Telehealth Frequently Asked Questions

Consent for telehealth ABA services is essential, just as it is for any provision of ABA services. Consent for telehealth ABA services must be obtained before provision of the services occur. The general requirements for consent to ABA services provided in person apply to consent for telehealth ABA services. Consent for telehealth ABA services, per se, should address:

To date, the data indicate that telehealth ABA services are effective in training and supervising persons implementing functional analyses (Barretto et al., 2006; Boisvert et al., 2010; Fisher et al., 2014; Gibson et al., 2010; Machalicek et al., 2010; Rios et al., 2020; Schieltz et al., 2020; Suess et al., 2016; Tomlinson et al., 2018; Tsami et al., 2019; Wacker et al., 2013). Typical clinical procedures should be followed, such as ruling out medical causes of problem behavior before assessment (Copeland et al., 2020) and conducting a thorough indirect assessment to design appropriate, individualized assessment conditions (Iwata & Dozier, 2008). However, additional precautions may be warranted for severe or dangerous behavior, such as providing or identifying protective equipment, teaching caregivers to block problem behavior or use protective equipment effectively, and conducting the indirect assessment and initial training without the client present. One of the modified forms of a functional analysis might be used to reduce risks posed by severe behavior, such as a pairwise comparison of a test and a control condition, latency-based functional analysis (Thomason-Sassi et al., 2011), or functional analysis of precursors to problem behavior (Smith & Churchill, 2002). Behavioral skills training with a confederate acting as the client can be effective during training. Alternatively, caregivers might wear a headset in order for the practitioner to provide immediate coaching and feedback during live sessions.

Regarding client outcomes (e.g., individuals receiving the therapy), the best evidence supports the use of telehealth to treat challenging behavior by conducting a functional analysis and functional communication training (Gibson et al., 2010; Lindgren et al., 2016; Schieltz et al., 2020; Suess et al., 2014; Suess et al., 2016; Tomlinson et al., 2018; Tsami et al., 2019; Wacker et al., 2013). However, some evidence indicates that not all clients will respond via telehealth treatment. It is recommended that practitioners determine if they can provide telehealth services ethically and effectively for clients whose caregivers likely will need more assistance than remote coaching can accommodate (Pollard et al., 2017; Romani et al., 2017). Additionally, practitioners should identify an on-site location where clients and their caregivers (as appropriate) can be treated in the event the client is non-responsive. Until supportive research has identified the best candidates for telehealth treatment, practitioners should develop a triage protocol and termination criteria for telehealth treatment. Practitioners also should consider the solutions to common issues shown in the table below.

Issues Related to Client Behavior

Client escalation of dangerous behavior during sessions (aggression/self-injury)	Mail protective equipment Coach caregivers/staff on blocking/use of padding Train caregivers/staff without client present (e.g., model on camera with colleague)
Client reactivity to practitioner’s presence in the camera or to the vocal instructions	Have caregivers/staff use bluetooth headphones Turn off video feed and/or mute audio Speak to caregivers in client’s absence Never speak directly to client Conduct initial free play sessions to reduce reactivity Communicate via text while muting microphone and camera
Client disrobes frequently	Be ready to turn off recording Have client wear clothes that are difficult to remove

There are many factors that must be considered when ethically adapting interventions from a face-to-face model to a telehealth model. The Table below highlights four critical considerations: (1) service model, (2) BCBA scope of competency and training, and (3) client choice and acceptability of telehealth, and (4) practitioner choice and acceptability of telehealth.

Consideration	Relevant Information	Resources
Service Model	Caregiver-mediated assessments and interventions are supported by the literature Direct service (e.g., 30 hour Early Intensive Behavioral Intervention model) is not supported by the literature Literature supports the practitioner coaching the caregiver in programming typically 2-3 times per week for 1-2 hour sessions	Relevant citations in the resources section below: Ferguson et al., 2019 Neely et al., 2017 Tomlinson et al., 2018 Unholz-Bowden et al., 2020 Service Model 1-pager for caregivers
BCBA Scope of Competency	BACB Code 1.04[d] guides Behavior analysts to practice only within their scope of competency. Preliminary evidence demonstrates that ABA practitioners require training to gain competency in telehealth practice (Lerman et al., 2020). LABA practitioners should seek out additional trainings including attending webinars, observing colleagues in their telehealth practice, recruiting feedback from colleagues and telehealth experts, and ongoing self-assessment of the effectiveness of their practice. Practitioners might also require training in telehealth technology (e.g., videoconferencing technology, data protection and confidentiality) or additional training in clinical competencies (e.g., caregiver coaching).	Relevant citations in the resources section below: Lerman et al., 2020 Training Resources: Lerman coaching caregivers CEU presentation Video examples
Client Choice and Acceptability of Telehealth	Acceptability of the telehealth modality for the client should be considered Choice of modality should be offered during the consent process	Relevant citations in the resources section below: Tsami et al., 2019 Service Model 1-pager for caregivers
Practitioner Choice and Acceptability of Telehealth	Acceptability of the telehealth modality for the client should be considered Provider wellness and health	Relevant citations in the resources section below: Crockett et al., 2020
Other	Privacy Licensure and State Regulations Emergency Provisions Documentation	Relevant citations in the resources section below: Crockett et al., 2020

