Telehealth and ABA: Best Practices for Optimal Client Experience

The coronavirus pandemic caused major disruptions to how healthcare services were provided, including services like Applied Behavior Analysis (ABA). Unlike other populations, a disruption in ABA services can place some clients at an increased risk for serious behavioral regression and losing acquired skills. Regression in behavioral progress could lead to emergency room visits and hospitalizations – two scenarios that are especially undesirable during a global pandemic. There is also the added incidence of caregiver stress that can occur due to inconsistent treatment. To prevent these scenarios, more and more ABA providers are now turning to telehealth to deliver the necessary treatment their clients require.

Telehealth allows for continuity of care while also reducing or eliminating the risk of transmission of COVID-19. The Council of Autism Service Providers (CASP) and other ABA associations have endorsed the use of different telehealth modalities for treatment, stating that “telehealth is a valuable option for providing continuity of care when environmental variables impede the provider’s ability to be in-person with their clients.”

CASP has provided several resources to help providers understand best practices for delivering ABA treatment via telehealth, including ways to optimize the experience for clients. The following are some recommendations for providing ABA via telehealth.

Before the telehealth ABA session – setting the stage for treatment

Before beginning any type of telehealth treatment, ABA providers must first determine the appropriate method of telehealth modality for the client and their caregiver. CASP outlines 4 different types of telehealth modalities that can be used for ABA:

• Partial Telehealth Model – This model involves the technician delivering services in-person while the behavior analyst provides clinical oversight remotely. This model has been shown to be effective for functional behavior assessments, preference assessments, behavior reduction procedures, and interventions to build language, social, and daily living skills.

• Telehealth Direct Services – This modality delivers ABA therapies directly to the client via interactive video or audio technology, or through real-time videoconferencing. Providers must first assess whether the client has the prerequisite skills to respond to interventions delivered through this method, which includes skills like basic joint attention, basic discrimination skills, and the ability to follow common 1-step instructions.

• Caregiver-Implemented Services – This model allows the caregiver to continue to implement protocols on which they have been trained. This is beneficial for scenarios where the client, caregiver, or another household member may be immunocompromised and needs to reduce contact with others. The provider must first consider which treatment protocols the caregiver can be trained on via telehealth, and whether they can be delivered without modifications or simplified for caregivers’ use. To assist with this, Relias created the ABA Parent Training Plan that provides education on different ABA techniques that can be implemented at home.

• Caregiver Consultations – For caregivers who cannot deliver services directly to clients, they may benefit from training and consultation with a behavior analyst. This type of telehealth should focus on problem-solving daily routines, maladaptive behaviors, and providing feedback and reinforcement on implementation strategies implemented at home. It is also an opportunity to evaluate any concerns directly related to COVID-19, such as changes in the client’s routine or home structure.

Before implementing any of these modalities of telehealth, the provider should evaluate the risks and benefits of each model, as well as determine the ability of the caregiver to engage in telehealth with the appropriate technology.

During the session – creating a positive experience

A positive client experience has been shown to lead to better outcomes in healthcare settings. Especially if it is the first time an ABA client or caregiver has used any type of telehealth technology, it is important for the technician or analyst to smile, be warm, and show the same personable nature as they would in an in-person session. The provider should give their undivided attention to the client, which involves silencing any electronic devices, and ensuring the provider’s home office is private and free of interruptions.

During a session, it can be beneficial to allow for frequent breaks. This can help the provider and the caregiver mitigate any behaviors they cannot adequately address via telehealth. The provider should encourage the client to invite other household members into the activities and be imaginative with the activities implemented. For children, there are many creative ways to implement ABA therapies via telehealth.

In regard to the type of technology used, small devices such as smart phones are not recommended for providing telehealth services. Small devices show a limited view of the client, caregiver, and client-environment interactions. Laptops and desktop computers are preferred, although depending on the resources available to the ABA provider, tablet technology may be provided at a minimum. General telehealth best practices should always be followed, including ideal monitor and camera placement, optimal lighting, and having an appropriate background.

After the telehealth ABA session – wrapping it all up

At the end of each session, allow an opportunity for input and questions from caregivers and the client. Review any recommendations provided during caregiver training and any training objectives that require follow-up. Always confirm the next appointment time and date with the caregiver and whether the appointment will be in-person or via telehealth.

After you have signed off from the telehealth session, gather any questions required for follow up and be sure to complete any necessary documentation. Depending on the telehealth modality you are providing, you may need to follow up with other materials, such as videos or remote monitoring tools.