By Tien Nguyen and Mia Templeton
Due to the nationwide pandemic, many countries were affected by the exposure to the coronavirus disease (COVID-19). Individuals worldwide had to self-quarantine to reduce the risk of infection or transmitting the virus unknowingly to a person; this has altered the daily lives of individuals. As a result, at BASICS we began researching alternative avenues to establish how we can better meet the needs of our clients as their environments and daily schedules changed. We realized we needed to pursue telehealth to conduct ABA sessions. We explored the available resources and realized there was a lack of previously published research on this subject. We watched ABA companies quickly pivot but were concerned that services were not meeting our company values of Innovative, Ethical, and Excellent. So, we did as much research as we could, started a telehealth accreditation process with BCHOE, and began a study that evaluated the effectiveness and feasibility of our telehealth interventions for ABA therapy to administer services to our clients and support the parents.
What is the purpose of our study?
The purpose of this study is to look at how telehealth may change the nature of our work. We wanted to determine whether telehealth was just as effective as in-person. We wanted to look at how telehealth may affect caregivers and therapists’ stress levels and to what extent it empowers them to implement behavioral interventions. To provide telehealth, we also needed to have certain technology in place for video calls. We wanted to look at whether our current technology is sufficient to effectively provide telehealth. Lastly, we wanted to know if the telehealth model would support the health of the company.
At BASICS ABA Therapy, one of our goals when designing a behavior intervention plan is to ensure that most, if not all, of the goals can be run in any setting across many situations. When designing goals for telehealth, we kept this goal in mind. That’s why we hypothesized that telehealth would be as effective as in-person therapy sessions. The idea was that telehealth goals would be the same as in-person goals. However, caregivers would play a bigger role in supporting the learner. As caregivers got more involved with the program and played a bigger role in supporting the intervention, they would feel more empowered to consistently provide behavioral intervention. Caregivers would be given more opportunities to practice behavioral intervention to aid the learner. We know from experiences that families that are more involved in the behavior intervention programs see higher successes in behavioral change. With more behavioral changes from the learner, families and therapists would lower their stress levels. This is because behavioral changes may result in more opportunities for play and enjoyment for the learner. This directly impacts the living environment of the learner’s entire relationship circle. As we learned and adapted to the telehealth environment, more variables affected how technology aided in the services being provided. We wondered if the current technology available to our company may not be sufficient in providing telehealth. This was because different households may have different internet connections. Different families may have access to a variety of devices that may not be compatible with our devices to run through the therapy session securely and efficiently. Lastly, telehealth would allow our company to stay open and thus, contribute to the health of the company.
What did we do to prepare and come up with the criteria?
To effectively collect our data, we had to compile multiple criteria to ensure that different aspects of telehealth can be measured. We looked at the purposes of our study and determined survey questions that may accurately measure those criteria. Since our questions involve measuring the stress of the caregivers and therapist, we had to come up with a rating scale that can be used across all the criteria. We determined that a rating scale between 1 and 5 would be sufficient and easy to use across all the participants; with 1 being “strongly disagree” and 5 being “strongly agree.” In order to determine the stress level and empowerment across all parties, participants in the study had their own survey. This means that therapists responded to a different survey than the caregivers. Learners that are able to respond to online surveys were also given their own survey to participate in. The different forms of the survey ensure that we tailor the criteria to fit the different relationships the learner may have.
We had to determine whether telehealth was possible for our participants before they signed up for the study. This is because we were not positive that each insurance plan that our families participated in covered telehealth. Once we were able to determine who was eligible for telehealth, we also had to determine whether it was safe for the caregivers to support the clients for telehealth. For example, clients that display aggression towards their caregivers would not be eligible for telehealth. This is because it would not be ethical to require parents to support these clients. Since the nature of telehealth required the caregivers to be present 100% of the session, it would not be safe for the caregivers if their child displayed aggression towards them. We also had to look at whether the environment in which the child lives is suitable for telehealth. Parents also had to want to receive telehealth. Lastly, we made sure that families can opt in and out of the study any time.
