Remote Coaching of Caregivers Via Telehealth: Challenges and Potential Solutions.

The use of telehealth technologies to provide clinical services to families of children with autism and other developmental disabilities is a rapidly growing area of research. In particular, remote training of caregivers via video conferencing appears to be a promising approach for disseminating behavior-analytic interventions (Neely, Rispoli, Gerow, Hong, Hagan-Burke, 2017; Tomlinson, Gore, & McGill, 2018). Although remote training offers a number of advantages, it brings a variety of challenges that are unique to this modality. The field would benefit from information on problems that practitioners may encounter when providing these services and how to train caregivers effectively. In this paper, we report on the experiences of 18 practitioners who provided caregiver training via telehealth from four different sites across a 4-year period. We describe a variety of technical and clinical issues that arose during service delivery, suggest strategies for preventing and remediating problems, and include case descriptions and data to illustrate our experiences. This information may help prepare practitioners to deliver telehealth services and guide further research in this area.

Parent Ratings of Generalized and Indirect Effects of Functional Communication Training for Children with Autism Spectrum Disorder.

Functional communication training (FCT) is a behavioral treatment that has been shown to reduce problem behavior and increase appropriate communication in young children with autism spectrum disorder (ASD). In this study, we assessed the effects of FCT on targeted and nontargeted problem behaviors outside of the training context, as well as parent stress, for 30 young children with ASD and their parents. Indirect measures of generalization treatment effects were administered prior to and following FCT treatment delivered via telehealth. Children demonstrated significant improvement on both targeted (measured via observation) and nontargeted (measured via checklist) problem behaviors, both within and outside of the training context, and parent stress was significantly reduced following treatment. These results suggest that the impact of FCT may extend beyond the training context for both the children being treated and the parents delivering treatment, even when generalization is not specifically programmed for during treatment.

A Randomized Controlled Trial of Functional Communication Training via Telehealth for Young Children with Autism Spectrum Disorder.

Many children with autism spectrum disorder (ASD) have problem behaviors that interfere with learning and social interaction. This randomized controlled trial compared treatment with functional communication training (FCT) to "treatment as usual" for young children with ASD (n = 38, ages 21-84 months). FCT was conducted by parents with training and real-time coaching provided by behavioral consultants using telehealth. FCT treatment via telehealth achieved a mean reduction in problem behavior of 98% compared to limited behavioral improvement in children receiving "treatment as usual" during a 12-week period. Social communication and task completion also improved. For children with ASD and moderate to severe behavior problems, parent-implemented FCT using telehealth significantly reduced problem behavior while ongoing interventions typically did not.

Prevalence and Treatment Patterns of Autism Spectrum Disorder in the United States, 2016.

Importance: Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder. Previous surveys have reported a steady increase in ASD prevalence in US children over the past decades. Several behavioral therapies and medications have been developed to treat the symptoms of ASD; however, little is known about the current status of treatment usage for children diagnosed as having ASD. Objective: To estimate the prevalence and treatment patterns of ASD among US children using nationally representative data. Design, Setting, and Participants: This study used data from the 2016 National Survey of Children's Health, a nationwide, population-based, cross-sectional survey. We included 43 032 children aged 3 to 17 years. Data were collected through questionnaires completed by a parent or guardian. Data were analyzed from February 2018 to March 2018. Main Outcomes and Measures: Outcome variables included ASD diagnosed by a physician or health professional and the use of behavioral treatment or medication treatment among children with ASD. Results: Of the 43 032 included participants, 22 072 (51.3%) were male, and the mean (SD) age was 10.7 (4.4) years. The weighted prevalence of ever-diagnosed ASD and current ASD were 2.79% (95% CI, 2.46-3.12) and 2.50% (95% CI, 2.21-2.79), respectively. The state-level prevalence of ever-diagnosed ASD varied from 1.54% (95% CI, 0.60-2.48) in Texas to 4.88% (95% CI, 2.72-7.05) in Florida. Nationally, about 70% of children with current ASD (70.5%; 95% CI, 65.1-75.8) were treated; 43.3% (95% CI, 37.4-49.2) received behavioral treatment only, 6.9% (95% CI, 3.7-10.1) received medication treatment only, and 20.3% (95% CI, 16.5-24.1) received both behavioral and medication treatments. The remaining 29.5% (95% CI, 24.2-34.9) of children with current ASD did not receive either behavioral or medication treatment. Conclusions and Relevance: This study showed that the prevalence of ASD in the United States was relatively high, and it varied substantially across US states. Almost 30% of US children with ASD did not receive behavioral or medication treatment, which calls for a critical need to understand and address the barriers for those children to receive appropriate treatments.

Effects of antecedent variables on disruptive behavior and accurate responding in young children in outpatient settings.

