Behavior analytic contributions to public health and telehealth

A Survey of the State of the Field of Applied Behavior Analysis in Vermont

As the number of and demand for board certified behavior analysts (BCBAs) grows across the United States, it is increasingly important to evaluate the status of the applied behavior analysis (ABA) workforce. The goal of this study was to evaluate the current status of the field of ABA within the state of Vermont. We surveyed practicing RBTs, BCaBAs, BCBAs, BCBA-Ds, and ABA professionals within Vermont. We gathered and analyzed information regarding practitioner training and supervision experiences, current work conditions, strengths and barriers related to education, supervision, and practice within the field of ABA in Vermont, and historical and demographic information. Survey responses were analyzed using quantitative and qualitative methods and themes and results are discussed. This study may serve as a model for other states to conduct similar analyses to better meet the needs of the changing landscape of the field of ABA.

A comparison of parental attention and preferred items during tummy time: A consecutive controlled case series evaluation

Tummy time is an activity for infants to practice their early motor skills. Although most pediatricians recommend tummy time, parents may avoid the procedures due to indices of infant discomfort during this period. This consecutive controlled case series evaluation compared the effects of preferred items selected from a preference assessment with those of parental attention on head evaluation and negative vocalizations during tummy time. In addition, we directly evaluated parental choice by inviting parents to select which tummy time treatment they wanted to implement. We found that both preferred items and parental attention effectively increased head elevation and decreased negative vocalizations during tummy time; however, parents tended to prefer the treatment that included the preferred item.

An Assessment of Response to Conversation Cues of Uninterest Conducted via Telehealth

Individuals diagnosed with autism spectrum disorder (ASD) exhibit deficits in social interaction and communication. Kronfli, Vollmer, et al. developed an in-person assessment to evaluate participant response to social cues indicating uninterest in a conversation. In the current study, we sought to extend these procedures to the assessment of conversation skills via telehealth given the ongoing pandemic and so that participants in remote areas could receive services. Participants were exposed to a hierarchy of social cues of uninterest ranging in salience from one-word responses to a clear verbal statement of uninterest until they demonstrated sensitivity to a social cue. One participant who did not demonstrate sensitivity to any cues received instruction using Behavioral Skills Training. Initial results support the utility of using a remote assessment model to screen for sensitivity to specific social cues in conversations and to provide services to participants via telehealth.

A Comparison Between Direct Telehealth and In-Person Methods of Teaching Expressive Labels to Children Diagnosed With Autism Spectrum Disorder

Recent behavior analytic research has demonstrated that the provision of applied behavior analytic services via direct telehealth can be an effective teaching modality for some learners with autism spectrum disorder (ASD). Historically, teaching procedures based on applied behavior analysis (ABA), including discrete trial teaching (DTT), have been provided and evaluated via in-person delivery. This study sought to compare the implementation of DTT via direct telehealth to DTT implemented in-person within and across participants. Specifically, this study evaluated the two delivery modalities in terms of skill acquisition, maintenance, efficiency, and learner responding during teaching sessions. Results of an adapted alternating treatments design nested into a multiple baseline design demonstrated that all three participants diagnosed with ASD met the mastery criteria for the expressive labels taught. Areas of future research, participant prerequisite skills, and clinical implications will be discussed in the context of these results.

An individualized approach to teaching adults with autism to successfully navigate job interviews via remote instruction

Adults with autism spectrum disorder (ASD) experience challenges securing employment, which may partially explain overall underemployment or unemployment in this population. One of the first steps to obtaining employment is participating in a job interview. However, social communication deficits may interfere with an individual with ASD's participation in a job interview. The current study evaluated the use of behavioral skills training delivered via remote instruction to teach interview skills to seven adults with ASD. Results showed overall improvement during interviews as well as posttraining tests with a career development expert. These data suggest that an individualized approach to teaching may be an effective strategy to help adults with ASD successfully navigate job interviews.

