A Proposed Process for Risk Mitigation During the COVID-19 Pandemic

A Survey of Barriers Experienced while Providing Supervision via Telehealth: Implications for Future Research and Practice

Telehealth is an acceptable service delivery mechanism for applied behavior analytic interventions and has led to positive outcomes for decreasing problem behavior and increasing skill acquisition in individuals with autism spectrum disorder. Literature regarding best practices for providing behavior analytic services via telehealth has increased; however, limited literature exists on training, best practices, implementation guidelines, and troubleshooting resources when providing supervision to supervisees via telehealth. Therefore, the purpose of this study was to understand the barriers to supervision via telehealth of BCBAs and those pursuing their BCBA credential. Following survey distribution and completion, participant data were analyzed for specific barriers encountered while providing behavioral supervision during telehealth and the strategies participants used to address or mitigate those barriers. Based on our findings, we also present troubleshooting resources and recommendations to help supervising behavior analysts prepare for and mitigate any supervisory barriers that may occur in the future.

A mixed-methods examination of clinicians' perceived barriers to telehealth delivered applied behavior analysis

Following the COVID-19 pandemic, clinicians relied on telehealth to ensure continuity of essential healthcare services, such as Applied Behavior Analysis (ABA). Identifying barriers and examining them in the context of other implementation outcomes is important to support appropriate adaptations and sustainability of telehealth-delivered ABA services. Convergent mixed methods design was utilized to identify barriers experienced by ABA clinicians (N = 388) when delivering ABA services over telehealth to autistic children and their families following the first six months of the COVID-19 pandemic. Additionally, barriers were examined in relation to telehealth implementation outcomes and intentions for continued adoption. Findings reveal that clinicians rated providing direct services (M = 3.52, SD = 1.14) as more difficult than conducting assessments (M = 3.29, SD = 1.06), and both as more difficult than providing parent-mediated interventions [(M = 2.47, SD = 1.11), F(2, 381) = 162.26, p < 0.001]. A principal components analysis indicated a 3-factor solution of barriers related to: (1) technology (α = 0.82), (2) administrative tasks (α = 0.88), and (3) client characteristics (α = 0.88). The most frequently endorsed barriers were related to client characteristics, including increased difficulty providing telehealth services to children who elope (M = 4.37, SD = 0.81), children who exhibit challenging behaviors (M = 4.31; SD = 0.83), and children who are in the preverbal stage or use nonverbal language to communicate (M = 4.07; SD = 1.00). Fewer barriers related to client characteristics uniquely predicted implementation variables including acceptability, appropriateness, and feasibility. Thematic analysis revealed challenges related to technology, caregiver involvement, child engagement, implementation of intervention strategies over telehealth, and administrative or logistical barriers. These findings highlight the need for targeted strategies that facilitate telehealth use to address specific client needs and support the implementation of telehealth services in usual care settings.

Age-based spatial disparities of COVID-19 incidence rates in the United States counties

COVID-19 incidence disparities have been documented in the literature, but the different driving factors among age groups have yet to be explicitly explained. This study proposes a community-based COVID-19 spatial disparity model, considering different levels of geographic units (individual and community), various contextual variables, multiple COVID-19 outcomes, and different geographic contextual elements. The model assumes the existence of age nonstationarity effects on health determinants, suggesting that health effects of contextual variables vary among place and age groups. Based on this conceptual model and theory, the study selected 62 county-level variables for 1,748 U.S. counties during the pandemic, and created an Adjustable COVID-19 Potential Exposure Index (ACOVIDPEI) using principal component analysis (PCA). The validation was done with 71,521,009 COVID-19 patients in the U.S. from January 2020 through June 2022, with high incidence rates shifting from the Midwest, South Carolina, North Carolina, Arizona, and Tennessee to the West and East coasts. This study corroborates the age nonstationarity effect of health determinants on COVID-19 exposures. These results empirically identify the geographic disparities of COVID-19 incidence rates among age groups and provide the evidentiary guide for targeting pandemic recovery, mitigation, and preparedness in communities.

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.

Effects of an Adapted Telehealth Training Curriculum for Registered Behavior Technicians®

Objectives

We evaluated a telehealth training curriculum to prepare Registered Behavior Technicians® (RBTs®) to conduct caregiver coaching on behavior analytic skills via telehealth.

Methods

A non-concurrent multiple baseline across therapists design was used to evaluate the training procedures delivered by Board Certified Behavior Analysts® (BCBAs®). All therapists (RBTs) worked with one family during the baseline and training phases and an additional session was conducted with a different family during the novelty probe condition to see if therapists were able to perform the newly acquired skills without BCBA support.

