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.

Tutorial: Lessons Learned for Behavior Analysts from Data Scientists.

Big data is a computing term used to refer to large and complex data sets, typically consisting of terabytes or more of diverse data that is produced rapidly. The analysis of such complex data sets requires advanced analysis techniques with the capacity to identify patterns and abstract meanings from the vast data. The field of data science combines computer science with mathematics/statistics and leverages artificial intelligence, in particular machine learning, to analyze big data. This field holds great promise for behavior analysis, where both clinical and research studies produce large volumes of diverse data at a rapid pace (i.e., big data). This article presents basic lessons for the behavior analytic researchers and clinicians regarding integration of data science into the field of behavior analysis. We provide guidance on how to collect, protect, and process the data, while highlighting the importance of collaborating with data scientists to select a proper machine learning model that aligns with the project goals and develop models with input from human experts. We hope this serves as a guide to support the behavior analysts interested in the field of data science to advance their practice or research, and helps them avoid some common pitfalls.

Bullying Victimization is Associated with Heightened Rates of Anxiety and Depression Among Autistic and ADHD Youth: National Survey of Children's Health 2016-2020.

Autistic youth and youth with ADHD have heightened rates of bullying victimization, anxiety, and depression. The purpose of this research is to use nationally representative US data to 1) estimate the prevalence of anxiety and depression among bullied neurodivergent youth and 2) investigate whether the association between bullying victimization and anxiety or depression is significantly greater among autistic youth and youth with ADHD. For this research, we used five years of data (2016-2020) from the nationally representative National Survey of Children's Health (NSCH), youth ages 12-17 years (n = 71,973). Data were analyzed with R and the R survey package to estimate average marginal percentages, risk differences, and additive interactions as recommended by STROBE guidelines. The study identified heightened anxiety and depression among bullied autistic or ADHD youth. Results also showed that the increase in the rate of anxiety or depression associated with bullying victimization was significantly greater among autistic youth and youth with ADHD relative to non-autistic non-ADHD youth; interactions were significant among both male and female youth. Autistic youth, youth with ADHD, and youth with co-occurring autism and ADHD are particularly vulnerable to bullying victimization and associated depression and anxiety. Future research is needed to understand why the association between bullying victimization and depression/anxiety is significantly greater among autistic and non-autistic ADHD youth. Recommendations include exploring school-wide anti-stigma initiatives to stop the reciprocal bullying-anxiety/depression cycle, routine bullying and mental health screening of autistic and ADHD youth, and clinical management of bullied autistic and ADHD youth with anxiety or depression.

Towards the development of a curriculum to train behavior analysts to provide services via telehealth.

The COVID-19 pandemic has led to a dramatic increase in behavior analysts' use of telehealth services. Nonetheless, no research has evaluated the skills or training needed for therapists to provide these services effectively. The purpose of this study was to develop and evaluate a curriculum for providing high-quality, parent-training telehealth services. Four in-service Board Certified Behavior Analysts® (BCBAs®) who received brief behavioral skills training on this curriculum reached 100% fidelity within four sessions. The skills generalized to a novel family and maintained nearly 1 year after the training. All participants rated the training as highly acceptable and effective. The independent ratings of 4 in-service BCBAs, blinded to the study conditions, also supported the social validity of the outcomes. This curriculum may be considered an initial step towards development of competency for interventionists providing ABA services via telehealth. Further research is warranted as demand for telehealth services continues to grow.

How Might Indices of Happiness Inform Early Intervention Research and Decision Making?

Objectives: The child-caregiver relationship is the foundation for which intervention occurs. Therefore, the acceptability of the intervention should be considered for both parties. Indices of happiness (IOH) have shown to be effective in assessing social validity and providing insight to improving interventions to promote better quality of life. However, to date, there is limited attention to the integration of IOH in very early caregiver-led intervention. The purpose of this study is to explore how researchers and clinicians might collect direct data on IOH to assess the acceptability of an intervention. Methods: Participants in this study included 4 children, ages 19-26 months old, identified as "at-risk" for autism, and their caregivers. Caregiver-led intervention focused on pairing, play, and following the child's lead. IOH data was collected on both child and caregiver using 10 s partial-interval recording. Data analysis from the intervention is presented using three different approaches: pre/post-analysis on an individual level, pre/post-analysis on a dyad level, and during intervention as a primary dependent variable. Results: Variations were seen in levels of happiness, both on an individual level and dyad level. IOH for caregivers increased in relation as their fidelity increased but child IOH decreased as they acquired the targeted skill. Conclusions: Direct observation of happiness data is likely to provide valuable insight into participants perception of an intervention. And retrospective analysis may be a valuable tool for reflection and guidance and planning of future interventions. Supplementary Information: The online version contains supplementary material available at 10.1007/s41252-022-00288-0.

