Is Telehealth ABA here to stay post-pandemic? Or should we wave goodbye to a solution that solved many problems when COVID first hit? What does the future of ABA look like?

Well, definitely across many other industries: Hybrid or Remote work is here to stay.

As COVID continues...and continues, now is the time to start looking ahead and considering where Telehealth belongs in the world of ABA. Front and center? Or a "break glass in case of emergency" temporary solution?

During 2020, many of us relied on remote services and/or technology to teach our kids, bring our groceries, attend professional conferences, receive doctor check ups, or check in on family and friends. Video calls became a way of life. ABA therapy was not exempt from that reality.

But many ABA companies that were forced to embrace Telehealth during the height of the pandemic are now starting to look into moving away from Telehealth, re-opening clinics at full capacity, going back to school based services, and reintroducing group therapy formats (such as social skill groups). Carefully, of course, and while following local and state level mandates.

I see lots of discussion and news content focused on should ABA Telehealth continue for clients (Is this the best decision for the clients). But little focus on "What about for the professionals?". Do ABA providers have a preference between Telehealth services and non-Telehealth services?

The answer to that question may vary according to comfort level/familiarity with technology, age of client/populations served, and the specific ABA provider. RBT's may be less comfortable with Telehealth than BCBAs. Or, vice versa. There are pros and cons on both sides of this issue, but the main takeaway here is this type of clinical decision needs to be made with all parties involved. And that includes the professionals/providers, not just company owners/employers, or clients and client families.

First, let's clarify what is meant by Telehealth:

Telehealth ABA services are provided virtually through HIPAA compliant means, usually a combination of video and audio that occurs live-time during the session. Typically, funding or clinical need is most appropriate for Telehealth BCBAs. While RBTs can work virtually as appropriate for the client, funding does not always allow for this.

Telehealth typically is utilized for homebased services, although clinic or school based providers can utilize Telehealth as well.

Virtual service delivery already has a long, established history in other fields such as Mental health counseling, Psychological services, and Medicine. Telehealth is not new. However, the field of ABA embracing Telehealth IS fairly new. Prior to COVID, many insurance funders did not even have billing codes for Telehealth services.

At the BCBA level, all service delivery can utilize Telehealth (as appropriate for the particular client), including assessment, parent support, and RBT supervision.

So why the pushback against Telehealth? Why do some funding sources, employers, or practitioners seem so against Telehealth? Well, sometimes Telehealth is applied with a broad brush to clients it may not be appropriate for. I know of clinicians who are currently very anti-Telehealth because of how they've seen it done, or having it thrust it upon them at work with little to no training or support. If you are a BCBA who hates Telehealth, did anyone take the time to train you on its use? Do you have someone to reach out to with troubleshooting and questions? If you are a RBT who hates Telehealth, was it explained to you at the onset of the case? Did you know going in the BCBA would not be on-site with you? Its important to separate personal bias and preference from the use of technology to provide services. Just because you do not like Telehealth, does not mean its all bad.

When utilized in an evidence based and ethically sound ways, Telehealth has numerous benefits. I have been utilizing Telehealth to service families since 2010. If it had not been an option, these families may have gone without help and assistance. For international or rural families, professional help may not be located up the street. It may be located in a different state, or country.

Telehealth allows me to clinically supervise in discreet, non-disruptive ways that minimize client reactivity. It allows me to easily hold progress meetings with client families who may not be available during scheduled therapy sessions. I can have a 20 minute videocall with a client's dad while he's on his lunch break at work. Trying to do that in person/on-site would present many logistical challenges. 

Telehealth allows me to work for a living while also being home to support my OWN family, during this pandemic craziness. I have a few close friends who are new moms, and if they did not have the option to work via Telehealth through their maternity leave and beyond, they would have been left with no choice other than resigning from their positions.

Lastly, I think the largest benefit of Telehealth ABA services may be explained in this data:

• United States – 1996 BCBAs in the state of MA
• United States – 107 BCBAs in the state of Nebraska
• United Kingdom – 321 BCBAs  
• Australia – 111 BCBAs 
• United Arab Emirates – 104 BCBAs
• Russian Federation – 33 BCBAs
• India – 27 BCBAs
• Spain – 26 BCBAs
• Brazil – 10 BCBAs
• Nigeria – 1 BCBA

(Source: www.QBS.com)

These numbers are a very sober reminder that Telehealth is not just about personal preference, pandemics, or open-minded employers. As the demand for ABA continues to grow, the supply is not keeping up. We have far more people in need of service, than qualified providers available to help.