Ecological Momentary Assessment: A Systematic Review of Validity Research

Ecological momentary assessment (EMA) is a self-report method that involves intensive longitudinal assessment of behavior and environmental conditions during everyday activities. EMA has been used extensively in health and clinical psychology to investigate a variety of health behaviors, including substance use, eating, medication adherence, sleep, and physical activity. However, it has not been widely implemented in behavior analytic research. This is likely an example of the empirically based skepticism with which behavioral scientists view self-report measures. We reviewed studies comparing electronic, mobile EMA (mEMA) to more objective measures of health behavior to explore the validity of mEMA as a measurement tool, and to identify procedures and factors that may promote the accuracy of mEMA. We identified 32 studies that compared mEMA to more objective measures of health behavior or environmental events (e.g., biochemical measures or automated devices such as accelerometers). Results showed that the correspondence rates varied considerably across individuals, behavior, and studies (agreement rates ranged from 1.8%-100%), and no unifying variables could be identified across the studies that found high correspondence. The findings suggest that mEMA can be an accurate measurement tool, but further research should be conducted to identify procedures and variables that promote accurate responding.

Eight Months of Telehealth for a State-Funded Project in Foster Care and Related Services: Progress Made and Lessons Learned

In response to the COVID-19 pandemic, many behavior analysts and other health professionals modified their services for delivery via telehealth modalities. The transition to telehealth is especially important for providers working with foster youth who exhibit challenging behavior because these youth often move to another placement due to such behaviors. The primary objective of this article was to evaluate the extent to which service indicators for a state-funded team working with foster youth changed after the service delivery model changed from in-person to telehealth services. In particular, we evaluated changes in monthly count of client contacts, appointments, intakes, closed cases, and medication reviews. The secondary objective was to outline potential benefits and environmental barriers encountered by the team and to integrate our findings with the literature on behavior-analytic services provided via telehealth. Overall, results show that we maintained service quality with a broad range of behavioral interventions and increased overall client appointments. Given these outcomes, our team may continue to provide behavioral services via telehealth after the COVID-19 pandemic.

Looking at Europe's recent behavioral telehealth practices for children and families impacted by neurodevelopmental disabilities

There is a widespread lack of behavioral professionals available to support children and families affected by neurodevelopmental disabilities. As a result of limited availability, services that can be provided from a distance have developed. Telehealth is a modality that can increase access to services, lessen financial constraints, and support assessments of generalization. Using either synchronous or asynchronous components it can foster evaluation and coaching. Guidelines for usage have surfaced in North America and been integrated into the continent's existing model of behavioral care. However, in Europe where all modalities of behavioral services are fighting to receive funding, frameworks are scarce. Understanding more about telehealth in behavioral care, its various applications throughout Europe, and the local context into which it can be applicable may promote system growth. To support this cause, a scoping review of recent behavioral telehealth practices for children and families impacted by neurodevelopmental disabilities in Europe was undertaken; looking specifically to assess types of studies, their targets and outcomes, telehealth modality components, barriers, and directions for future work. Although few studies surfaced, valuable conclusions can be drawn about the model's empirical validation, creating a groundwork for sustainability, and the need for developing policy and standardized application.

Leveraging applied behavior analysis research and practice in the service of public health

Human behavior plays a central role in all domains of public health. Applied behavior analysis (ABA) research and practice can contribute to public health solutions that directly address human behavior. In this paper, we describe the field of public health, identify points of interaction between public health and ABA, summarize what ABA research has already contributed, and provide several recommendations for how ABA research and practice could continue to promote public health outcomes. A clearer focus on behavior and widespread adoption of research designs and interventions informed by the ABA literature could lead to better public health outcomes. Reciprocally, better integration of public health goals and strategies into ABA research, harnessing of technology, and more collaboration would help diversify and disseminate our applied science and could yield more effective and scalable interventions to prevent and treat public health problems.

Evaluating the Cool Versus Not Cool Procedure via Telehealth

Autistics/individuals diagnosed with autism spectrum disorder (ASD) commonly display qualitative impairments in social behavior that commonly result in the use of interventions directly targeting the development of social skills. The COVID-19 pandemic has highlighted the need for effective social skills interventions that can be delivered directly via telehealth. The Cool Versus Not Cool procedure has continually been documented as effective within the literature. However, its reported use has been limited to in-person delivery. The purpose of this study was to evaluate the effectiveness of the Cool Versus Not Cool procedure conducted via telehealth to teach three children diagnosed with ASD to change the conversation when someone is bored. The results of a nonconcurrent multiple-baseline across-participants design demonstrated that all three participants reached the mastery criterion in four to eight sessions. Responding generalized to another adult for two of the three participants, and all three participants maintained correct responding. Social validity measures indicated the skill was important to teach, the intervention was acceptable and effective, and the telehealth format was an acceptable replacement for in-person intervention for these three participants.