Effects of an Adapted Telehealth Training Curriculum for Registered Behavior Technicians®.

Objectives: We evaluated a telehealth training curriculum to prepare Registered Behavior Technicians® (RBTs®) to conduct caregiver coaching on behavior analytic skills via telehealth. Methods: A non-concurrent multiple baseline across therapists design was used to evaluate the training procedures delivered by Board Certified Behavior Analysts® (BCBAs®). All therapists (RBTs) worked with one family during the baseline and training phases and an additional session was conducted with a different family during the novelty probe condition to see if therapists were able to perform the newly acquired skills without BCBA support. Results: Seven therapists who received behavioral skills training on the curriculum reached mastery criteria within three sessions. All RBTs were able to provide caregiver coaching via telehealth with high degrees of fidelity and were able to independently conduct a telehealth session with a new family without support from the BCBA. Conclusions: Results of the current study provide support for the use of the telehealth training curriculum to prepare RBTs to conduct ABA services via telehealth.

Effects of telehealth-mediated behavioral assessments and interventions on client outcomes: A quality review.

The purpose of this review was to evaluate the quality of research focused on the effects of telehealth-mediated behavior-analytic assessments and interventions on client outcomes. The majority of studies utilized a single-case methodology (n = 44; 81%), while 10 studies (19%) used a group design. Of the 246 single-case designs, 99 (40%) met design standards with or without reservation. For the 10 group design studies, 7 (70%) met the design standards. When evaluating the evidence offered according to the prime independent variable (e.g., behavior assessment, intervention designed for behavior reduction, and intervention designed to establish or strengthen behavior), the literature supports the use of telehealth to conduct behavior assessments and provide interventions designed to establish or strengthen behavior. Additional research is necessary to establish the use of telehealth to conduct interventions designed for behavior reduction. Implications for future research and practice are discussed.

Impact of language on behavior treatment outcomes.

Resurgence of problem behavior following effective functional communication training (FCT) can occur if the functional communication response contacts extinction. For children from dual-language households, extinction may unintentionally occur due to language variations among communication partners. In the current study, the experimenters evaluated the effect of language on FCT outcomes. Participants were 3 children with autism who engaged in problem behavior and whose parents reported Spanish as the primary home language. The experimenters conducted FCT in the English language followed by probes in the Spanish language. Results suggest that functional communication responses (FCRs) learned in the first language (English) may lead to resurgence of problem behavior when English FCRs do not contact reinforcement in the untaught language (e.g., Spanish). Two of the participants required additional teaching in the secondary language (Spanish), while the third participant eventually emitted Spanish FCRs in the Spanish condition without explicit teaching.

Preliminary Findings of Culturally Responsive Consultation with Educators.

Behavior analysts are increasingly called to serve culturally and linguistically diverse populations. The culture of a population can provide context in which to identify behaviors likely to be reinforced by the client's social environment, stimuli established as reinforcers for client behavior, and behavioral repertoires shaped by the client's social environment. One of the largest and fastest growing minority groups in the United States is the Latinx population. This article offers preliminary evidence of incorporating cultural adaptations into the context of behavioral consultation for the Latinx population. Cultural adaptation of behavioral consultation can lead to improved outcomes for educators. In this study, 5 educators received behavioral consultation consisting of behavioral skills training to implement culturally responsive class-wide behavior management procedures. All 5 educators improved their treatment fidelity of the culturally responsive behavior management practices. Implications for practitioners and future research are discussed.

Quantitative-Analysis of Behavioral Interventions to Treat Sleep Problems in Children with Autism.