Telehealth makes it possible for 1 BCBA to service clients who may live in different zip codes, states, or countries. It helps companies with dire staffing deficits open up their services to more clients, it helps RBT's in dire staffing areas receive clinical support and BCBA help, and it attracts (and possibly retains) BCBAs located out of area. 

Gone are the days where the ABA provider needs to spend 7 hours in their car crisscrossing the city to see 3 clients. Now with Telehealth, not only can those 3 clients be seen WITHOUT traffic jams, but the provider could add on more clients in the same day. Removing the commute means staff spend more time working, and less time sitting in traffic (aka increased productivity). 

Opening up Telehealth services means getting families off of waiting lists, and starting up services. No more waiting months to locate and hire a BCBA in the area.

Also, sickness/illness: What about minor but still contagious illnesses, such as pink eye, stomach virus, strep throat, rashes, etc.? The provider doesn't need to cancel the session when they can just implement Telehealth instead.

What about when staff move out of area? Instead of losing quality providers, forcing the family to accept the transition, and disrupting care, how about the BCBA remains on the cases via Telehealth?

Just being able to offer Telehealth/work from home as an option to employees/staff means being a more open-minded, accommodating, and future focused employer. It is attractive to applicants when a work setting provides options. 

Again, Telehealth may not be the appropriate choice for every client or family. But, when appropriately utilized Telehealth can make the job of the ABA clinician easier and more efficient. And what employer isn't a fan of efficiency? ;-)

*Further Reading/Resources:

What does Telehealth ABA Look Like?

Telehealth for Children with Disabilities

Telehealth ABA - Best Practices

Moving Forward while Staying Home 

Practical Guidelines for Telehealth ABA

Therapy During COVID 19

Telehealth: Challenges & Solutions

Rapid Conversion from Clinic to Telehealth ABA 

Guidelines for TelePsychology 

Guidelines for Telehealth Related Ethics

Is Telehealth ABA Here to Stay?

Read more »

Tameika Meadows, BCBA, Blog Author

 

*Recommended Resources:

Helping your ASD child cope with COVID

Strategies for supporting learning at home

Homeschooling special needs children

Mastering Homeschooling

Podcast Episode: "Take Off the Cape"

During this global pandemic, schools have been as impacted as everyone else when it comes to figuring out a New Normal. 

The most recent stats indicate that globally, there are 1.2 billion children learning outside of the classroom due to school closures (source: We Forum) . E-learning has increased dramatically, with parents and caregivers now finding themselves thrust into the role of "Home Education Assistant".  

I have multiple clients who are learning at home this year, and both the parents and the children are struggling to adjust to this unanticipated change. 

For the children, it may be hard to understand why they aren't at school, why the regular routine has been so disrupted, and why they have to sit and learn at a computer all of a sudden.

For the parents, this is an added stressor during an already challenging year, it is hard to navigate a school at home schedule while also working from home (or returning to work on-site), and for parents of ASD children there are added unique challenges to help the child benefit from online learning.

Very few of the clients I serve are able to sit and learn through a device/computer screen for an entire school day. That just isn't happening. So what we are doing instead is helping the caregivers in the home learn how best to support their child's school day with this new format. Especially since none of us really know for sure when schools will be "back to normal".

Below are some tips I share with my client families, I hope they are helpful for you and your children:

• Tip #1 is THE MOST important tip: Talk to your treatment team. By "treatment team", I mean the ABA team/case BCBA, Speech Therapist, Teacher, Counselor, etc. The best person to ask about your child's learning is a professional who already knows and works with your child. Seriously, I have had so many meetings this year with client teachers, and the teachers were all so understanding, accommodating, and willing to work together, because this year is hard for all of us. You will have no idea how much the online school day can be modified until you ask.

• A daily schedule will be your BFF. It will be nearly impossible to adjust to the demands of school at home without a consistent schedule in place. Create a schedule based on when your child needs to log-on/be active in class vs. when they can work on assignments off-screen/off-camera. Be sure to include breaks (Pleeeeeease don't expect your child to sit at a computer screen all day with 0 breaks. That won't end well), meal times, reinforcement time/play, and calming or sensory activities as needed. Just like the rest of us, your child is probably highly stressed from the challenges of 2020. Though they may be unable to communicate that, just depending on ability level.

