Assessing the Usability and Feasibility of Digital Assistant Tools for Direct Support Professionals: Participatory Design and Pilot-Testing.

BACKGROUND: The United States is experiencing a direct support professional (DSP) crisis, with demand far exceeding supply. Although generating documentation is a critical responsibility, it is one of the most wearisome aspects of DSPs' jobs. Technology that enables DSPs to log informal time-stamped notes throughout their shift could help reduce the burden of end-of-shift documentation and increase job satisfaction, which in turn could improve the quality of life of the individuals with intellectual and developmental disabilities (IDDs) whom DSPs support. However, DSPs, with varied ages, levels of education, and comfort using technology, are not likely to adopt tools that detract from caregiving responsibilities or increase workload; therefore, technological tools for them must be relatively simple, extremely intuitive, and provide highly valued capabilities. OBJECTIVE: This paper describes the development and pilot-testing of a digital assistant tool (DAT) that enables DSPs to create informal notes throughout their shifts and use these notes to facilitate end-of-shift documentation. The purpose of the pilot study was to assess the usability and feasibility of the DAT. METHODS: The research team applied an established user-centered participatory design process to design, develop, and test the DAT prototypes between May 2020 and April 2023. Pilot-testing entailed having 14 DSPs who support adults with IDDs use the first full implementation of the DAT prototypes during 2 or 3 successive work shifts and fill out demographic and usability questionnaires. RESULTS: Participants used the DAT prototypes to create notes and help generate end-of-shift reports. The System Usability Scale score of 81.79 indicates that they found the prototypes easy to use. Survey responses imply that using the DAT made it easier for participants to produce required documentation and suggest that they would adopt the DAT if this tool were available for daily use. CONCLUSIONS: Simple technologies such as the DAT prototypes, which enable DSPs to use mobile devices to log time-stamped notes throughout their shift with minimal effort and use the notes to help write reports, have the potential to both reduce the burden associated with producing documentation and enhance the quality (level of detail and accuracy) of this documentation. This could help to increase job satisfaction and reduce turnover in DSPs, both of which would help improve the quality of life of the individuals with IDDs whom they support. The pilot test results indicate that DSPs found the DAT easy to use. Next steps include (1) producing more robust versions of the DAT with additional capabilities, such as storing data locally on mobile devices when Wi-Fi is not available; and (2) eliciting input from agency directors, families, and others who use data about adults with IDDs to help care for them to ensure that data produced by DSPs are relevant and useful.

Direct Support Professionals' Perspectives on Using Technology to Help Support Adults With Autism Spectrum Disorder: Mixed Methods Study.

BACKGROUND: Documentation is a critical responsibility for direct support professionals (DSPs) who work with adults with autism spectrum disorder (ASD); however, it contributes significantly to their workload. Targeted efforts must be made to mitigate the burden of necessary data collection and documentation, which contributes to high DSP turnover rates and poor job satisfaction. OBJECTIVE: This mixed methods study aimed to explore how technology could assist DSPs who work with adults with ASD and prioritize aspects of technology that would be most useful for future development efforts. METHODS: In the first study, 15 DSPs who worked with adults with ASD participated in 1 of the 3 online focus groups. The topics included daily tasks, factors that would influence the adoption of technology, and how DSPs would like to interact with technologies to provide information about their clients. Responses were thematically analyzed across focus groups and ranked by salience. In the second study, 153 DSPs across the United States rated the usefulness of technology features and data entry methods and provided qualitative responses on their concerns regarding the use of technology for data collection and documentation. Quantitative responses were ranked based on their usefulness across participants, and rank-order correlations were calculated between different work settings and age groups. The qualitative responses were thematically analyzed. RESULTS: In study 1, participants described difficulties with paper-and-pencil data collection, noted benefits and concerns about using technology instead, identified benefits and concerns about particular technology features, and specified work-environment factors that impact data collection. In study 2, participants rated multiple features of technology as useful, with the highest usefulness percentages endorsed for task views (ie, by shift, client, and DSP), logging completed tasks, and setting reminders for specific tasks. Participants also rated most data entry methods (eg, typing on a phone or tablet, typing on a keyboard, and choosing from options on a touch screen) as useful. Rank-order correlations indicated that the usefulness of technology features and data entry methods differed across work settings and age groups. Across both studies, DSPs cited some concerns with technology, such as confidentiality, reliability and accuracy, complexity and efficiency, and data loss from technology failure. CONCLUSIONS: Understanding the challenges faced by DSPs who work with adults with ASD, and their thoughts about using technology to meet those challenges, represents an essential first step toward developing technology solutions that can increase DSPs' effectiveness and job satisfaction. The survey results indicate that technology innovations should incorporate multiple features to account for different needs across DSPs, settings, and age groups. Future research should explore barriers to adopting data collection and documentation tools and elicit input from agency directors, families, and others interested in reviewing data about adults with ASD.