Sleep is an essential activity for human development. Often, children with autism spectrum disorder (ASD) are affected by a lack of sleep due to various types of sleep problems. We identified and analyzed studies that were aimed at utilizing sleep interventions for children with ASD. A systematic search of databases, reference lists, and ancestral searches identified 18 studies for inclusion. Studies were summarized in terms of (a) participants, (b) targeted sleep problem and measures, (d) intervention components, (e) research design and rigor, and (f) results. The aim of this review was to analyze the literature by evaluating the most commonly treated sleep problems, the various treatment components, and strength of the results using a between case parametric effect size estimate. The most commonly treated sleep problems were night wakings and bedtime disturbance. For interventions, all the studies incorporated multiple treatment components, most often including the use of a consistent bedtime routine. Effect size calculations indicated a moderate effect size, however, limited due to the small number of studies. Results suggest the overall effectiveness of behavioral interventions for the treatment of sleep problems for children with ASD. Based on our analysis, suggestions for practitioners regarding current practices and future directions for research are discussed.

The Use of Differential Reinforcement of Other Behaviours to Establish Inhibitory Stimulus Control for the Management of Vocal Stereotypy in Children with Autism.

OBJECTIVE: This study examined the efficacy of an inhibitory stimulus control procedure (ISCP) for the management of vocal stereotypy in three children with autism. METHOD: During discrimination training, implemented within a changing criterion design, participants were taught that there were no consequences for vocal stereotypy in the absence of an inhibitory stimulus but that differential reinforcement procedures were in effect in the presence of the stimulus. Functional control of the inhibitory stimulus was subsequently assessed within a reversal design. RESULTS: Inhibitory stimulus control was established during discrimination training, with participants inhibiting vocal stereotypy for 30 min periods in the presence of the inhibitory stimulus. Reductions in vocal stereotypy were maintained in the presence of the inhibitory stimulus and in the absence of further programmed consequences. DISCUSSION: This study extends current knowledge by demonstrating the efficacy of ISCPs paired with reinforcement only, and illustrating the functional control of the inhibitory stimulus.

Interventionist Acquisition of Incidental Teaching Using Pyramidal Training via Telehealth.

We investigated the effects of a telehealth pyramidal training package on participants' implementation of incidental teaching. A total of eight adults worked with eight children with autism. Coaches were first taught to implement incidental teaching and then taught subsequent interventionists. The training package consisted of an online module and delayed video-based feedback provided via videoconferencing. Following the telehealth training program, coaches and interventionists reached the preset performance criteria and implemented incidental teaching with high fidelity. All of the child participants increased mands above baseline levels. Results suggest that interventionists can be trained via telehealth in behavior analytic interventions.

Systematic Review of Differential Reinforcement of Alternative Behavior Without Extinction for Individuals With Autism.

The purpose of this article is to review the literature on differential reinforcement of alternative behavior procedures without extinction for individuals with autism. Using predetermined inclusion criteria, a total of 10 studies were included and summarized in terms of the following: (a) participant characteristics (e.g., sex, age, and diagnosis), (b) treatment setting, (c) problem behavior, (d) function, (e) alternative behavior, (f) intervention, (g) outcomes, and (h) conclusiveness of evidence. Of the 10 studies, nine demonstrated positive effects and one mixed effects. Five studies successfully reduced problem behavior by manipulating different reinforcement parameters (magnitude, immediacy, and quality) and four manipulated the schedule of reinforcement. One study had mixed results with two of the three participants requiring extinction. The findings of this review suggest that variations of differential reinforcement of alternative behavior interventions without an extinction component may be considered promising practices for the treatment of challenging behavior in individuals with autism.

The effect of caregiver-delivered social-communication interventions on skill generalization and maintenance in ASD.