Real-Time Telehealth Treatment Team Consultation for Self-Injury by Individuals with Autism Spectrum Disorder

OBJECTIVES

Self-injurious behavior (SIB) refers to any repeated self-directed, non-suicidal, behavior that may cause or has the potential to cause physical harm to the person's body. Behavioral interventions provide the standard evidence-based treatments for SIB by people with autism spectrum disorder (ASD) and intellectual disabilities (ID). Translating the proven effectiveness of behavioral interventions to treatment of self-injury in community settings by clinicians and caregivers has not been totally successful. The aim of the present study was to advance translational research by providing real-time telehealth consultation to a treatment team at a community-based mental health agency that provided inpatient and outpatient services to individuals with ASD and ID.

METHOD

The participants of this single-case experimental study were three adolescents with ASD who had been referred for services because of their increasingly unmanageable SIB both at home and at school. The telehealth consultant provided real-time assistance to the treatment team within a translational model of care in the development and implementation of a behavior support plan and an informal mindfulness-based Soles of the Feet (SoF) program.

RESULTS

Both visual and statistical analyses demonstrated reductions in the frequency of SIB for all three adolescents, with overall clinically significant reductions only with the SoF intervention.

CONCLUSION

The results of this translational study suggest that telehealth consultation might be a viable technological alternative in situations which preclude face-to-face consultation. Telehealth consultation could be one method of supporting people with behavioral difficulties during pandemics, such as COVID-19.

Sleep Education for Elders Program (SLEEP): Promising Pilot Results of a Virtual, Health Educator-Led, Community-Delivered Sleep Behavior Change Intervention

PURPOSE

Sleep problems pose serious public health concerns, and evidence suggests that the problem is worsening. Both sufficient sleep quantity and quality are needed for optimal health, particularly among older adults, but access to sleep care can be difficult. This study examined the efficacy of a six-week sleep behavior change program designed for older adults that was delivered virtually by health educators.

PARTICIPANTS AND METHODS

This quasi-experimental pilot study (intervention n = 22; control n = 31) explored the effects of the Sleep Education for Elders Program (SLEEP) on sleep outcomes, which included: 1) sleep quality, measured by the Pittsburgh Sleep Quality Index (PSQI); 2) sleep duration, extracted from the PSQI; 3) insomnia symptoms, measured by the Insomnia Severity Index; 4) sleep hygiene behaviors, obtained from the Sleep Hygiene Index; and 5) excessive daytime sleepiness, measured by the Epworth Sleepiness Scale.

RESULTS

After SLEEP, the intervention group experienced significantly improved sleep quality (p < 0.001), a reduction in maladaptive sleep hygiene behaviors (p = 0.007), and reduced daytime sleepiness (p < 0.027) compared to the control group. Effect sizes for all five sleep measures were medium or large. In the intervention group, all changes were judged to be clinically meaningful (≥ 0.5 SD) except for improvements in daytime sleepiness.

CONCLUSION

These data support the efficacy of a group-based, virtual behavior change intervention in improving sleep outcomes among older adults.

Parent-implemented brief functional analysis and treatment with coaching via telehealth

We evaluated the use of parent-implemented brief functional analyses in the home with coaching delivered via telehealth. Parents of 7 children with autism conducted functional analyses of their child's challenging behavior. For 4 participants, the brief functional analysis provided information regarding the function of the child's challenging behavior. A full functional analysis indicated a social function for 1 participant. The brief functional analysis yielded false positive results and subsequent assessment indicated an automatic function for another participant. The final participant did not engage in sufficient rates of challenging behavior to provide information regarding the function of the child's challenging behavior. Treatment evaluations occurred with 4 participants; these evaluations provided support for the results of the functional analysis. Together with previous research, the results indicate that parent-implemented brief functional analyses, followed by additional assessment as needed, may be an effective method for assessing and treating challenging behavior via telehealth.