Parent-implemented self-management intervention on the on-task behavior of students with autism.

Despite extensive research examining self-management interventions for individuals with autism spectrum disorder (ASD),¹ researchers have failed to evaluate self-management procedures for on-task behavior in the home environment or with parents as interventionists. Using an ABAB design, the present study examined the effectiveness of a parent-implemented intervention consisting of self-monitoring, self-evaluation, and contingent reinforcement to increase on-task behavior of three participants completing independent school work in their home. Traditional and masked visual analysis of single-case design data indicate that, across participants, the intervention increased on-task behavior, intervention effects were maintained at postintervention, parents implemented the intervention with high fidelity, parents and children rated procedures as high in social validity, and observations via live video technology resulted in high correspondence between parent and child ratings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Physician Perspectives on Severe Behavior and Restraint Use in a Hospital Setting for Patients with Autism Spectrum Disorder.

Hospitals, with many features that can evoke severe behavior in patients with autism spectrum disorder (ASD), often use restraint as a behavior management strategy. Prior research on restraint in patients with ASD has primarily focused on children or specific departments. Twenty-five physicians and medical trainees from an urban teaching hospital participated in discussions about experiences managing severe behavior in patients with ASD across the lifespan. Twenty themes emerged from thematic analysis of participant transcripts. The five most salient themes included: lack of procedural knowledge with restraint implemented by other hospital professionals; alternative strategies to manage severe behavior; negative perceptions of restraint; helpful role of caregivers; and limited experience treating patients with ASD, and critical need for training in function-based management.

Efficiency and preference for alternative activities during schedule thinning with functional communication training.

Functional communication training is an effective treatment for decreasing socially reinforced destructive behavior (Carr & Durand, 1985). Clinicians frequently use multiple schedules to thin the reinforcement schedule (Hanley et al., 2001). Individuals are often taught to wait for functional reinforcers without alternative programmed stimuli. However, concurrently available items and activities are often accessible in the natural environment. In this study, we taught 4 participants a functional communication response to access functional reinforcers. We implemented a multiple schedule during schedule thinning, comparing a control condition (nothing available during SΔ intervals) to separate conditions with items/activities (moderately preferred tangible items, attention, demands) noncontingently available during SΔ intervals. After reaching the terminal schedule in one condition, therapists assessed participant preference across SΔ conditions. For all participants, the terminal schedule was reached with alternative items and activities, and participant preference corresponded with the most efficient schedule thinning condition. Therapists also indicated preference for alternative items/activities.

Accuracy of caregiver identification of demands for children with escape-maintained challenging behavior.

BACKGROUND: Although stimulus preference assessments are widely used to identify reinforcers and to inform positive reinforcement conditions in a functional analysis (FA), direct assessments of potential negative reinforcers are not as commonly employed. Demands are often selected from caregiver report alone. AIMS: The purpose of the current study is to (a) replicate the Demand Assessment for Individuals with Severe Disabilities (DAISD) indirect assessment interview for caregivers to identify demands that may evoke challenging behavior; (b), compare the correspondence of the DAISD in relation to an established direct assessment, the demand latency assessment (DLA); and (c) evaluate if the demands that caregivers identify as the most aversive are more likely to evoke challenging behavior and identify an escape function in an FA than those demands caregivers identify as least aversive and replicate validation of the DLA. METHODS AND PROCEDURES: This study evaluated caregiver accuracy at identifying demands most likely to evoke escape-maintained challenging behavior for four children with developmental disabilities. Caregiver-informed aversiveness hierarchies from the DAISD were compared to child-informed aversiveness hierarchies from the DLA. Functional analyses included separate escape conditions with DAISD and DLA most and least aversive demands. OUTCOMES AND RESULTS: Although all caregivers identified at least eight demands, caregivers' accuracy with demand aversiveness was variable as indicated by (a) a false negative FA outcome for one of four participants with the caregiver-nominated most aversive demand; (b) higher rates of challenging behavior with the caregiver-nominated least aversive demand than most aversive for three of four participants; and (c) lack of a strong positive rank order correlation between caregiver- and child-hierarchies for all participants (range, -0.76 to .48). Compliance was not a strong predictive variable of challenging behavior with either assessment. CONCLUSIONS AND IMPLICATIONS: Results indicate that the DAISD interview is useful at identifying multiple demands presented in the natural environment, but should be followed up with direct assessment to determine demand aversiveness rather than used for caregivers to rank demand aversiveness.

Acceptability and Feasibility of Virtual Behavior Analysis Supervision.

