Delivering Interventions Via Telehealth: Functional Communication Training with a Child with Autism as a Case Example.

In this article, we provide a case example of how telehealth can be used by care providers in their homes to access empirically validated procedures such as functional communication training. As shown in the case example, complex assessment and intervention procedures were implemented successfully by care providers in their homes while receiving real-time coaching by behavior analysts who were located in a hospital in a different city. This case example is representative of the results we obtained thus far; substantial improvements in challenging and adaptive behavior occurred. Given these results obtained to date with telehealth, in terms of both outcomes of interventions and rated acceptability of the procedures by care providers, further and more widespread application of telehealth is warranted.

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.

The Long-Term Effects of Functional Communication Training Conducted in Young Children's Home Settings.

This article describes the results of a series of studies that involved functional communication training (FCT) conducted in children's homes by their parents. The 103 children who participated were six years old or younger, had developmental delays, and engaged in destructive behaviors such as self-injury. The core procedures used in each study were functional analyses (FA) and FCT conducted by parents with coaching by the investigators. The overall results of the projects showed that the FA plus FCT intervention package produced substantial reductions in destructive behavior (M = 90%), which were often maintained following treatment. In terms of behavioral momentum theory, these results suggest that analyses of behavioral persistence provide an explicit technology of maintenance.

Mand Modality Preference Assessments among High- and Low-Tech Options for Individuals with Intellectual and Developmental Disabilities: A Systematic Review.

The extant literature demonstrates that individuals with intellectual and developmental disabilities (IDD) exhibit preferences among communication modalities when multiple modalities are available and produce reinforcement on identical reinforcement schedules. High- and low-tech communication options, such as voice output devices and picture cards, are commonly recommended for individuals with limited vocal communication skills. In this study, we conducted a systematic literature review of research studies that implemented mand modality preference assessments (MMPAs) that included both a high- and low-tech communication option with individuals with IDD. We identified 27 studies meeting our inclusion criteria and summarized the participant demographics, MMPA design and procedural variations, and MMPA outcomes. The results suggested that high-tech communication options were generally more preferred over low-tech options. However, there was a high degree of variability in how the studies were conducted and conclusions were reached. We discuss some of the current research gaps and the implications for clinical practice.

A comparative effectiveness trial of functional behavioral assessment methods.

Clinicians report primarily using functional behavioral assessment (FBA) methods that do not include functional analyses. However, studies examining the correspondence between functional analyses and other types of FBAs have produced inconsistent results. In addition, although functional analyses are considered the gold standard, their contribution toward successful treatment compared with other FBA methods remains unclear. This comparative effectiveness study, conducted with 57 young children with autism spectrum disorder, evaluated the results of FBAs that did (n = 26) and did not (n = 31) include a functional analysis. Results of FBAs with and without functional analyses showed modest correspondence. All participants who completed functional communication training achieved successful outcomes regardless of the type of FBA conducted.

AN EVALUATION OF RESURGENCE DURING FUNCTIONAL COMMUNICATION TRAINING.

Three children who displayed destructive behavior maintained by negative reinforcement received functional communication training (FCT). During FCT, the children were required to complete a demand and then to mand (touch a card attached to a microswitch, sign, or vocalize) to receive brief play breaks. Prior to and 1 to 3 times following the initiation of FCT, extinction probes were conducted to evaluate the resurgence of destructive behavior when the microswitch without the mand card was present or the microswitch and the mand card were absent to determine if different patterns of resurgence occurred when the microswitch was present or absent and, for 2 of the children, if changes in resurgence occurred at different points in treatment. Results showed that FCT led to relatively rapid reductions in destructive behavior. During all extinction sessions, resurgence of destructive behavior occurred with only minimal differences across the switch/no card and no-switch conditions.

A Retrospective Analysis of Therapists' Coaching Behavior When Directing Parents to Conduct Behavioral Assessments and Treatments Via Telehealth.

