Behavioral Telehealth Consultation with Families of Children with Autism Spectrum Disorder

In this study, desktop video teleconferencing was used to facilitate behavioral consultation at a distance with three parents of school‐age children with autism spectrum disorders. Parents were supported via desktop video teleconferencing as they conducted functional analyses and learned to implement an antecedent manipulation strategy, functional communication training, and a consequence‐based strategy. Parents then conducted a brief multi‐element treatment comparison to evaluate the preliminary effectiveness of each intervention strategy on their child's challenging behavior. The results of this study provide additional support to previous research suggesting that a telehealth model of behavioral consultation may be an effective way to assist parents of children with autism spectrum disorders address challenging behavior that disrupts family routines. Suggestions for future research are discussed. Copyright © 2016 John Wiley & Sons, Ltd.     

Effectiveness and acceptability of parent training via telehealth among families around the world

Teaching parents to conduct functional analyses and to implement functional communication training is an efficacious approach for treating socially maintained problem behavior (Derby et al., 1997). Research has found that delivering this assessment and intervention package via telehealth technologies is efficient and acceptable to caregivers in the United States (Wacker et al., 2013b). We replicated this work with families residing in rural and urban areas of eight countries. Two behavior therapists located in the United States conducted appointments in the participants' native languages, using interpreters as needed. Parent‐implemented functional analyses and treatment with functional communication training were highly effective in reducing problem behavior in children diagnosed with autism. Furthermore, parents rated the procedures as acceptable and indicated that the treatment would be effective with their children. These findings indicate that telehealth technologies are a viable option for clinicians to provide behavior analysis services to families around the world.     

Preliminary evidence on the use of telehealth in an outpatient behavior clinic

Previous studies have shown that telehealth can be an effective way to deliver behavior‐analytic services. In this study, we provided a demonstration of the use of telehealth to assess and initiate treatment of problem behavior in an outpatient clinic. We coached parents of children with autism via telehealth to conduct functional analyses during 1 appointment that lasted 1 hr and subsequently coached them as they implemented functional communication training during 3 subsequent appointments (15 min each). Social functions were identified for most children, and problem behavior was reduced by an average of 65.1%.     

Effects of Presession Pairing on the Challenging Behavior and Academic Responding of Children with Autism

Presession pairing is an antecedent‐based procedure in which an instructor engages with preferred items with a child for a few minutes before an instructional session. Although this procedure has been described in manualized treatment guidelines for working with children with autism, there are currently no direct investigations of whether this manipulation has a beneficial impact on target responding or the child's social interactions. Functional analyses with three children with autism showed escape or attention and escape as reinforcers for their challenging behavior. Preference assessments identified highly and moderately preferred stimuli. In the context of a multiple baseline across participants design, the participants exhibited fewer challenging behaviors when instructional sessions were preceded by presession pairing than when they were not. Academic responding showed modest increases. Subsequently, in the presence of presession pairing with a novel task, the participants emitted no challenging behavior and similar or higher levels of accurate academic responding. One participant was available for a maintenance session without presession pairing 5 months later and showed near‐zero levels of challenging behavior and comparable levels of accurate academic responding. The implications of the findings and future directions are discussed. Copyright © 2015 John Wiley & Sons, Ltd.     

Using telehealth to provide outpatient follow‐up to children with avoidant/restrictive food intake disorder

The COVID‐19 global health crisis compelled behavior analysts to consider alternatives to face‐to‐face services to treat children with feeding disorders. Research suggests telehealth is one method behavior analysts could use to initiate or continue assessment of and treatment for feeding disorders. In the current paper, we conducted pilot studies in which we analyzed chart records of patients with Avoidant/Restrictive Food Intake Disorder; who graduated from an intensive, day‐treatment program; and transitioned to an outpatient follow‐up program. In Experiment 1, we analyzed the data of participants who received follow‐up both in‐clinic and via telehealth. In Experiment 2, we analyzed goal attainment for participants who received outpatient follow‐up either in‐clinic exclusively or via telehealth exclusively. Results of both studies showed that outcomes were equivalent along most dimensions for in‐clinic and telehealth services. We provide recommendations for telehealth feeding services and discuss other considerations relevant to telehealth service delivery.     

Telehealth mask wearing training for children with autism during the COVID‐19 pandemic

SARS‐CoV‐2 is the virus causing COVID‐19 and is spread through close person‐to‐person contact. The use of face masks has been described as an important strategy to slow its transmission. We evaluated the effects of coaching caregivers via telehealth technologies to teach face mask wearing to children with autism spectrum disorder. Six participants with a history of challenging behavior associated with mask wearing were recruited from different parts of the world, and trained using graduated exposure, shaping, and contingent reinforcement. By the end of the intervention, all participants wore a face mask for a period of 10 min without exhibiting challenging behavior. The skills generalized to a novel mask or a community setting. Mask wearing did not affect the percentage of oxyhemoglobin saturation of participants, and caregivers found the intervention useful. The findings support previous tolerance training treatment evaluations in children with developmental disorders exhibiting resistance to healthcare routines.     