The COVID-19 pandemic necessitated a rapid transition to virtual service delivery and supervision. This preliminary study examined acceptability and feasibility of virtual supervision for 94 BCBA/BCaBA trainees during COVID-19, including variables that affected perceived satisfaction, effectiveness, and supervision preference for this sample. Results indicate a decrease in accrual of direct client hours during the pandemic, with a third of participants reporting a decrease in individual supervision. In general, participants were satisfied with virtual individual and group supervision as indicated by high satisfaction domain scores and individual item means, with minimal overall change in satisfaction. Participants indicated preference for in-person or hybrid supervision and considered in-person most effective. In general, participants reported that virtual supervision was feasible and supervisors used best-practice strategies. We discuss variables that affected satisfaction (e.g., length of supervisory relationship), preference (e.g., age, services provided), and perceived effectiveness (e.g., time supervisor was a BCBA). We provide practical implications and recommendations for virtual supervision.

Use of a paired-stimulus demand analysis to evaluate demands for inclusion in functional analyses.

Clinicians regularly use both indirect and direct assessments to identify preferred stimuli to include in control conditions and positive reinforcement test conditions in a functional analysis (FA). However, clinicians often rely on indirect assessment alone (e.g., caregiver report) to identify aversive stimuli to include in negative reinforcement test conditions. In this study, we evaluate a paired-stimulus demand analysis and validate assessment results via FA. Results indicate that, for all 4 participants, the demands selected least often evoked higher rates of destructive behavior than more frequently selected demands. We identified an escape function for all 4 participants in the escape-least selected (LS) condition (true positive finding) and for only 1 participant in the escape-most selected (MS) condition (false negative finding for 3 of 4 participants). These results support the utility of empirically deriving stimuli for inclusion in the negative reinforcement test condition of an FA to decrease the likelihood of false negative findings.

Effects of Magnitude on the Displacement of Leisure Items by Edible Items During Preference Assessments.

Studies on preference assessments have shown that when both edible and leisure items are compared, edible items tend to displace leisure items in preference hierarchies. However, the mechanisms behind this process are currently unclear. One possibility is that displacement may be a product of the relatively brief periods of access to leisure items typically used in preference assessments. The purpose of the current investigation was to examine whether the duration of access to leisure items affects displacement. In this study, participants chose between preferred leisure items and the edible items that had previously been shown to displace those leisure items in a preference hierarchy. Duration of access to the leisure item was systematically increased across series to identify the magnitude at which leisure items became more preferred than edible items. Results indicate that as the duration of access to leisure items increases, displacement decreases.

Minimizing resurgence of destructive behavior using behavioral momentum theory.

The resurgence of destructive behavior can occur during functional communication training (FCT) if the alternative response contacts a challenge (e.g., extinction). Behavioral momentum theory (BMT) suggests that refinements to FCT could mitigate resurgence of destructive behavior during periods of extinction. Following a functional analysis and treatment with FCT, we combined three refinements to FCT (i.e., the use of a lean schedule of reinforcement for destructive behavior during baseline, a lean schedule for the alternative response during FCT, and an increase in the duration of treatment) and compared the magnitude of resurgence relative to a condition in which FCT was implemented in a traditional manner. Results suggested that the combination of these three refinements to FCT was successful in decreasing the resurgence of destructive behavior during an extinction challenge. We discuss the implications of these findings, as well as areas for future research.

Clinical outcomes of behavioral treatments for elopement in individuals with autism spectrum disorder and other developmental disabilities.

The external validity of behavioral treatments for elopement (i.e. leaving supervision without permission) remains unclear because studies to date include only small samples ( n = 1-3). This study quantified the overall effectiveness of behavioral treatments for elopement by retrospectively examining treatment data from all patients seen for the treatment of elopement at an intensive day treatment clinic ( n = 11), irrespective of treatment success. Reductions in elopement from baseline to the final treatment for each participant demonstrate that behavioral intervention is a highly effective treatment for elopement, as determined by the large effect size (Cohen's d = 1.18).

Clinical Outcomes of Behavioral Treatments for Pica in Children with Developmental Disabilities.

Pica is a potentially deadly form of self-injurious behavior most frequently exhibited by individuals with developmental and intellectual disabilities. Research indicates that pica can be decreased with behavioral interventions; however, the existing literature reflects treatment effects for small samples (n = 1-4) and the overall success of such treatments is not well-understood. This study quantified the overall effect size by examining treatment data from all patients seen for treatment of pica at an intensive day-treatment clinical setting (n = 11), irrespective of treatment success. Results demonstrate that behavioral interventions are highly effective treatments for pica, as determined by the large effect size for individual participants (i.e., NAP scores ≥ .70) and large overall treatment effect size (Cohen's d = 1.80).