Research on the delivery of behavioral assessment and treatment via telehealth has focused largely on child outcomes and parent procedural fidelity. By contrast, the behavior of the therapists coaching parents to conduct assessment and treatment has garnered little research consideration. In this study, we conducted a retrospective analysis of behavior therapists' coaching behaviors when directing parents to conduct functional analysis (FA) and functional communication training (FCT) with their young children with autism via telehealth. Coaching behaviors for five experienced behavior therapists across seven parent-child dyads were scored using a combination of standardized and novel behavior codes. Therapists displayed more social engagement behaviors than any other type of behavior throughout the study, and rates of antecedent and consequence behaviors shifted across the FA and FCT phases. Results are discussed in relation to therapists' goals during behavioral assessment and treatment and the implications for training behavioral therapists to coach parents via telehealth.

Using fNIRS to evaluate ADHD medication effects on neuronal activity: A systematic literature review.

Background: Functional near infrared spectroscopy (fNIRS) is a relatively non-invasive and inexpensive functional neuroimaging technique that has shown promise as a method for understanding the differences in neuronal activity associated with various neurodevelopmental conditions, including ADHD. Additionally, fNIRS has been suggested as a possible tool to understand the impact of psychotropic medications on brain activity in individuals with ADHD, but this approach is still in its infancy. Objective: The purpose of this systematic literature review was to synthesize the extant research literature on the use of fNIRS to assess the effects of ADHD medications on brain activity in children and adolescents with ADHD. Methods: A literature search following Preferred Reporting Items for Systematic Literature Reviews and Meta-Analyses (PRISMA) guidelines was conducted for peer-reviewed articles related to ADHD, medication, and fNIRS in PsychInfo, Scopus, and PubMed electronic databases. Results: The search yielded 23 published studies meeting inclusion criteria. There was a high degree of heterogeneity in terms of the research methodology and procedures, which is explained in part by the distinct goals and approaches of the studies reviewed. However, there was also relative consistency in outcomes among a select group of studies that demonstrated a similar research focus. Conclusion: Although fNIRS has great potential to further our understanding of the effects of ADHD medications on the neuronal activity of children and adolescents with ADHD, the current research base is still relatively small and there are limitations and methodological inconsistencies that should be addressed in future studies.

Behavioral Assessment and Treatment via Telehealth for Children with Autism: From Local to Global Clinical Applications.

Functional analyses (FA) and functional communication training (FCT) are the most commonly used behavioral assessment and treatment approaches via telehealth for children with autism spectrum disorder (ASD) who display challenging behavior. The FA + FCT telehealth model has been shown to maintain treatment effectiveness (i.e., child behavioral outcomes and parent acceptability), as well as demonstrate treatment efficiency (i.e., cost savings). However, the majority of these studies have been conducted in the United States. Therefore, the purpose of this study was to evaluate the outcomes obtained with the telehealth FA + FCT model that included global applications. Descriptive statistics were used to analyze the results of the 199 participants who enrolled in the telehealth project across all project sites. The results showed that behavioral outcomes and parent acceptability maintained at similar levels to previous studies across all sites. Additionally, very few differences were found across project sites in relation to drop-out rates, visit cancellations, and technology issues. These results demonstrate the effectiveness of the FA + FCT telehealth model for addressing the challenging behavior needs of children with ASD globally and highlight areas in need of additional evaluation (e.g., drop-outs, cancellations) to determine the conditions under which telehealth could be best used.

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.

Indirect Effects of Functional Communication Training on Non-Targeted Disruptive Behavior.