Caregivers play a large role in the context of the telehealth modality, often serving as the direct service provider. As such, adoption of the telehealth modality must include caregivers from the very start. To begin, practitioners may first consider the service delivery model. A paper by Columbo and colleagues (2020) provides a nice decision-making model that practitioners may reference. Within that model, the authors provide three options for service that they titled “indirect telehealth”, “direct telehealth”, and “reduced services”. Broadly, the “indirect telehealth” model and “reduced services” model both map onto the telehealth model supported by the extant literature (e.g., caregiver-mediated assessment and treatment). The third option, “direct telehealth”, is not currently supported by the literature. When pivoting treatment to the telehealth modality, practitioners may consider utilizing telehealth to explicitly program for maintenance and generalization of skills, to implement a caregiver training curriculum, or to target skills that may not be appropriate for the clinic setting (e.g., adaptive skills necessary for the home). Practitioners might also be interested in reading guidance from Kennedy Krieger Institute regarding their process to rapidly convert their assessment and treatment process to telehealth amidst the pandemic (Crockett et al., 2020).

Once the target skills are identified, the data collection is similar to what is done in a clinic setting with the addition of the caregiver as the service mediator. The practitioner would coach the caregiver through the behavior assessment and baseline data collection. The baseline and assessment data would then inform the design of the intervention and intervention data would be collected during each telehealth session. Since the practitioner will be working through the caregiver to provide the treatment, it is highly recommended that one skill is targeted at a time and the data collection is streamlined. For example, instead of interval data, the practitioner might utilize trial-based data for a functional communication training program. The practitioner might also consider collecting probe data on a smaller subset of trials, however, this approach can also overestimate skill acquisition (Lerman et al., 2011).

All of the elements of behavioral skills training (BST; Parsons et al., 2012) can be delivered remotely, albeit with some modifications. Practitioners might consider the following strategies for each component of BST (instructions, modeling, rehearsal, practice):

Instructions	Modeling	Rehearsal	Practice
E-mail written descriptions of procedures to caregiver prior to and following each appointment	Role play with colleague in front of webcam to demonstrate procedures	Role play with caregiver during synchronous on-line appointments	Observe caregiver with recipient of intervention, providing prompts and feedback as needed
Review written handouts during synchronous on-line appointments	Pretend to implement procedures with doll or teddy bear	Show caregiver how they should demonstrate procedure virtually (e.g., hold a preferred item up to the camera to indicate when they would deliver a reinforcer, gesture towards the camera to indicate when they would deliver a gesture prompt, grasp their own arm and move it in front of the camera to indicate when they would use physical guidance)	Arrange for caregiver to wear wireless Bluetooth headsets or earbuds during practice sessions
Use simple descriptions and illustrations (e.g., pictures flowcharts) to explain procedures	Create video models to share during appointments or make available to caregivers for asynchronous viewing	First have caregiver role play as the recipient of the intervention, then switch roles	Use clear, simple prompts and feedback
		Continue role play until caregiver’s performance meets a mastery criterion	Begin with immediate feedback and gradually delay feedback as caregiver’s performance improves

The practitioner may need to revisit written and vocal instructions, modeling, and rehearsal if the caregiver has difficulty implementing the procedures with high integrity during practice sessions with the recipient. In some cases, the practitioner may find it helpful to focus on one procedural component at a time (e.g., delivering reinforcement for correct responses) and then introduce training for additional components (e.g., using three-step prompting) when the caregiver masters the previous ones. Recording practice sessions and reviewing these videotaped sessions with the caregiver also may be helpful.

First of all, behavior analysts have to consider the caregiver as a client. When a caregiver is unwilling or unable to assist as the direct service provider, there are a couple of issues to consider. See the table below for some of the most common issues and potential solutions. If a behavior analyst implements the following steps and is still unsuccessful, they might consider referring the family to a colleague. Ultimately, if the efforts are still unsuccessful, then services via telehealth may be discontinued until in-person services can be resumed.

Issue	Potential Solution
Difficulty learning via telehealth	Teach the caregivers target skills using behavioral skills training (BST; Parsons et al., 2012). Start with straightforward goals with few learning components so the caregiver is likely to be successful and access reinforcement quickly (e.g. playing with their child). Shape the skills once the foundational skills are established using BST. Behavior analysts may consider creating task analyses to teach caregivers more complex skills. Additional guidance is provided here
Competing demands	Problem solve barriers to telehealth and help the caregiver set up the home environment to facilitate telehealth services (Lerman et al., 2020)
Lack of motivation	Establish a relationship with the caregiver and build rapport. Reassess goals and programs as they may not be acceptable for the home environment. Recognize and reinforce caregiver’s role in the telehealth service model. Re-evaluate the acceptability of the telehealth modality. May have to return to the initial consent procedure and review service delivery options.

