Working with Children with Autism and Other Developmental Disabilities through a Telehealth Modality

Telehealth sessions can bring a new element of fun to behavior analysis for children with autism spectrum disorder or developmental disabilities and provide an opportunity for clinicians to observe clients in their home environment while creating a highly effective, individualized plan for interventions with the client’s caretakers.

“In person, they may be shifting their behaviors because there’s a new person in the room,” said Katerina Monlux, faculty at Pepperdine University’s online Master of Science in Applied Behavior Analysis program. “But by doing telehealth, you can reduce that reactivity by making yourself less of a presence.” 

Social anxiety can be a barrier to effective interventions for kids with autism spectrum disorder or other developmental disabilities. But telehealth appointments offer a solution: all the benefits of flexible communication, without the pressure of physical interaction.

It’s important for “everyone to be on the same page of what level of assistance should be provided,” Monlux said, “so each child has the biggest opportunities for independence.”

Telehealth, sometimes called telemedicine, refers to any use of technology to transmit health information, health education, and health care services. The New England Journal of Medicine synopsis of telehealth indicates that it can include the use of emails, video calling software, phone calls, text messages, and even slideshow presentations. 

During a telehealth appointment, people on both ends of the communication make use of devices like tablets, smartphones, computers, headphones, or other devices that make technology more accessible. For people with disabilities or neurological disorders, accessible technology includes screen readers, voice-to-text programs, captioning services, and other tools that make digital information easier to access and understand. 

Telehealth itself is also a means of accessibility because it can provide access to health care services and information that may otherwise be out of reach for a number of reasons such as cost; geographic location; and, in the case of the global pandemic, stay-at-home orders. 

Benefits of Telehealth for Children with Developmental Disorders 

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• Less social anxiety from being in a clinical space
• Minimal intrusiveness of the clinician’s presence
• Clinician can observe natural behaviors that occur at home
• Financial access that isn’t restricted by geographic location
• Flexibility of parent or caregiver’s involvement 

The global pandemic has prompted more clinicians to provide interventions to clients through telehealth because of social-distancing and safety guidelines. But even before the pandemic, a global shortage of behavior analysts led to research on telehealth services for behavioral interventions, and researchers found that telehealth modalities were helpful and effective for families in rural areas.

Board Certified Behavior Analysts (BCBAs) can use telehealth services to provide clinical supervision to children remotely, through which they can observe the behaviors of the clients, assess and analyze the opportunities for changes, and implement plans to improve and shape behavior. 

Monlux said the inclusion of a caregiver or parent is crucial to the success of telehealth interventions, especially when clients are first making the switch from in-person appointments to remote meetings. 

“Keeping the social validity of the intervention in mind—when you’re proposing it—is going to be even more critical when using telehealth because you’re really going to need buy-in from the parents,” she said.

Before jumping into a new strategy, parents and caregivers can consider several factors when deciding whether telehealth would be an appropriate and effective style of intervention for their children; however, they should always speak with a clinician first. 

Considerations for Telehealth Interventions

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• Do you have an existing relationship with a clinician who can help with the transition?
• Do you have a stable WiFi connection at home for streaming video calls? 
• How proficient are your child’s communication and listening skills?
• Is a parent or caregiver available to be present or on-call during sessions?
• Do you have a controlled environment where your child can be during sessions?

“You really need to be pretty confident that all of that is working really well before you start running a lesson where the child is the one who needs to be actively participating with everything,” Monlux said.

Many clinicians will use parent-training sessions to help with transitions from in-person care to virtual care. Working closely with clinicians can help parents know what to expect and establish a support system for behavior interventions at home. 

Studies show that implementing parent training into treatment can be highly effective in behavioral interventions for children on the autism spectrum. In a 2019 report on parent training in the Journal of Applied Behavior Analysis, researchers highlighted the importance of functional communication between parents and clinicians. 

Monlux said initial parent trainings with a clinician may include talking through the terms and strategies they’ll be using throughout the sessions, as well as explaining the interventions that parents will help with implementing. Clinicians may also coach parents through strategies or activities during each session.