The purpose of this study was to evaluate the effects of functional communication training (FCT) on the occurrence of non-targeted disruptive behavior. The 10 participants were preschool-aged children with developmental disabilities who engaged in both destructive (property destruction, aggression, self-injury) and disruptive (hand flapping, spinning in circles, shrill laughter, screaming, crying) behaviors. Only destructive behavior was targeted for the functional analyses and FCT, but data were also collected on disruptive behaviors. All procedures were conducted in the participants' homes by their mothers with investigator coaching. Phase 1 consisted of conducting a functional analysis within a multielement design. Phase 2 consisted of conducting FCT with demand fading and repeated extinction baselines within a reversal design. Single-case data are provided for 3 participants, and summary data are provided for all 10 participants. Results of phase 1 showed that all participants' destructive and disruptive behavior was maintained, at least in part, by negative reinforcement. Results of phase 2 showed that both destructive behavior and non-targeted disruptive behavior occurred at lower levels during FCT when compared to the functional analysis demand condition and baseline conditions, suggesting that FCT was effective in decreasing both target destructive behavior and non-targeted disruptive behaviors.

A Preliminary Evaluation of Functional Communication Training Effectiveness and Language Preference When Spanish and English are Manipulated.

We evaluated whether differences in treatment effectiveness or preference between languages emerged across Spanish and English during functional communication training (FCT) for young children with developmental disabilities exposed to Spanish and English in the home environment. Participants were 2 young children with developmental disabilities who displayed destructive behavior maintained by social contingencies and whose families spoke Spanish and English at home. All procedures were conducted in the participants' homes by their mothers with coaching from the investigator. The effectiveness of FCT was evaluated within a reversal design across baseline, FCT, and extinction conditions. A multielement design across language type (Spanish and English) was embedded within the reversal design during the extinction and FCT conditions to evaluate differences in treatment effectiveness across type of language. Finally, during all FCT sessions, a concurrent schedules design was used to evaluate participant preference for type of language. Results suggested that FCT was effective in reducing destructive behavior, increasing manding, and/or increasing task completion for these 2 participants across Spanish and English treatment conditions. Preference for the type of language did not emerge for either participant during FCT. Results are discussed in terms of the merits of systematically evaluating language variables when working with culturally and linguistically diverse families and children.

Evaluating the Effects of Instructional Prompts and Strategic Incremental Rehearsal on the Letter Identification Mastery of Two Typically Developing Kindergarteners.

Letter identification impacts the developmental progression of future reading skills. In this study, we evaluated the effects of instructional prompts on letter identification in a single-subject design for 2 kindergarten students who experienced difficulties with letter identification skills. In Phase 1, we evaluated the number of letters participants correctly identified without instructional prompts, and in Phase 2, we evaluated the effects of 2 different instructional prompts and rewards. Phase 3 evaluated the combined effects of strategic incremental rehearsal (SIR) and the most effective instructional prompt identified in Phase 2. Results showed that an effective, yet different instructional prompt was identified for each participant and that SIR plus an instructional prompt was effective for further increasing both participants' correct letter identification. The results of this study demonstrated a useful and effective method for identifying instructional prompts, strategies, or other interventions that improve students' academic responding.

Functional assessment and function-based treatment delivered via telehealth: A brief summary.

As the world navigates the COVID-19 health crisis, behavior analysts are considering how best to support families while maintaining services and ensuring the health and safety of everyone involved. Telehealth is one service delivery option that provides families with access to care in their own communities and homes. In this article, we provide a brief summary of the telehealth literature in applied behavior analysis that provided coaching and training to families for individuals who displayed challenging behavior. These studies targeted functional assessment and function-based treatment for challenging behavior. We briefly summarize what is known relative to the assessment and treatment of challenging behavior via telehealth, place these results within a descriptive context of the decisions made by the research team at the University of Iowa, and discuss what we, as behavior analysts, should consider next to advance our understanding and practice of telehealth.

An evaluation of resurgence following functional communication training conducted in alternative antecedent contexts via telehealth.