Results

Seven therapists who received behavioral skills training on the curriculum reached mastery criteria within three sessions. All RBTs were able to provide caregiver coaching via telehealth with high degrees of fidelity and were able to independently conduct a telehealth session with a new family without support from the BCBA.

Conclusions

Results of the current study provide support for the use of the telehealth training curriculum to prepare RBTs to conduct ABA services via telehealth.

Spartan Caregiver Support: Program Description and Key Findings During Michigan's Stay-At-Home Order

Objectives

The purpose of this paper is to describe a university program, Spartan Caregiver Support, that provided free on-demand telehealth services to caregivers of people with autism during the State of Michigan's 2020 Stay-at-Home order.

Method

Participants (n = 17) were caregivers of people with autism residing within the State of Michigan. Participants engaged with program members over video-conference technology, where participants received specific advice to support social and behavioral needs.

Results

We found that caregivers reported a variety of social and behavioral concerns, including concerns related to problem behavior, social/play skills, school/academics, and daily living.

Conclusions

This program description provides a framework for how to deliver on-demand telehealth support to caregivers of people with autism, especially during moments of crisis or emergency.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41252-022-00281-7.

Systemic Challenges in Internship Training for Health-Service Psychology: A Call to Action From Trainee Stakeholders

The challenges observed in health service psychology (HSP) training during COVID-19 revealed systemic and philosophical issues that preexisted the pandemic, but became more visible during the global health crisis. In a position paper written by 23 trainees across different sites and training specializations, the authors use lessons learned from COVID-19 as a touchstone for a call to action in HSP training. Historically, trainee voices have been conspicuously absent from literature about clinical training. We describe longstanding dilemmas in HSP training that were exacerbated by the pandemic and will continue to require resolution after the pandemic has subsided. The authors make recommendations for systems-level changes that would advance equity and sustainability in HSP training. This article advances the conversation about HSP training by including the perspective of trainees as essential stakeholders.

Training Staff to Create Equivalence-Based Instruction Materials in Qualtrics

Staff training is an important line of research to ensure that clinicians in the field of applied behavior analysis provide quality services. One approach to providing training involves the use of asynchronous training materials in which the trainer and trainee do not need to be physically present at the same time. This allows for training despite limited numbers of trainers or geographic restrictions. The purpose of this study was to train participants to create equivalence-based instruction (EBI) materials in Qualtrics, a commercial survey software package. In the first phase of the study, participants experienced a training package consisting of a video model and task analysis that described how to create EBI materials. Phase 2, evaluated whether the EBI materials created in Phase 1 led to equivalence-based responding. Results indicated that the training was effective for training staff and that staff found the training socially acceptable. Results also demonstrated that the EBI materials resulted in the learning of the trained and derived relations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40732-021-00497-4.

Psychosocial and Behavioral Effects of the COVID-19 Pandemic on Children and Adolescents with Autism and Their Families: Overview of the Literature and Initial Data from a Multinational Online Survey

Since COVID-19 has become a pandemic, everyday life has seen dramatic changes affecting individuals, families, and children with and without autism. Among other things, these changes entail more time at home, digital forms of communication, school closures, and reduced support and intervention. Here, we assess the effects of the pandemic on quality of life for school-age autistic and neurotypical children and adolescents. First, we provide a comprehensive review of the current relevant literature. Next, we report original data from a survey conducted in several countries, assessing activities, well-being, and social life in families with autism, and their changes over time. We focus on differences between children with and without autism from within the same families, and on different outcomes for children with high- or low-functioning autism. While individuals with autism scored lower in emotional and social functioning than their neurotypical siblings, both groups of children showed comparable decreases in well-being and increases in anxiety, compared to before the pandemic. By contrast, decreases in adaptability were significantly more pronounced in autistic children and adolescents compared to neurotypical children and adolescents. Overall, although individual families reported some positive effects of pandemic restrictions, our data provide no evidence that these generalize across children and adolescents with autism, or even just to individuals with high-functioning autism. We discuss the increased challenges that need to be addressed to protect children and adolescents’ well-being under pandemic conditions, but also point out potentials in the present situation that could be used towards social participation and success in older children and young adults with autism.

Towards the development of a curriculum to train behavior analysts to provide services via telehealth

The COVID-19 pandemic has led to a dramatic increase in behavior analysts' use of telehealth services. Nonetheless, no research has evaluated the skills or training needed for therapists to provide these services effectively. The purpose of this study was to develop and evaluate a curriculum for providing high-quality, parent-training telehealth services. Four in-service Board Certified Behavior Analysts® (BCBAs®) who received brief behavioral skills training on this curriculum reached 100% fidelity within four sessions. The skills generalized to a novel family and maintained nearly 1 year after the training. All participants rated the training as highly acceptable and effective. The independent ratings of 4 in-service BCBAs, blinded to the study conditions, also supported the social validity of the outcomes. This curriculum may be considered an initial step towards development of competency for interventionists providing ABA services via telehealth. Further research is warranted as demand for telehealth services continues to grow.