The key is to set expectations, she added, so that children and parents aren’t frustrated or caught off guard by surprises in the session.

Setting Expectations for Children Using Telehealth

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• Find the best place in the house for internet connection. 
• Dedicate a consistent space for sessions. 
• Minimize the number of distractions in the room.
• Practice a Zoom call that’s low-stakes, fun, and short. 

When children are surrounded by distractions, it becomes more difficult to focus and can ultimately derail the effectiveness of the intervention. 

“It’s really challenging to make the right choice and go back to homework when you could just turn off the video feed,” she said. 

Clinicians have to put a great deal of work in on the front end to ensure sessions will run smoothly with the parent and their child. Similar to in-person appointments, clinicians can establish multiple ways to keep in contact in case of technical issues.

“There’s nothing more frustrating than potentially trying to coach a parent through handling some problem behavior and then you lose internet connection,” Monlux said. 

Before telehealth was widely accessible, clinicians would use email and phone and digital portals to communicate with clients and their families. Continuing to use these methods can also lead to low-stakes opportunities for practicing communication. For instance, a parent can take a video of a child’s behavior and send it to the clinician, who can assess it on their own time and provide prompt feedback. 

“Even if I’m not directly doing a parent-training session, I want to have the caregiver’s phone number, especially if I’m somewhere else providing coaching remotely,” Monlux said. Being available as a support to parents can reduce parents’ stress and improve the effectiveness of interventions, according to a study Monlux recently published on the use of telehealth for children with Fragile X Syndrome and other neurological disorders (PDF, 933 KB).

Monlux described several strategies that clinicians can use to work as a team with the parents or caregivers who are present during sessions. 

Working as a Team with the Caregiver

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• Involve the caregiver as much as you can, especially at the beginning, so that they can be informed and supportive during interventions.  
• Ask the caregiver about the child’s typical habits and behaviors to get a better idea of what to expect during virtual sessions.
• Schedule practice sessions or preliminary phone calls with the caregiver to work out any technical issues and get the hang of a new platform. 
• Ask the parent for their preferred method of communication so it’s easier to keep in touch during and outside of sessions.
• Be verbally descriptive with instructions and modeling behaviors. It can be challenging to communicate with body language over video, but possible with practice and strategies such as gesturing with a “thumbs up” and nodding.
• Show video examples. Using video conferencing software can make incorporating video modeling seamless.
• Start with short sessions and work your way up to longer ones to build stamina and avoid fatigue from too much screen time. 
• Find ways to include elements of fun, including changing your background, playing engaging videos, and paying attention to the child’s interests to incorporate them.

“Once you get a little bit more savvy with it, it can actually be pretty fun,” Monlux said. “Some kids think it’s cool to talk to me on an iPad, and we’re buds.”

She suggested parents and clinicians explore different opportunities for providing positive reinforcement, like token boards, points systems, and other methods to motivate kids to stay engaged. 

“If you don’t have the [child’s] motivation and you’re struggling with technical difficulties, it’s not going to set you up well for success,” she said. 

The development of digital and technological skills takes a great deal of practice and is deeply embedded into the curriculum for students at Pepperdine. Even before the start of the pandemic, the Pepperdine program was designed for seamless virtual communications. 

“By nature of the whole course being online, you have to be really proficient in a lot of skills that are necessary for telehealth,” Monlux said. 

For example, students are required to manage all their documents and communication digitally, so they build a proficiency for communicating, organizing, and maintaining relationships through digital platforms. 

Monlux said that in her classes, “almost everyone is working in some level of telehealth. Talking to other clinicians in other agencies, and sharing what works and what doesn’t work, means our students are really well set up for working in telehealth.” 

In an increasingly digital world, building virtual communications skills will help clinicians serve their clients more effectively for years to come. 

Citation for this content: OnlinePsychology@Pepperdine, the Online Master of Psychology program from Pepperdine University.