The effects of transition to technician‐delivered telehealth ABA treatment during the COVID‐19 crisis: A preliminary analysis

Telehealth delivery of applied behavior analysis treatment has focused on supervision or staff and parent training, rather than the direct delivery of treatment to clients. The novel coronavirus (COVID‐19) crisis had the potential to significantly disrupt access to direct treatment for individuals with autism. We report a sample of 17 cases that transitioned from in‐person to telehealth delivery of treatment when shelter‐in‐place orders were issued. Of these cases, 76% of participants transitioned to technician‐delivered telehealth services whereas the rest transitioned to a caregiver‐implemented telehealth model. Participants continued to access a similar dosage of treatment hours per week in spite of the treatment model transition (in‐person M = 12; telehealth M = 11) and maintained or improved correct independent responding across all targets from in‐person treatment (M = 75%) to telehealth treatment (M = 80%). These findings provide initial evidence that some clients with autism benefit from technician‐delivered telehealth services.     

ON THE RELATION OF MANDS AND THE FUNCTION OF DESTRUCTIVE BEHAVIOR

When standard analogue functional analysis procedures produce inconclusive results in children with conversational speech, the child's mands may help to identify the function of destructive behavior. In the current investigation, functional analyses conducted with 2 children who exhibited self-injury, aggression, and property destruction were undifferentiated across conditions. Based on informal observations and school and parental report, an analysis was conducted using mands to help determine the function of the destructive behavior. Using a multielement design, the therapist's compliance with the child's mands occurred either on a fixed-ratio (FR) 1 schedule or contingent on destructive behavior. Destructive behavior occurred at high and consistent levels when reinforcement of mands was contingent on destructive behavior and at near-zero levels when reinforcement of mands occurred on the FR 1 schedule. Based on these results, a second analysis was conducted in which compliance to mands occurred only when the child appropriately requested it (i.e., functional communication training plus extinction) and, for 1 child, compliance with mands was terminated contingent upon destructive behavior (i.e., functional communication training plus response cost). For both children, the rates of destructive behavior decreased markedly. The results suggest that assessing the child's mands may be useful in decreasing destructive behavior when a functional analysis is inconclusive.     

Adult attention and interaction can increase moderate‐to‐vigorous physical activity in young children

Evidence suggests that physical inactivity is prevalent among young children. To combat this, one recommendation for caregivers is to become actively involved in their child's physical activities. However, this general recommendation does not specify how or when a parent should become involved. The purpose of the current study was to conduct a functional analysis to identify a social consequence that would increase the moderate‐to‐vigorous physical activity (MVPA) exhibited by preschool‐aged children, and then to compare the effects of that social consequence when it was provided contingent on MVPA and when provided independent of MVPA. The results of the functional analyses indicated that 3 of 7 children were most active when attention or interactive play was provided contingent on MVPA. Results of the intervention analysis suggested that caregivers of young children should provide attention or interactive play contingent on MVPA when those consequences are identified as reinforcers in a functional analysis.     

Comparison of blocking strategies informed by precursor assessment to decrease pica

Pica is dangerous behavior and often maintained by automatic reinforcement. We conducted a latency functional analysis (FA) using safe consumption items to verify that pica was maintained in part by automatic reinforcement and exclude participants for whom pica was likely maintained solely by attention. Next, we identified precursors to pica through a probability analysis and conducted a brief blocking assessment for participants' whose pica occurred in the alone and attention conditions of the FA. Finally, we compared blocking precursors with pica, touching an inedible item and the pica itself. Results showed that five of the six participants' pica was likely maintained by automatic reinforcement, and pica decreased during the brief blocking assessment for three of four participants. Results of the blocking comparison showed that blocking behaviors earlier in the response hierarchy was as effective as only blocking pica attempts for two participants and more effective for one participant.     

Assessing the social validity of telehealth-based applied behavior analysis services for autism spectrum disorder

During the COVID-19 pandemic, applied behavior analysis services for many autistic individuals were transitioned to telehealth. The current study assessed caregiver-reported quality of life (QoL) and social validity for families of autistic children receiving only telehealth services (n = 96) or a combination of telehealth and in-person services (n = 173). Barriers to the telehealth experience were analyzed via an ANOVA, and the impact of funding source was analyzed using an independent samples t-test. Caregivers reported benefit across QoL and social validity items, with scores ranging from 3.31 to 4.44 (1 = least benefit, 5 = most benefit). While many caregivers reported no barriers regarding technology (44.61%), childcare (69.52%), and employment (64.68%), the presence of those barriers significantly impacted QoL and social validity scores. Funding source was not found to have a significant impact. Overall, caregivers found value in their child's telehealth services. Clinicians have an obligation to mitigate barriers to ensure the success of the intervention.     