Before beginning to provide telehealth ABA services, behavior analysts should check carefully regarding the policies and requirements related to telehealth by any serviced funding entities. When a funder is an insurance company, that particular company must be contacted regarding its policies and requirements for telehealth services for the particular policy in question. (NOTE: the policies and requirements can vary considerably across the various types of policies that a particular insurance company provides as well as varying considerably across insurance companies.) Issues to explore include the following: Any limitations on hours of telehealth services, restrictions on types of telehealth services, payment rates for telehealth services, billing codes to be used for telehealth services, and documentation requirements. Practitioners or the relevant administrative personnel should make sure that insurance company policies and requirements are consistent with relevant statutes (e.g., state, federal, provincial).

First, it is recommended that the practitioner video record all behavioral observation portions of videoconferencing sessions, as it can be challenging to collect data in real time while observing remotely. Practitioners should obtain consent to record before recording. Prior to observations, ask caregivers to arrange one or more of the following to increase the likelihood of unobstructed views:

• Move or block access to furniture or large objects in room
• Block or obstruct exits from area
• Position camera so entire room fits within range of camera lens
• Select small, enclosed area in home that fits within range of camera lens
• Set up multiple cameras in area
• Wear a body camera
• Position a cell phone or other web cam closer

In some cases, practitioners may need to rely on caregiver report of behaviors when video or audio are poor or when the connection fails. It is highly recommended that practitioners directly evaluate the reliability of these reports by having caregivers periodically provide them when the practitioner can independently collect data for the same behavioral observation. For more guidance, see Lerman and colleagues’ paper (2020).

Locating the legal and governmental mandates for the provision of applied behavior analysis (ABA) services in the state(s) one provides such services is critical. It is also important to note that a state may have a multitude of statutes or regulations related to telehealth (see TxABA Public Policy Telehealth Task Force Report). These could include statues and regulations across professions but further specific to a funding source. For states in which behavior analysts are licensed, the first recommendation would be to search, locate, and read the states licensing law and regulations. This often is found on the webpage of the board responsible for overseeing behavior analysts. For example, in Texas, behavior analysts are regulated under the Texas Department of Licensing and Regulation (TDLR) which has a dedicated webpage to behavior analysts with a specific link to the law and regulations.

Irrespective of whether behavior analysts are licensed in a state or jurisdiction, it is recommended one review the state’s or jurisdiction’s behavior analysis association webpage for resources related to legal and governmental mandates for that state or jurisdiction. If information related to telehealth mandates are not available, it is recommended one inquire with the leaders of the state’s or jurisdiction’s behavior analysis association about resources for ABA providers related to provision of telehealth services.

Finally, it is recommended that any regulations or mandates be discussed with administrators of the funding source for services. It may be that regulations in the state permit the utilization of telehealth for ABA services, but the rules for a specific funding source do not permit it. For example, in the state of Texas, there currently are no statues or rules that address provision of behavior analysis services utilizing telehealth. However, telehealth ABA services are permitted within the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Medicaid-waiver programs but are not permitted under the Community Living Assistance & Support Services (CLASS) Medicaid -waiver program.

Telehealth removes some of the logistical barriers of receiving treatment, such as transportation and exposure to Covid-19. However, it also requires the caregiver to serve as the direct service provider, which can be stressful and time consuming. As such, you might notice a significant increase in missed or rescheduled sessions. Below are some suggestions and considerations focused on increasing attendance and participation in telehealth sessions.

Multiple Reminders	Although this suggestion increases the response effort of the practitioner and requires significant pre-planning, multiple reminders can provide caregivers the prompt they need to remember session. Ask the caregiver how they prefer to be contacted or provide various options. Practitioners can use web-calendar invitations, text messages, phone calls, emails, or app notifications to send the session information. The reminder should not only include the date and time of the session, but the videoconference link and materials needed for the session as well. The easier the videoconference link is to locate, the better!
Provide Options	If the caregiver has been unable to attend the scheduled appointment, provide alternative times or days for re-scheduling. Practitioners may also offer the option for shorter sessions, more focused programming, or a hybrid model of training. This allows the caregiver to identify what they are comfortable with taking on, as well as what times work best for the schedule of their family.
Consider Caregiver Motivation	Caregivers are invested in improving the quality of life for their child but will be more motivated in intervening on behaviors or skills that affect their family life on a daily basis. When transitioning to telehealth and obtaining consent to continue, ask the caregiver about their priorities and work together to develop goals for what’s best for the child and the caregiver. Demonstrating improvement in skills that impact their daily activities (e.g., independent living or leisure skills) may be reinforcing to the caregiver. For example, getting a child dressed in the morning can take a significant amount of time and be extra stress for the caregiver. Implementing a procedure focused on independent dressing skills will not only improve the quality of life for the child but alleviate the stress of the caregiver as well.

• Behavior Analysis in Practice volume 13, issue 3
• Behavior Analysis in Practice volume 13, issue 4
• Journal of Applied Behavior Analysis volume 53, issue 3
• Journal of Behavioral Education volume 29, issue 2