Training Caregivers Via Telehealth...

transcript

Training Caregivers Via

Telehealth Technologies

Dorothea C. Lerman, Ph.D., BCBA-D

WE CAN SAVE THE WORLD WITH BEHAVIOR ANALYSIS!

HIPAA-Compliant Software

• Vidyo

• Vsee

• Zoom

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EBSCO Search – “Telehealth” or “Telemedicine”

Peer-viewed articles

◼ Functional Analysis of Problem Behavior

◼ Functional Communication Training

The Pioneer of Telehealth ABA Services

(2006 - )

David Wacker, Ph.D

University of Iowa (recently retired)

THE WILD WEST

◼ Comparison of Behavioral Assessments Using Telehealth

for Children with Autism (NIH Grant with University of Iowa

and Emory/Marcus)

Our Current & Recently Completed Projects

http://www.worldometers.info/world-population/population-by-country/

Country, BCBAs, Population

32,000 BCBAs

327 million

Russia

12 BCBAs

144 million

Africa

17 BCBAs

1.293 billion

America

43 BCBAs

424 million

Loukia Tsami, M.A., BCBA

Research Associate

University of Houston, Clear Lake

Özlem Toper-Korkmaz, Ph.D.

Assistant Professor, Special Education

Uludağ University

Telehealth ABA World Project

Founder and Director: Loukia Tsami, BCBA

Telehealth ABA World Project Interpreters

Areli Barajas

Spanish

Irina Shutts

Russian

Sarah Alsaleh

Arabic

Maria Quadri

Urdu Dieu Truong

Vietnamese

Grace Shay

Mandarin Chinese

Naomi Alphonso

Prisca Deliperi

French

Andrew Bennett

French

Linh Đào

Vienamese

Trang Tran

Vietnamese

Anna Amagou

French

Interpreter in behavior analyst’s location

Mexico

Interpreter in separate (third) location

Pakistan

Interpreter in third location

Russia

5 1 0 1 5 2 0 2 5

S e ss io n s

F u n c tio n a l A n a ly s is

F C T + E X T

C a r d

T o u c h

V o c a l

P la y

D e m a n d

A tte n tion

T a n g ib le

T o u ch

5 1 0 1 5

S e ss io n s

C a r d N o C a r d

F C T + E X T

Agios, Greece

0 5 1 0 1 5 2 0 2 5 3 0 3 5 4 0

S e s s i o n s

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2 . 5 m

F C T + E X T

0 5 1 0 1 5 2 0 2 5 3 0 3 5 4 0

S e s s i o n s%

F C T + E X T

0 s 5 s 1 0 s 1 m 2 m 2 . 5 m

Bursa, Turkey

Translator (Spanish) with Family Translator (Arabic) with Behavior Analyst

T a n g i b l e

5 1 0 1 5 2 0 2 5

S e s s i o n s

F u n c t i o n a l A n a l y s i s

P l a y

A t t e n t i o n

D e m a n d

G e r r y

F C T + E X T

S - : 5 s 2 0 s 4 0 s 6 0 s1 0 s

: 5 s - - - - - - - - - - - - - - - - - - - - - - - - >

5 1 0 1 5

S e s s i o n s

F C T + E X T

S - D e l t a : 5 s 2 0 s 4 0 s 6 0 s1 0 s

: 5 s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - >

T A N G

1 0 2 0 3 0 4 0 5 0

S e s s i o n s

T o m m y

F C T + E X T

( E s c a p e + T a n g i b l e )

F a d i n g

1 0 2 0 3 0

S e s s i o n s

F C T + E X T

( E s c a p e + T a n g i b l e )

F a d i n g

Interpreter (Russian) in Third Location

5 1 0 1 5 2 0 2 5 3 0 3 5 4 0

S e s s i o n s

F u n c t i o n a l A n a l y s i s

P L A Y

F C T + E x t i n c t i o n

2 3 4 65

F a d i n g

5 1 0 1 5 2 0 2 5 3 0 3 5 4 0

S e s s i o n s

F u n c t i o n a l A n a l y s i s F C T + E x t i n c t i o n

2 3 4 65

F a d i n g

◼ Coached Directly by Behavior Analysts

FA: M = 97% (93% - 100%)