We also ensured we met the requirements for HIPAA for online services. Many requirements were put on hold through emergency legislation, but we got BAAs to ensure our software and communication modes were HIPAA Compliant. We also ensured we had multiple platforms (Zoom and Meet) so it could be accessed from various types of devices. We also found that families were able to access the internet- either through existing technology or through government technology grants.
How did we train our staff?
We were able to train our staff through training sessions designed to teach them about the new concepts and procedures of telehealth. We were able to test out our telehealth methods in a few sessions to determine any issues that we may need to troubleshoot. Certain new procedures were put in place in order to successfully have telehealth sessions. For example, we had to come up with procedures on what to do if a learner becomes unsafe during the telehealth session. Staff were given telehealth training by our trainer. We also made sure to go over new procedures with them. Most importantly, the supervisors overlapped with the staff on their first telehealth session with each learner.
How did we prepare the families for telehealth?
In order to qualify for telehealth, we must determine whether or not the learner’s behaviors will allow for effective sessions. We also determined whether or not the caregivers were able to support the learner during the telehealth sessions. This was done through a formal meeting between the BCBA
and the caregiver. During this meeting, we went over concepts and skills that the caregiver may need in order to support the learner. We also discussed safety procedures and other concerns that the caregivers may have. We also determined any barriers that may prevent effective telehealth sessions. These barriers were then addressed. A formal document was filled out in an attempt to address all barriers. Unfortunately, the telehealth model did not work for some families due to unsafe behaviors from the learner and skillset of the caregiver. To effectively apply a behavioral intervention program, we must promote the safety of our staff, the learner, and anyone the learner interacts with during the session. For example, it would be unethical for the caregiver to support a learner that displays high levels of aggression if the caregiver is not properly trained on physical management procedures and de-escalation. We look forward to further training on how we can implement this type of training.
What did we do to obtain data for the study?
Our data consisted of surveys answered by the caregivers, learners (if they’re able to), and the staff. Each week, the participants filled out the survey questionnaires. Reminders were sent to families and staff each week to fill out the survey questionnaires. Each family was set into their own groups so data can be compared week after week. This allowed for us to keep track of any concerns that the families may have and address the issue as soon as possible. Only families with 3 or more surveys completed were used in the study. Families that did not meet requirements were omitted at the end of the data collection. However, we still ensure that those families’ concerns are addressed in order to maintain service quality.
How did we troubleshoot issues?
When conducting the study, we had therapists fill out a "Technology, Compliant, and Paise" google form at the end of each telehealth session. The therapists could utilize the google form to report the caregiver's experience with ABA Telehealth, any concerns the caregiver or the therapist had, and some technical issues that arose during their online session.
Were there any technology issues? If so, what were they? What was our initial result?
The data collected from the "Technology, Compliant, and Paise" have shown a few connectivity issues such as audio delays, the device the individuals were using was not working, or the screen display being delayed. Caregivers and therapists had some speculation about the effectiveness of ABA telehealth and if the number of hours would be adequate for the learner. However, after analyzing the data, the finding suggests caregivers and therapists were pleased with ABA online services and their ability to learn new skills using a new platform in delivering services. The results also reported that caregivers and therapists were satisfied with their learner's progress. Overall, caregivers and therapists found ABA telehealth suitable and happy with the service being remote from home.
What was the result of the client-answered survey?
Clients who were able to answer a short questionnaire survey by themselves were able to do so. The surveys were similar to the ones that caregivers filled out. Data collection began on May 9, 2020 and ended on January 9, 2021. The data collected indicated clients found ABA. online to be beneficial in helping them within their households and were able to learn skills during their telehealth sessions. The data showed clients that participated in telehealth received more structure in their day. As a result, clients express having fewer outbursts and feeling less upset from using online ABA. Clients were asked if their personal schedules made them inaccessible for receiving online ABA. The findings indicated that they were available and open to receiving ABA through Telehealth.