Brief functional anlaysis and treatment of elopement in preschoolers with autism

As a result of the impact of functional analysis methodologies in identifying maintaining variables of problem behavior, considerable research has been devoted to tailoring the methodologies to be practical for an outpatient setting. The purpose of this study was (a) to use brief functional analysis (BFA) methodologies to empirically demonstrate the function of elopement exhibited by two preschoolers diagnosed with autism and (b) to develop function‐based interventions derived from the results of the BFA. In phase one, a BFA consisting of 5‐min sessions with multiple repetitions of each condition was conducted with each participant. In phase two, the efficacy of function‐based interventions was assessed using a pairwise design. Both participants' rates of elopement were differentially lower during the implementation of the function‐based intervention relative to baseline. Collectively, these results demonstrated that brief functional methodologies could be applied successfully to the assessment and treatment of elopement. Moreover, the application of BFA and the ensuing treatment in an outpatient setting extend the existing research on functional analysis. Copyright © 2008 John Wiley & Sons, Ltd.     

Using brief assessments to evaluate aberrant behavior maintained by attention

We examined the use of brief functional assessments to identify idiosyncratic variables associated with aberrant behavior maintained by positive reinforcement in the form of attention. Two participants with severe developmental disabilities and their parents were involved in the assessment and treatment evaluation process. A modified attention condition was introduced, which involved both parents interacting with a third person. Results of the assessment demonstrated that aberrant behavior occurred only in the modified attention condition for both participants. Treatment consisted of the parents delivering attention on a fixed-time schedule during this specific social context. Results indicated that the treatment reduced problem behavior. Follow-up evaluations with 1 participant indicated maintenance of treatment effects for up to 6 months.     

Achieving socially significant reductions in problem behavior following the interview‐informed synthesized contingency analysis: A summary of 25 outpatient applications

Jessel, Hanley, and Ghaemmaghami (2016) reported the results of 30 interview‐informed, synthesized contingency analyses (IISCAs) and found the IISCAs to be an effective tool for identifying the functions of problem behavior across a variety of topographies, participants, and settings. Jessel et al. did not, however, include data on the effectiveness of the corresponding treatments. In the current study, we collected and summarized 25 additional applications, from analysis to treatment, in which the IISCA was applied in an outpatient clinic. The IISCA identified various social functions of problem behavior, which informed personalized treatments of functional communication training with contingency‐based reinforcement thinning. A 90% or greater reduction in problem behavior was obtained for every participant by the end of the treatment evaluation. The assessment and treatment process was socially validated by caregivers who rated the procedures highly acceptable and helpful, and the improvement in their child's behavior highly satisfactory.     

Assessment and treatment of escape from attention in the form of conversation

The purpose of this study was to evaluate treatment procedures for problem behavior maintained by escape from attention in the form of conversation for a child diagnosed with autism spectrum disorder. After conducting a functional analysis that confirmed this function, we implemented a preference assessment to identify some forms of attention that were not aversive. Treatment consisted of four conditions, implemented in a series of reversals. During each condition, the participant chose from some of the following concurrently available options: three forms of attention, escape from conversation, and escape from conversation with a 2‐min delay. We implemented the delay to reduce (devalue) the reinforcing value of escape from conversation. The participant preferred escape from conversation to social interaction when all four consequences were available immediately. When escape from conversation was possible with a delay, the participant's preference changed to social interaction. Implications for clinical practice and future research are discussed.     

THE EFFECTS OF A CHILD'S SELF-EVALUATION PROGRAM ON COMPLIANCE WITH PARENTAL INSTRUCTIONS IN THE HOME

A self-evaluation program was implemented with a kindergarten-aged boy in the home to increase compliance with parent instructions and decrease inappropriate verbal behavior. The self-evaluation package included the child's assessing the appropriateness of his behavior in 5-min intervals, receiving chips for positive self-evaluations, and exchanging chips for a reward following experimental sessions. In a reversal design, analyses were conducted of the effectiveness of the self-evaluation program, the requisite conditions for effective child behavior change with a self-evaluation approach, and the parent's efficiency in using the self-evaluation package. The self-evaluation procedures typically resulted in increased compliant behavior and decreased inappropriate behavior, although the effects generally weakened with time. Behavioral gains were greater and better maintained when the self-evaluation procedures were preceded by a phase of external evaluation via the mother than by baseline, suggesting that self-evaluation procedures may serve more to maintain the effects of external evaluation rather than to induce their own changes. The parent generally was efficient in implementing the procedures. Research and clinical implications for using self-evaluation procedures in a home setting are discussed.     

Using International Videoconferencing to Provide Staff Training on Functional Behavioral Assessment

Videoconferencing has been successfully implemented to teach functional analysis (FA) procedures to service providers who support individuals with autism spectrum disorders. The purpose of the current study was to evaluate the acquisition of the competencies for implementing FA methodology for special education teachers after participation in a group‐format workshop via a videoconferencing program in which the training site and the remote site were located on different continents, connected through the internet. Four special education teachers in Saudi Arabia who did not have previous exposure to functional behavior assessment participated in the study. Teachers received 3 h of group‐format training via Skype followed by individualized feedback. Training involved role‐playing, video modeling, and reading materials. Results indicate that all four participants mastered the skills across at least two of the conditions with one participant demonstrating mastery across all four conditions. Copyright © 2015 John Wiley & Sons, Ltd.