FCT: M = 99% (98% - 100%)

◼ Interpreters

FA: M = 96% (89% - 100%)

FCT: 98% (97% - 100%)

Parent Procedural Integrity

Families Served:

◼ 47 Families (children aged 3 -13 years)

◼ 22 Countries Greece, 10

Turkey, 2

Mexico, 5

Saudi Arabia, 4

Costa Rica, 1

Russia, 1

Outcomes to Date

Ukraine, 1

Vietnam, 3

China, 1

Cameroon, 2

Ghana, 1

Morocco, 3

Algeria, 1

Egypt, 2

Pakistan, 4

Oman, 1

Nepal, 1

England, 1

Spain, 1

Iran, 1

India, 1

Nigeria, 1

Treatment Outcomes:

◼ 27 completed treatment successfully

◼ 5 in currently in treatment

◼ 15 did not complete treatment

4 – problem behavior no longer a concern

1 – could no longer afford internet

2 – scheduling conflicts (up to 12 hr time difference)

8- inadequate internet speed (Countries in Africa: Morocco 3, Ghana 1, Algeria 1, Egypt 1,

Countries in Asia: Nepal 1, Pakistan 1)

Outcomes To Date

32 Houston Participants

◼ Ages: 2 – 11 years

◼ Settings: 31 Clinic-Home,

1 Clinic-Clinic

◼ Languages: 2

◼ Interpreters: 1

Comparison of FA and FCT data

Participants from Houston vs 13 countries

29 International Participants

◼ Ages: 3 – 13 years

◼ Settings: 28 Clinic-Home,

1 Clinic-Clinic

◼ Languages: 10

◼ Interpreters: 17 (7 at BCBA’s

location, 1 with family, 8 in a

third location)

◼ 30 differentiated FAs

◼ 2 - no PB (6%)

◼ 0 FA Modifications

Comparison of FA data

All FAs: 5-min sessions

Conditions included: Attention, Escape, Tangible*, Play

◼ 26 differentiated FAs

◼ 3 – no PB (10%)

◼ 1 FA Modification (escape from touch)

Houston Participants: 30 FAs

◼ Tangible + Escape: 10 (33%)

◼ Tangible: 7 (23%)

◼ Attention + Tang + Escape: 6 (20%)

◼ Attention: 3 (10%)

◼ Attention + Tangible: 2 (7%)

◼ Escape: 1 (3%)

◼ Automatic: 1 (1%)

◼ Attention + Escape: 0

FA Results

International Participants: 26 FAs

◼ Tangible: 8 (31%)

◼ Escape: 7 (27%)

◼ Tangible + Escape: 4 (15%)

◼ Attention + Tang + Escape: 3 (12%)

◼ Attention: 1 (4%)

◼ Attention + Tangible: 1 (4%)

◼ Attention + Escape: 1 (4%)

◼ Escape from Touch: 1 (4%)

◼ Automatic: 0

Houston Participants: 23

◼ 20 completed (87%)

100% met criterion

◼ 3 withdrew (13%)

Functional Communication Training

International Participants: 26

◼ 21 completed (91%)

100% met criterion

◼ 2 withdrew (9%)

International Participants:

Average 13 appointments

Range: 8-30 appointments

Houston Participants:

Average 19 appointments

Range: 5-31 appointments

Treatment Duration

International Participants:Houston Participants:

Acceptability Rating (1-7):

◼ How acceptable do you find the treatment to be

regarding your concerns about your child?