Moreover, we wanted to see if the learners felt they were being supported at home with their guardians, and reports have shown that they were satisfied with the assistance they were receiving in coping with their challenging behaviors. Similar clients were pleased with the number of hours they were receiving for ABA Telehealth. At the end of the survey, clients were asked, "if the COVID-19 crisis were not happening, I would want to do online ABA," and the data showed clients would remain interested in online ABA as an alternative way of receiving services.
What was our result at the end of the study?
The data shows that 83% of all the kids showed positive change and became more engaged. We also researched what the parents were feeling and 33% of parents felt more empowered. However, 33% remain the same with being empowered. The rest felt less empowered. 20% of the therapists would not do telehealth if there were no pandemic and 80% of therapists would continue to do telehealth if there were no pandemic. 100% of the therapists felt that they were being supported. 100% of the therapists felt like they were gaining new skills to provide therapy.
Were there any differences in the ages of the clients?
We had a variety of ages for this study. The majority of the participants were teenagers ages 13 to 17. We had one preteen aged 9. Lastly, we had 2 children ages 4. Our data showed that the preteen did not benefit from telehealth throughout the data collection of this study. Even though the parents felt more supported as the study progressed, the participant’s behaviors appeared to have deteriorated. We had more success with clients that were teenagers at the time of the study; ages 13 to 17 years old. These participants were able to add more structure to their day and gained new skills. The parents also felt more empowered to work on more skills with their children outside of telehealth. For our participants that were 4 years old at the time of the study, telehealth also appeared to support the participants and their behaviors. Parents felt more empowered to work on skills outside of the session and the program provided more structure for the families. One of these participants had increased high magnitude behaviors that were ineffective. However, the family felt that they were being supported.
What is our conclusion?
Majority of participants showed positive behavioral change and became more engaged. The overall data did not support that telehealth allows families to feel more empowered. However, families did feel more empowered to work on skills outside of the sessions and to try new methods.
Therapists and families were pleased with the technology used to provide the service. They also were pleased with the services.
For the therapists that worked with the participants during telehealth, they were being supported by admin and supervisors throughout the whole process. The majority of the therapists did not have an increase in the level of support by the supervisor. However, they all felt adequately supported. They also felt less stress during telehealth. However, it should be noted that this criteria did not change throughout the data collection process. This means that the therapist’s stress levels were consistently the same throughout the data collection process. The majority of therapists consistently said that they would still want to do telehealth if there were not pandemic.
How does our conclusion be applied to the real world?
The data suggests that telehealth can be used for children and teenagers to supplement their ABA services. During a world pandemic, this is an alternative option to receiving in-person therapy since the alternative would be to not receive any ABA Therapy at all. Telehealth also supports an ABA company since our company was able to remain open throughout the entire pandemic. We must also note that some clients that did not receive telehealth were able to continue to receive in-person ABA Therapy. This means that telehealth is a great way to supplement the number of hours lost from the pandemic. However, not every client is going to benefit. Precautions should be made individualized for each client. Even though telehealth is new, we still have to make sure that our ethical guidelines are followed.
What were our limitations?
There were several limitations we ran into during the study and from analyzing the result of our findings. In the study, we had two participants who were able to fill out the short questionnaires on their own instead of their caregiver filling out the survey. The participants’ experience may have been vastly different from their caregivers’. However, we utilized these 2 forms of the surveys to come up with our conclusions about the results of the study. This may have affected our results. Due to the low number of participants, the findings of the results may not reflect the entire company or real-world settings. In addition, the surveys were self-reporting. This means that they may not have captured the true intent of the person filling out the survey. Another limitation was the data could have been skewed from the participant's internal or external conflict, such as having a difficult day or not feeling well. Those that filled out the survey may have interpreted the questions differently since we did not go over the survey questions with the participants. More data are needed in order to fully support our findings and our hypothesis.