Treatments based on differential reinforcement may inadvertently increase the recurrence of problem behavior in the face of challenges because reinforcers for appropriate behavior occur in the same context as problem behavior. The current study evaluated one potential approach to mitigating these problems with differential reinforcement treatments based on behavioral momentum theory. Specifically, appropriate behavior was trained in contexts without a history of reinforcement prior to intervening with problem behavior. Participants were 4 children with autism spectrum disorder. Treatment used telehealth to implement functional communication training (FCT) in three alternative contexts with minimal or no history of reinforcement for problem behavior before initiating FCT in the treatment context. Evaluations of the effects of treatment and tests of resurgence were conducted intermittently during treatment to evaluate maintenance. When FCT treatment was initiated in alternative contexts, initial results were comparable to more typical implementations of FCT. Resurgence was reduced to similar levels during tests of resurgence for all participants when compared to more typical previously published implementations of FCT, but clinically significant reductions in resurgence occurred more quickly in the present study. These findings support training appropriate behavior in an alternative context to mitigate the resurgence of problem behavior during differential reinforcement treatments.

Ethical Considerations When Delivering Behavior Analytic Services for Problem Behavior via Telehealth.

Delivery of healthcare services via telehealth has been growing in popularity, and work completed by behavior analytic researchers and practitioners have supported this trend. Behavior analysts at the University of Iowa Children's Hospital (UICH) developed a telehealth model of service delivery to build upon their already established in-clinic and in-home services. Results from their telehealth studies showed positive effects. Social functions were identified for most children, and problem behavior decreased by an average of 94.14%. Additionally, parent satisfaction was quite high, suggesting this mode of service delivery was acceptable to caregivers. Given the increasing empirical support for providing behavior analytic services via telehealth, careful consideration needs to be given to the numerous ethical issues involved in telehealth service delivery. The current article describes the telehealth service delivery model developed at UICH as well as the ethical issues considered at different points when delivering these telehealth services. Following these ethical considerations, implications for future research and clinical practice are discussed.

Basing assessment and treatment of problem behavior on behavioral momentum theory: Analyses of behavioral persistence.

The connection, or bridge, between applied and basic behavior analysis has been long-established (Hake, 1982; Mace & Critchfield, 2010). In this article, we describe how clinical decisions can be based more directly on behavioral processes and how basing clinical procedures on behavioral processes can lead to improved clinical outcomes. As a case in point, we describe how applied behavior analyses of maintenance, and specifically the long-term maintenance of treatment effects related to problem behavior, can be adjusted and potentially enhanced by basing treatment on Behavioral Momentum Theory. We provide a brief review of the literature including descriptions of two translational studies that proposed changes in how differential reinforcement of alternative behavior treatments are conducted based on Behavioral Momentum Theory. We then describe current clinical examples of how these translations are continuing to impact the definitions, designs, analyses, and treatment procedures used in our clinical practice.

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.

An evaluation of persistence of treatment effects during long-term treatment of destructive behavior.

Eight young children who displayed destructive behavior maintained, at least in part, by negative reinforcement received long-term functional communication training (FCT). During FCT, the children completed a portion of a task and then touched a communication card attached to a microswitch to obtain brief breaks. Prior to and intermittently throughout FCT, extinction probes were conducted within a withdrawal design in which task completion, manding, and destructive behavior were placed on extinction to evaluate the relative persistence of appropriate and destructive behavior over the course of treatment. FCT continued until appropriate behavior persisted and destructive behavior failed to recur at baseline levels during extinction probes. The completion of FCT was followed by four challenges to the persistence of treatment effects conducted within mixed- or multiple-schedule designs: (a) extended extinction sessions (from 5 to 15 min), (b) introduction of a novel task, (c) removal of the microswitch and communication card, and (d) a mixed schedule of reinforcement in which both appropriate and destructive behavior produced reinforcement. The results showed that although FCT often resulted in quick reductions in destructive behavior and increases in appropriate behavior, destructive behavior often recurred during the extinction probes conducted during the initial treatment. When the effects of treatment persisted during the extinction probes, the remaining challenges to treatment effects resulted in only mild to moderate disruptions in behavior. These results are consistent with the quantitative predictions of behavioral momentum theory and may provide an alternative definition of maintenance as constituting behavioral persistence.