Item on

Questionnaire

PRE POST

Treatment 6.9 (4-7) 6.6 (4-7)

Item on

Questionnaire

PRE POST

Treatment 6.5 (5-7) 6.7 (6-7)

◼ 20 (63%)

◼ 6 (19%)

◼ 5 (16%)

◼ 1 (3%)

Hardware

◼ 17 (59%)

◼ 6 (21%)

◼ 3 (10%)

Devices

◼ Phone

◼ Laptop

◼ iPad

◼ Desktop

International Participants: 320 Appointments, 26 Participants

Houston Participants: 424 Appointments, 29 Participants

Connectivity Ratings

1.6% 5%

International Participants:356 Appointments, 29 Participants

Houston Participants:476 Appointments, 31 Participants

Cancelled Appointments

Educational Series for Caregivers and Professionals:

19 countries, 55 presentations, ~2,880 attendees❑ Greece (Veroia, Naoussa)

❑ Mexico

❑ Russia

❑ Nigeria (Asaba, Kaduna, Port Harcourt)

❑ Nepal

❑ Morocco

❑ Pakistan (Karachi, Peshawar, Kashmir,

Islamabad, Rawalpindi, Lahore)

❑ Cameroon

❑ Liberia

Outcomes To Date

❑Saudi Arabia

❑Namibia

❑South Africa

❑France

❑Vietnam

❑Ghana

❑Jamaica

❑Ivory Coast

❑Philippines

❑Bangladesh

Prince Sultan Military Medical FacilityRiyadh, Saudi Arabia

Karachi, Pakistan

Private School

Kaduna, Nigeria

Private School

https://www.facebook.com/TelehealthABA/

Like our Facebook page and follow us on twitter

Help us #savetheworldwithaba

Telehealth ABA World Project

The Wild Frontier:

Telehealth ABA Service Challenges

and Some Potential Solutions

Matthew J. O’Brien1, Leslie Neely2, Nathan A. Call3,

Loukia Tsami4, Kelly M. Schieltz1, Wendy K. Berg1, Jessica

Graber5, Pei Huang1, Todd Kopelman1,

and Linda J. Cooper-Brown1

1University of Houston, Clear Lake; 2University of Iowa;

3University of Texas at San Antonio; 4Marcus Institute;

and 5Autism Treatment Center of San Antonio

My Collaborators

◼ Leslie Neely, Ph.D. – University of Texas at San Antonio

and Jessica Graber, Ph.D. – Autism Treatment Center

◼ Transfer of parent training skills from in-person to remote

modalities

◼ Three behavior analysts – 2 years experience

Do BCBAs Need Specialized Training?

F a c e - to -F a c e T e le h e a lth

B e t ty

E l le n

5 1 0 1 5

S e ss io n s

Fidelity Checklist =

14 “core items”

Fidelity Checklist =

14 core + 9 suppl items

◼ Identify challenges and possible solutions

◼ Empirically evaluate solutions

◼ Develop competences/goals

◼ Develop training curriculum

What Can We Do?

◼ 18 practitioners (1-20 years of experience [0-6 telehealth])

◼ Four different sites (Texas, Iowa, Georgia)

◼ 237 families (January 2015 and April 2019)

Children: 1.7 – 16 years old

◼ 2,242 total appointments

◼ FA/FCT

Method

VERSUS

Technical Issues

Categories of Challenges

Challenges with Remote Viewing

Disruptions in Client’s Environment

Other Issues Related to Client Behavior

Issues Related to Caregiver Behavior

Issues at the Practitioner’s (Host) Site

Technical Issues

◼Hardware unavailable Loaners; alt. facility

◼Connectivity issues Upgrade; reduce # devices

Challenges and Potential Solutions

US (Texas) Participants N=52, 564 Appointments

73%-91%

55%-72%

20%-54%

Percentage

of Appt

Completed

Technical Issues

◼Hardware unavailable Loaners; alt. facility

◼Connectivity issues Upgrade; reduce # devices

◼Difficulty using software TA; instruct via phone

◼Hardware/software failures Backups

Challenges and Potential Solutions

◼ For HIPAA Compliance:

Software license must include Business Associate

Agreement (BAA)

◼ Client not always in view

Challenges and Possible Solutions

31% of 289 appointments

◼ Client not always in view

2 0 4 0 6 0 8 0 1 0 0

S e s s io n s

M a g e d

L iv in g R o o m P la y ro o m

F ig u re 2 . F req u e n cy o f M ag ed 's e lo p em en t a ttem p ts d u r in g

sess io ns in th e in itia l lo ca tion (liv in g ro o m ) and a fte r

re - lo ca tin g sess io n s to a p lay ro o m

◼ Difficulty seeing/hearing client behavior

◼Difficulty hearing practitioner

5 1 0 1 5 2 0

S e s s io n s

T o m m y

A lte rn a tiv e

I te m s A v a ila b le

A l l I te m s R e s t r ic te d

(T a n g ib le C o n d i t io n )

T a n g ib le

P la y

E s c a p e

A tte n tio n

F u n c tio n a l A n a ly s is

F ig u re 3 . R e sp o n ses p e r m in u te o f T o m m y 's p ro b lem

b eh av io r d u rin g th e in ita l se ss io n s o f th e fu n ctio n al

an aly sis an d afte r item s w ere restr ic ted in the tan g ib le

co n d itio n o f th e fu n c tio n a l an a ly s is

1 0 2 0 3 0 4 0 5 0

S e s s io n s

B r ia n

F a th e r a b s e n t

F a th e r p re s e n t

F ig u re 4 . R esp o n ses p e r m in u te o f fam ily

m em b ers en te rin g th e ro o m d u rin g B rian 's

sess io n s w h en h is fa th e r w as p resen t v e rsu s

ab sen t in th e h o m e

◼Escalation in problem behavior

◼Reactive effects of camera

Possible Solutions

5 1 0 1 5 2 0 2 5

S e s s io n s

G e o r g e

V id e o /A u d io O n

V id e o /A u d io O f f

F ig u re 5 . P ercen tag e o f 10 -s in te rv a ls w ith

G eo rg e 's re a c tiv e re sp o n se s d u r in g se ss io n s

w ith th e v id eo an d a u d io fee d tu rn ed o n v e rsu s

◼ Insensitivity to vocal instructions

1 0 2 0 3 0 4 0

S e s s io n s

C a lv in

E X T F C T + E X T

F a th e r

M o th e r

F ig u re 6 . P e rcen tag e o f trea tm en t s tep s

im p lem en ted co rrec tly b y C alv in 's fa th e r v e rsu s

m o th e r ( to p p an e l) a n d p e rcen ta g e o f 1 0 -s

in terv a ls w ith p ro b lem b eh av io r fo r C alv in

(b o tto m p a n e l) ac ro ss tre a tm e n t se ss io n s

Issues at the Practitioner’s (Host) Site

◼ Schedule initial troubleshooting session

Send written guidelines in advance

Initially work with caregiver alone

Troubleshoot with play/leisure sessions, preference

assessment

General Recommendations

◼ Tailor terms of service

Expectations and roles

Agreements about loaners

Limitations of remote services

Potential limits to confidentiality

◼ Recruit IT professional for team

◼ Maintain phone contact with caregiver

◼ Video record all sessions

General Recommendations

◼ Fidelity Checklist – 9 supplementary items

Arranges for phone contact

Checks connection prior to session

Checks speaker, mic, and camera prior to session

Prepares room for optimal visibility and professionalism

Prepares environment for confidentiality

Begins session with check of systems

Provides extra time during pauses in conversation

Provides enhanced verbal descriptions

Makes modifications to limit reactivity as necessary

Training Curriculum…. A Beginning

Drs Neely and Graber

◼ But we still need to determine

Who is appropriate for telehealth services?

What types of ABA services are appropriate?

Training Curriculum…. A Beginning

QUESTIONS?

Training Caregivers Via Telehealth...

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