• Seek help if you are physically unable to supervise your child's online learning. I have some client families where both parents are working from home right now. It is tough, but they are able to adjust their day so at least one parent is always monitoring the child's learning. I have other client families where this is not at all possible. Every household is different. Consider having a neighbor, grandparent, older sibling, or family friend monitor your child during the school day. For some families, "monitoring" may be all that is needed. For other families, see the next tip.....

• DO understand that for some children, sitting at a laptop and attending for more than a few seconds at a time will not be possible. It won't. You are not a bad parent if this is the case. You have not failed, and you should not beat yourself up. This simply means your child will need a high level of support to benefit from schooling at home. I have some clients in this scenario, and it does mean that an adult must sit with the child and help them participate in online school. But guess what? For these types of kids, a 6- hour school day is not the goal. A 4- hour school day isn't even the goal. We work on helping the child participate as much as possible, and then we take breaks. Then we try some more. Then we take breaks....get the picture? Which leads me to my last tip....

• Let's get real. And I mean, really real. We are in the midst of a pandemic. Families are struggling mentally, emotionally, financially, etc. Your child with ASD may not understand what is going on, and why all of a sudden you are acting like a teacher. Stress levels, anxiety, and depression, are sky-high for many people. You have to assess your capacity as a parent to do school at home. It truly is not for everyone. And that's OK! Please re-read tip #1. Talk to the school. Talk to your child's teacher. Explain your situation, and discuss the barriers to teaching your child at home. See what strategies or modifications the school can make. You might be surprised how many options you have that you just don't know about. You are not Superman or Superwoman, and are under no requirement to be perfect. Do the best you can, in the surreal circumstances we all find ourselves in right now. Best of luck to you!

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Tameika Meadows, BCBA, Blog Author

If your child was participating in any therapies before this global crisis began, those services likely transitioned to a telehealth model within the past 30 days or so.

Ideally, this process was explained to you, along with potential benefits vs risks, and you feel competent as a parent/caregiver to utilize this remote model of therapeutic intervention.

If not, you are the the reason for this post.


For far too many families, the decision to move to telehealth for ABA services was made for them, or presented as a "take it or leave it" option. This could be due to staffing issues (as more and more people are self-quarantining), more funders allowing for telehealth, or just the preference of the service provider. Maybe you are filled with anxiety and confusion as to how telehealth will be effective for your child. You may think your child is too young to benefit, or too old to benefit, or can't attend to a screen, or attends TOO much to a screen, etc.

Whatever your particular situation may be, I hope to help alleviate some of your concerns by providing an overview of Telehealth ABA.

Let's dive in...

Before our current quarantine reality, telehealth was being used quite effectively to provide ABA services to consumers in under served areas, to supplement in-person services, and to work with consumers internationally. I have also found benefit of telehealth when it comes to illness or travel (basically, being unavailable). If someone in the consumer home has a contagious illness, I can still support my client remotely using telehealth. Or if I am traveling for a professional conference, I can check in on my clients using telehealth. So even if you aren't currently a fan of telehealth, know that it does have benefit for many families.

To provide a definition, Telehealth is the use of communication technology to assist in education and treatment of health related conditions (Ferguson, Jenny et al. 2019).


Telehealth is not something to just jump into. Like any other therapeutic service, there are some foundational steps to complete first. Before beginning ANY telehealth therapeutic treatment, you and your service provider should be openly discussing the following:

1. Technology Capability - As a caregiver, how comfortable are you with using technology? Do you have access to reliable wi-fi? Do you have a quality web cam, camera, or cell phone to use for video chats or calls? Will you need to purchase a headset or microphone, or are your computer speakers fine to use? Do you have a scanner and printer, if needed? If not, who will help you get up to speed with technology?

2. Scheduling & Availability - Are there time zone differences to consider? What is your schedule of availability to virtually meet with the service provider? Does telehealth increase or decrease your availability? What time of day would work best for your child? Are they more likely to be attentive in the am or pm? Is the telehealth schedule being created based on what works for your household, or just when the service provider says they have time?

3. Caregiver Participation - Are your current stress and emotional levels at a point where you can do this? Has it been explained to you that telehealth may require an adult in the home assist with the session, for the duration of the session?  Do you know how to manage challenging behavior in the absence of the service provider being physically present? Do you understand how to provide reinforcement to your child, in the absence of the service provider being physically present? What will your other children be doing while you are assisting with the telehealth session? If you are also doing school at home right now, can you do both that and this?

