists except for one agreed or strongly agreed and recommended Telehealth for contacting BCBA- thus, socially validating the practice of Telehealth. One of the goals for this study was to calculate cost effectiveness of Telehealth and compare that to onsite training. Due to less number of BCBAs practicing in Europe and developing countries BCBAs have to be called from USA and travel expenses and services charges have to be managed by the parents or the institutes.

Telehealth has proved to be quite cost effective. Overall Telehealth has been viewed as manageable, accessible to everyone with minimal cost as compare to onsite training. Although online training was halted at some points when internet connection was unstable or the child got distracted by the equipment which should be tackled in future with familiarization (i.e. setting equipment before the start of training so that child could get familiar with). Telehealth is best for countries with stable internet connections when it comes to developing countries equipment should be loaned and proper information should be provided to the interventionists regarding its usage .