BACKGROUND: Although caregiver-delivered social communication interventions have been considered scientifically proven practices for individuals with autism spectrum disorders, it is not well examined if these types of intervention modes are truly effective in promoting skill generalization and maintenance within those individuals with autism spectrum disorders. AIMS: The purpose of this meta-analysis was to evaluate the status of the extant literature regarding the measures on generalization and/or maintenance of effects of caregiver-delivered communication interventions for children with autism spectrum disorders. METHODS AND PROCEDURES: This systematic literature review and meta-analysis evaluated peer-reviewed research regarding the effects of caregiver-implemented interventions on the maintenance and generalization of the social-communication skills for children with autism spectrum disorders. A total of 34 articles were included following a systematic search. Articles were summarized according to the following categories: (a) generalization dimension, (b) generalization assessment design, (c) maintenance assessment design, (d) generalization/maintenance teaching strategy, and (e) latency to maintenance probes. After application of design standards, aggregate Tau-U and non-overlap of pairs effect sizes were calculated with a total of 67 separate contrasts across seven studies. OUTCOMES AND RESULTS: Overall, effect size scores ranged from small to large effects across all comparisons. On average, most of the baseline to maintenance and generalization comparisons produced moderate to large effects. Whereas, small to moderate or even deteriorate effects were found in most of the intervention to maintenance and generalization comparisons. CONCLUSIONS AND IMPLICATIONS: The findings in this review suggest that caregiver-delivered social-communication interventions are likely to result in mixed effects on skill generalization and maintenance within children with autism spectrum disorders. Implications for future research and practice are discussed.

Transferring picture exchange requests to receptive identification for children with ASD.

The purpose of this study was to evaluate a procedure to transfer stimulus control from picture exchange requests to receptive identification. Three children with autism spectrum disorder (ASD) and absent receptive identification repertoires participated. An adapted alternating treatment design was used. During intervention, two high-preferred and two low-preferred targets were available during picture exchange requesting sessions. Participants requested primarily for one or both high-preferred targets. During receptive identification instructional sessions, one participant acquired one high-preferred target, one participant acquired all targets, and one participant demonstrated no improvements. Generalization to novel examples of targets was assessed pre- and post-intervention and programmed if necessary. One participant generalized his acquired high-preferred target without programming. Another participant generalized a high-preferred and a low-preferred target without programming, and acquired a high-preferred target with programming. Potential benefits of this intervention and suggestions for future research are presented.

Generalization and maintenance of functional communication training for individuals with developmental disabilities: A systematic and quality review.

BACKGROUND: Functional communication training (FCT) is considered an evidence-based practice for treating problem behavior in individuals with developmental disabilities (e.g. autism, intellectual disabilities, down syndrome, etc.). However, there is little known on how to sustain behavioral change following FCT interventions. This systematic and quality review synthesizes the current literature base evaluating the maintenance and generalization of behavioral effects following FCT. METHOD: A systematic review identified 37 studies that met the pre-set inclusion criteria. Those studies were summarized in terms of: (a) generalization dimension, (b) generalization assessment design, (c) maintenance assessment design, (d) maintenance and generalization teaching strategy, and (e) latency to maintenance probes. All studies employed single-case research designs and were evaluated using the What Works Clearinghouse pilot single-case research standards (Kratochwill et al., 2013) as adapted by Maggin, Briesch, and Chafouleas (2013). Maintenance and generalization data were evaluated using a researcher-developed rubric based on the WWC standards. RESULTS AND DISCUSSION: Results indicate that 30 studies met standards or met standards with reservations while only six studies also met all of the maintenance and generalization standards. Of the six studies, five did not implement any additional strategies beyond the contacting natural contingencies that is inherent in the FCT intervention. Implications for future research and practice are discussed.

Tablet-based interventions for individuals with ASD: Evidence of generalization and maintenance effects.

