It has been a rocky start to 2020 for most of us. The coronavirus pandemic has challenged families in many ways. We all miss the comfort of a daily routine and a clear sense of the future.
And for people with autism, uncertainty may bring out some challenging behaviors. Disruption in routine can set off everything from nervous tics to loss of self-care skills to bouts of aggression or self-injury.
In ABA, we do our best to prepare clients for an occasionally unpredictable or confusing world. But we certainly did not think to prep kids for a world with no school, no therapy, no community outings, and no social interactions. But now that is our reality, and so we adapt!
Within the past month, health insurance carriers have relaxed policies to cover telehealth delivery of some ABA services. Now, therapy takes place in front of a computer and ABA providers have a new desk job: coaching and cheering on family members via video conferencing. Somehow, these parents, grandparents, and siblings have stepped up to be their child’s therapist on top of everything else.
Here are our top 3 telehealth lessons so far:
Parent Training is Priority #1
In person or by telehealth, ABA therapy does not work very well without family involvement. The transition to telehealth has been easier on the parents who were participating all along. But even for those who weren’t, we have an opportunity here to make parent training priority #1.
In telehealth, a provider can’t jump in and take over when things go wrong. Instead, we have to use our ABA skills to shape parent behavior and use our soft skills to gently correct errors. Being observed is stressful; parents will need plenty of encouragement to keep participating.
When working with children, we ensure their success with simple tasks, prompts, or errorless learning. We can do the same for parents. If the parent has a favorite program or a skill they prioritize, then we can start with that. There will be time for difficult tasks later as parents gain confidence. With the right approach, parents might come out of this crisis empowered with a better understanding of their child’s therapy program.
Video Conferencing is Not for Everybody
We have had the most success providing telehealth for two categories of clients:
1. Conversational kids who are interested in showing and telling. These are usually school-age kids or teens who can engage with a therapist for 30 minutes or more. These kids can participate in a video call with minimal adult help and do not elope or engage in dangerous problem behavior. Intervention targets might include direct instruction in social, leisure, or life skills; natural environment social skills teaching; discrete trial training in communication skills; or creation of daily schedules and routines.
2. Caregivers who can run discrete trials with prompting and fading. These are usually parents of early learners or individuals with intellectual disabilities. These parents have reinforcers and learning materials at home. They are interested enough to sit at the table and become the child’s therapist for a few hours each week. These parents also know how to prevent and respond to challenging behavior without anyone getting hurt.
There are also plenty of kids who may not benefit much from ABA delivered remotely. For example, kids whose deficits are related to peer interactions or who have severe problem behavior. It also would be difficult (but not impossible!) to supervise parent implementation with a family new to ABA. In these cases, it may be best to stick with the usual parent training curriculum or weigh the risks and benefits of in-person services.
And there are also parents who might not want to prioritize ABA while trying to keep it all together during a global pandemic. That’s fine! We can look for other ways to help: for example, checking in via email to see what is needed.
Soft Skills are Key
Behavior analysts have a tricky balance to maintain. It is our job to observe behavior, analyze it, and provide feedback. But we are met with lots of resistance if we appear judgmental while doing so.
In person with kids, it’s not difficult to distract from the reality that we are there to analyze. We have fun games, exciting outings, M&Ms, stickers, etc. But in telehealth, most of that is out the window. There are a few activity reinforcers we can deliver remotely (videos, online games, books, etc.) and we can enlist the help of a family member to provide tangible reinforcers if necessary. But more than anything, our presence and company can reinforce social skills or adaptive behavior. We can keep smiles and gestures both enthusiastic and genuine, ask kids to show and tell about their favorite things, and be a good listener for kids who are worried or upset.
When working with parents, this can be even trickier. Parents might see a telehealth session as just one more video meeting they must participate in. Of course, we can still use some of our usual reinforcement strategies: specific praise and sincere enthusiasm for their efforts. But we have to rely our soft skills more than ever. A helpful provider notices the difference between “I want a solution” and “I want to vent.” She does her best to model calm but show humanity.
And though we would like to, we just can’t solve every problem. Yes, we can be a listening ear and we can comfort a parent who is having a tough time. But if a parent’s or child’s emotional needs begin to dominate the conversation, it is time to gently offer a referral to a clinical psychologist or mental health therapist.