The effects of manipulations of task variables on inaccurate responding and disruption were investigated with 3 children who engaged in noncompliance. With 2 children in an outpatient clinic, task directives were first manipulated to identify directives that guided accurate responding; then, additional dimensions of the task were manipulated to evaluate their influence on disruptive behavior. With a 3rd child, similar procedures were employed at school. Results showed one-step directives set the occasion for accurate responding and that other dimensions of the task (e.g., preference) functioned as motivating operations for negative reinforcement.

Client satisfaction with rural substance abuse case management services.

Although many substance abuse organizations offer case management services, little is known about clients' satisfaction as consumers of case management services. The purpose of this study was to evaluate consumer preferences regarding the delivery of case management services in a rural substance abuse treatment program. For this study, 120 clients (30 in each of four research conditions) were interviewed about their experiences in the Iowa Case Management Project (ICMP), a field-based clinical trial evaluating a strengths-based model of case management for rural clients in drug abuse treatment. A mixed-method approach evaluated clients' responses from a semistructured interview. Most clients preferred meeting with their case manager in their own home. Clients also stated that they preferred specific characteristics of case management services-namely, convenience, privacy, comfort, and accessibility. Finally, clients wanted more time with their case managers over time. Although clients in drug treatment are not often considered as consumers, we found that client satisfaction with case management services could be studied and that clients appreciated being asked about their experiences. By targeting perceived and actual barriers to meeting with case managers (e.g., availability of transportation), service utilization by clients may be increased along with overall satisfaction.

Telehealth and Autism: Treating Challenging Behavior at Lower Cost.

OBJECTIVE: To determine whether challenging behavior in young children with autism and other developmental disabilities can be treated successfully at lower cost by using telehealth to train parents to implement applied behavior analysis (ABA). METHODS: We compared data on the outcomes and costs for implementing evidence-based ABA procedures to reduce problem behavior by using 3 service delivery models: in-home therapy, clinic-based telehealth, and home-based telehealth. Participants were 107 young children diagnosed with autism or other neurodevelopmental disorders, and data analysis focused on the 94 children who completed treatment. RESULTS: All 3 service delivery models demonstrated successful reduction of problem behavior by training parents to conduct functional analysis and functional communication training. The mean percentage reduction in problem behavior was >90% in all 3 groups after treatment, and treatment acceptability based on parent ratings was high for all groups. Total costs for implementing treatment were lowest for home telehealth, but both telehealth models were significantly less costly than in-home therapy. CONCLUSIONS: This research demonstrated that parents can use ABA procedures to successfully treat behavior problems associated with autism spectrum disorders regardless of whether treatment is directed by behavior consultants in person or via remote video coaching. Because ABA telehealth can achieve similar outcomes at lower cost compared with in-home therapy, geographic barriers to providing access to ABA for treating problem behavior can be minimized. These findings support the potential for using telehealth to provide research-based behavioral treatment to any family that has access to the Internet.

Guidelines for Developing Telehealth Services and Troubleshooting Problems with Telehealth Technology When Coaching Parents to Conduct Functional Analyses and Functional Communication Training in Their Homes.

The researchers in the project used telehealth to conduct functional analyses and functional communication training in homes of children diagnosed with autism who displayed problem behavior. Parents conducted all assessment and treatment procedures within their homes while receiving coaching from applied behavior analysts located approximately 200 miles away from them. In this article, the researchers summarize the technical systems they used to develop a telehealth service and the concerns and problems they have encountered using telehealth and provide some guidelines for how to troubleshoot those problems.

Conducting Functional Communication Training via Telehealth to Reduce the Problem Behavior of Young Children with Autism.

Functional communication training (FCT) was conducted by parents of 17 young children with autism spectrum disorders who displayed problem behavior. All procedures were conducted at regional clinics located an average of 15 miles from the families' homes. Parents received coaching via telehealth from behavior consultants who were located an average of 222 miles from the regional clinics. Parents first conducted functional analyses with telehealth consultation (Wacker, Lee, et al., in press) and then conducted FCT that was matched to the identified function of problem behavior. Parent assistants located at the regional clinics received brief training in the procedures and supported the families during the clinic visits. FCT, conducted within a nonconcurrent multiple baseline design, reduced problem behavior by an average of 93.5%. Results suggested that FCT can be conducted by parents via telehealth when experienced applied behavior analysts provide consultation.

Conducting functional analyses of problem behavior via telehealth.

Behavior consultants conducted functional analyses (FAs) via telehealth with 20 young children with autism spectrum disorders between the ages of 29 and 80 months who displayed problem behavior and lived an average of 222 miles from the tertiary hospital that housed the behavior consultants. Participants' parents conducted all procedures during weekly telehealth consultations in regional clinics located an average of 15 miles from the participants' homes. Behavior consultants briefly trained parent assistants to provide on-site support for families during consultations. FAs completed within a multielement design identified environmental variables that maintained problem behavior for 18 of the 20 cases, and interrater agreement averaged over 90%. Results suggested that behavior analysts can conduct FAs effectively and efficiently via telehealth.