BACKGROUND: Despite positive effects of and established empirical evidence for tablet-based interventions for individuals with autism spectrum disorder (ASD), it is not known whether such findings can be applicable to maintenance and generalization effects of those interventions. AIMS: This systematic review evaluated peer-reviewed single-case experimental design (SCED) studies concerning evidence of generalization and maintenance effects of tablet-based interventions for individuals with ASD. METHODS: To evaluate the methodological rigor of the literature in terms of generalization and maintenance effects, the authors adopted four of the basic design standards developed by What Works Clearinghouse (WWC; Kratochwill et al., 2010/2014). In addition, the authors used Tau-U effect size measure and attempted to calculate effect sizes differentiated by the type of generalization and maintenance teaching strategies. RESULTS: A total of 21 studies assessed generalization and/or maintenance effects. In the first evaluation of evidence of generalization and maintenance effects, it was found that more than half of the studies included in this review collected interobserver agreement (IOA) on at least 20% of sessions across all generalization and maintenance conditions and met the minimum quality thresholds of IOA. Meanwhile, less than one third of the studies included more than three data points in each generalization and maintenance condition. With regard to maintenance of effects, about half of the reviewed studies did not report the latency to the maintenance measure, which may hamper the assessment of the clinical and practical significance of the effect of the tablet-based intervention. In the second evaluation, the omnibus Tau-U effect size for baseline to generalization comparisons resulted in a moderate effect. For the contrasts between intervention and generalization comparisons resulted in a small effect. The omnibus Tau-U effect size for baseline and maintenance comparisons resulted in a strong effect. For the contrasts between intervention to maintenance comparisons, the omnibus Tau-U effect size resulted in a small effect. CONCLUSIONS AND IMPLICATION: Findings in this review suggest that efforts should be made to establish a system for appraising generalization and maintenance procedures in SCED studies. In addition, future studies should investigate if tablet-based interventions are truly effective in creating sustainable behavioral change in individuals with ASD.

An examination of within-session responding following access to reinforcing stimuli.

Previous research has shown tangibly maintained challenging behavior can be temporarily decreased by providing presession access to the relevant tangible. However, the duration of this beneficial effect is unknown. We measured the subsequent duration of behavior reduction effects following presession access during extended classroom observation sessions by analyzing within-session patterns of responding in three children with autism. An alternating treatments design was used to analyze within- and across-session responding following presession access and presession restriction conditions. The cumulative frequency of challenging behavior was higher following the presession restriction condition for all participants and lower following presession access. Within-session analysis revealed the same basic pattern of responding across participants. Specifically, the first half of the sessions contained very little, if any, challenging behavior; however, after 60 min, the rate of challenging behavior began to increase rapidly for two of the three participants. Results are discussed in terms of implications for practitioners, satiation, habituation, and behavioral contrast.

The effects of video modeling in teaching functional living skills to persons with ASD: A meta-analysis of single-case studies.

BACKGROUND: Many individuals with autism spectrum disorders (ASD) show deficits in functional living skills, leading to low independence, limited community involvement, and poor quality of life. With development of mobile devices, utilizing video modeling has become more feasible for educators to promote functional living skills of individuals with ASD. AIMS: This article aims to review the single-case experimental literature and aggregate results across studies involving the use of video modeling to improve functional living skills of individuals with ASD. METHODS AND PROCEDURES: The authors extracted data from single-case experimental studies and evaluated them using the Tau-U effect size measure. Effects were also differentiated by categories of potential moderators and other variables, including age of participants, concomitant diagnoses, types of video modeling, and outcome measures. OUTCOMES AND RESULTS: Results indicate that video modeling interventions are overall moderately effective with this population and dependent measures. While significant differences were not found between categories of moderators and other variables, effects were found to be at least moderate for most of them. CONCLUSIONS AND IMPLICATIONS: It is apparent that more single-case experiments are needed in this area, particularly with preschool and secondary-school aged participants, participants with ASD-only and those with high-functioning ASD, and for video modeling interventions addressing community access skills.

Effects of antecedent exercise on academic engagement and stereotypy during instruction.

Antecedent physical exercise has emerged as a potentially promising treatment for reducing challenging behavior and increasing academic behavior in individuals with autism spectrum disorder (ASD). The purpose of this study was to evaluate the effects of physical exercise conducted prior to instructional sessions (antecedent physical exercise) on academic engagement and stereotypy during instructional sessions for two children diagnosed with ASD. Functional analysis results suggested stereotypy was maintained by automatic reinforcement for both participants. A multielement design was employed to evaluate academic engagement and stereotypy during instructional sessions following randomly sequenced conditions involving either (a) no antecedent exercise, (b) brief durations of antecedent exercise, or (c) antecedent exercise that continued until the participant engaged in a systematically determined behavioral indicator of satiation. Both participants demonstrated higher levels of academic engagement and reduced levels of stereotypy during the instructional sessions which followed antecedent physical exercise that continued until behavioral indicators of satiation occurred. This study replicates previous research suggesting that individuals with ASD may benefit from physical exercise prior to academic instruction and further suggests that the duration of antecedent exercise may be optimally individualized based on behavioral indicators of satiation.