4. Unique Client Needs - What does your child need in order to benefit from this? Visual supports? Token boards? If your child is very active and reinforced by physical touch or play, how will that happen virtually? Will it be upsetting or confusing to your child to see and hear the service provider, but they aren't physically there? Should the treatment goals be reduced for telehealth sessions? What abut the session length; can your child participate in a virtual 2 or 3 hour session? Will there be a Registered Behavior Technician (RBT) or direct therapist with you, as the Board-Certified Behavior Analyst (BCBA) joins in virtually? Or will it just be you and your child? Which is likely to be more effective?

There are 3 main services delivered by ABA providers: Supervision, Direct Service, and Family Support (commonly referred to as "parent training").
I will explain how each type of service could look using a telehealth format. Remember, the specific service that is selected for a telehealth modality should be decided by you and the service provider based on what would be most effective for your child. In other words, direct service via telehealth may not be a great idea, just depending on the specific needs of your child and the unique demands of your household.

• Supervision is most often provided by the BCBA for a percentage of the hours the RBT or direct staff work with your child. Some providers may choose to have RBT's continue coming to your home, with the BCBA joining the session virtually. Other providers may have both the RBT and the BCBA conduct virtual sessions. There is no set answer to this, and it will vary by area and by provider. This is also a funding decision, as not all funders permit non-BCBAs to provide telehealth. In the event that you are only receiving services from a BCBA, they do not require supervision. However, RBTs and Board-Certified Assistant Behavior Analysts (BCaBAs) cannot practice independently.
• Direct service is most often provided by the RBT or direct therapist. If the RBT you work with is able, in-person direct service can still occur with the BCBA supervising remotely. If not, the RBT and/or BCBA may provide direct service virtually. Depending on the unique circumstances of treatment, direct service may need to be modified for telehealth. For example, goals may need to be reduced or placed on hold temporarily, like goals that require peers or going into the community. Any issues with your child attending, leaving the instructional area/running off, or trying to hit/disrupt the video call equipment can be addressed with the BCBA. They will be able to tell you how to help your child benefit from telehealth services. Please note that direct service provided virtually will most likely require an adult in the home assist with the session as far as prompting, delivering reinforcement, managing challenging behavior, troubleshooting technical difficulties, etc.
• Family support can occur with any parent or legal guardian, and will have specific goals and measurable outcomes. Family support can include your child, and it can also occur with just you and the BCBA (most funders only permit BCBAs to provide family support). Keep in mind that due to the virtual format, family support time may steal your attention and focus away from other household activities. For example, if the BCBA needs to virtually meet with you to review progress and discuss changes to the treatment plan, it may be unrealistic to try to do this as you simultaneously cook dinner or engage your other children. 

Depending on the specific service being delivered, the amount of upheaval and stress in the client household, the current functioning of your Autistic child (will telehealth work for them??),  and caregiver ability to fully participate, telehealth can be more or less beneficial to families.
And that is OKAY.

You are not required to continue therapy services in the midst of a global pandemic. Think about the pros vs the cons, and make the best decision you can for your family.




*Resources & Further Information:

ABA Parent Training using Telehealth

Behavior Babe

Central Reach

Benefits of Telehealth

ABA Parent Training via Telehealth video 1, and video 2 

Podcast: ABA services in a global pandemic

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Tameika Meadows, BCBA, Blog Author

Here we all are, in the midst of an unprecedented life event and trying our best to continue providing ABA services to the clients who need our help now more than ever.

So yeah, no pressure or anything. :-)


Prior to this pandemic, maybe you had some clinical telehealth experience, maybe you didn't, but either way I hope to provide either a review of information you already know, or a crash course in Telehealth 101. 

I suspect that for many of us even after the current crisis ends, telehealth could become the New Normal as far as the way we do our jobs. Don't you think? 
If so, then it's pretty important to get your skill set up to speed with using technology to serve consumers.


So take a breath, relax, and let's dive in to some strategies for implementing your ABA magic remotely!

You can listen to the audio presentation here.




* HUGE* resource file for this presentation: Click Here to Download
Sharing is caring, pass this resource along to your ABA colleagues! We're in this thing together.

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Tameika Meadows, BCBA, Blog Author