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Training Caregivers Via Telehealth Technologies Dorothea C. Lerman, Ph.D., BCBA-D
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
Num
ber
of P
ublis
hed A
rtic
les
◼ 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
Our Current & Recently Completed Projects
http://www.worldometers.info/world-population/population-by-country/
Country, BCBAs, Population
USA
32,000 BCBAs
327 million
Russia
12 BCBAs
144 million
Africa
17 BCBAs
1.293 billion
South
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
Hindi
Prisca Deliperi
French
Andrew Bennett
French
Telehealth ABA World Project Interpreters
Linh Đào
Vienamese
Trang Tran
Vietnamese
Anna Amagou
French
Telehealth ABA World Project Interpreters
Interpreter in behavior analyst’s location
Mexico
Interpreter in separate (third) location
Pakistan
Interpreter in third location
Russia
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2 .5
S e ss io n s
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ble
m B
eh
av
ior
(RP
M)
F u n c tio n a l A n a ly s is
F C T + E X T
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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
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T o u ch
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S e ss io n s
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f T
ria
ls
(In
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FA
C a r d N o C a r d
F C T + E X T
Agios, Greece
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Bursa, Turkey
Translator (Spanish) with Family Translator (Arabic) with Behavior Analyst
T a n g i b l e
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S e s s i o n s
Pr
ob
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F u n c t i o n a l A n a l y s i s
P l a y
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G e r r y
F C T + E X T
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T A N G
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% O
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F a d i n g
2 3
Interpreter (Russian) in Third Location
A T T
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S e s s i o n s
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F u n c t i o n a l A n a l y s i s
P L A Y
D E M
F C T + E x t i n c t i o n
2 3 4 65
F a d i n g
S a m
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S e s s i o n s
Pe
rc
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)
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)
32 Houston Participants
◼ 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
29 International Participants
◼ 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)
32 Houston Participants
◼ 20 (63%)
◼ 6 (19%)
◼ 5 (16%)
◼ 1 (3%)
Hardware
29 International Participants
◼ 17 (59%)
◼ 6 (21%)
◼ 3 (10%)
◼ 3 (10%)
Devices
◼ Phone
◼ Laptop
◼ iPad
◼ Desktop
International Participants: 320 Appointments, 26 Participants
Houston Participants: 424 Appointments, 29 Participants
Connectivity Ratings
86%
1.6% 5%
International Participants:356 Appointments, 29 Participants
Houston Participants:476 Appointments, 31 Participants
Cancelled Appointments
10.6%
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/
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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?
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Ste
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C
om
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C
orr
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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
Categories of Challenges
Disruptions in Client’s Environment
Categories of Challenges
Other Issues Related to Client Behavior
Categories of Challenges
Issues Related to Caregiver Behavior
Categories of Challenges
Issues at the Practitioner’s (Host) Site
Categories of Challenges
Technical Issues
◼Hardware unavailable Loaners; alt. facility
◼Connectivity issues Upgrade; reduce # devices
Challenges and Potential Solutions
86%
9%
2%1%
2%
US (Texas) Participants N=52, 564 Appointments
>92%
73%-91%
55%-72%
20%-54%
<20%
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)
Challenges with Remote Viewing
◼ Client not always in view
Challenges and Possible Solutions
31% of 289 appointments
IOWA
Challenges with Remote Viewing
◼ Client not always in view
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S e s s io n s
Fre
qu
en
cy
(E
lop
em
en
t A
tte
mp
ts)
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
Challenges with Remote Viewing
◼ Difficulty seeing/hearing client behavior
◼Difficulty hearing practitioner
Disruptions in Client’s Environment
Challenges and Possible Solutions
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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
Disruptions in Client’s Environment
Disruptions in Client’s Environment
1 0 2 0 3 0 4 0 5 0
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Pe
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inu
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(Oth
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em
be
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oo
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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
Other Issues Related to Client Behavior
◼Escalation in problem behavior
Challenges and Possible Solutions
Other Issues Related to Client Behavior
◼Escalation in problem behavior
Other Issues Related to Client Behavior
◼Reactive effects of camera
Other Issues Related to Client Behavior
◼Reactive effects of camera
Possible Solutions
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-s I
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(Re
ac
tiv
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)
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
o ff
Issues Related to Caregiver Behavior
Challenges and Possible Solutions
Issues Related to Caregiver Behavior
◼ Insensitivity to vocal instructions
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C a lv in
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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
Categories of Challenges
◼ 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?