Behavioral Training and Performance Management of Human Services Organization Care Providers During the COVID-19 Pandemic

Objectives

This report describes a model of training and performance management that was designed for and implemented with care providers at a residential school for children with neurodevelopmental and intellectual disabilities in response to the COVID-19 pandemic. The model focused on health and safety concerns, risk mitigation, and intervention integrity.

Methods

Procedures followed an applied behavior analysis (ABA) and organizational behavior management (OBM) framework. Action plans addressed (a) critical COVID-19 protocols, (b) behavior-specific implementation guidelines, (c) remote and in-person training formats, (d) in vivo supervision, and (e) knowledge and performance assessments.

Results

A competency evaluation (field study) revealed that participant care providers (N = 25) acquired and maintained COVID-19 protocols at near 100% proficiency immediately following and 1-month post-training. Supervisors had uniformly positive approval and acceptance ratings of school responsiveness to the COVID-19 pandemic.

Conclusions

Integrated and evidence-based care provider training and supervisory practices can promote risk mitigation and performance effectiveness during health crises such as the COVID-19 pandemic. More controlled research that includes multiple dependent measures is needed to replicate and extend our findings to similar human services settings.

COVID-19 Pandemic and Impact on Patients with Autism Spectrum Disorder

The COVID-19 infectious disease pandemic has caused significant fear and uncertainty around the world and had significant adverse psychological impact. Children, adolescents and adults with autism spectrum disorder (ASD) are a particularly vulnerable population, impacted by stay-at-home orders, closures at nonessential services, and social distancing standards. This commentary describes various challenges faced by individuals with ASD in the United States including disruptions caused by educational and vocational changes, challenges to home and leisure routines, limited access to behavioral health services and changes in health services delivery due to the pandemic. We highlight the need for ongoing skills development for individuals and development within systems to better respond to needs of the ASD population in future emergencies.

Adapting Direct Services for Telehealth: A Practical Tutorial

Due to the pandemic brought on by the novel coronavirus (COVID-19), consumers of applied behavior-analytic interventions may be experiencing disrupted access to services. In response to the need for services, behavior analysts and therapists may find themselves treading unchartered waters as they use telehealth to provide direct intervention to consumers. Direct service provision via telehealth extends beyond the bounds of existing telehealth research, which primarily focuses on caregiver training and consultation. In the transition to telehealth, behavior analysts can consider how to adapt an existing evidence base of behavior-analytic strategies from a face-to-face format to intervention via a teleconferencing platform (i.e., Zoom). In this tutorial, we provide practice recommendations, task analyses, and a curated list of Zoom walk-throughs to help behavior analysts construct conceptually systematic learning opportunities in their direct telehealth services. Leveraging teleconferencing features to provide behavior-analytic intervention directly to consumers could spur future research to support these need-inspired practices and guide telehealth applications during and beyond the current pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-020-00529-5.

Organizational Responsiveness to the COVID-19 Pandemic: a Mixed Methods Social Validity Assessment of Human Services Care Providers

OBJECTIVES

The COVID-19 pandemic posed many challenges to human services organizations serving persons with pre-existing conditions and health concerns. Study objectives were to assess organizational responsiveness to the pandemic through training, safety, and risk mitigation initiatives at community-based group homes for adults with intellectual disability (ID) and acquired brain injury (ABI).

METHOD

This was a two-phase mixed methods study with human services care providers. In phase 1, 54 focus group participants responded to standardized interviews about leadership actions in the early months of the COVID-19 pandemic and discussed implementation effectiveness. These qualitative findings informed the design and distribution of a multi-item questionnaire in phase 2 that quantified acceptance and approval of leadership actions among 498 participants.

RESULTS

Both focus group and questionnaire participants identified several consistent leadership actions that had a positive impact on risk mitigation, health promotion, and participant satisfaction. Participants also converged on priority needs and recommendations for performance improvement.

CONCLUSIONS

The study supports previous research on the effects of pandemic health crises among frontline healthcare workers and more definitively the impact on direct care providers of adults with ID and ABI during COVID-19. Care providers were able to judge organizational effectiveness and provide feedback to aide strategic planning. Mixed methods research provides an approach to large-scale program evaluation through integrated qualitative and quantitative analyses.

The Effect of COVID-19 on Education

COVID-19 has changed education for learners of all ages. Preliminary data project educational losses at many levels and verify the increased anxiety and depression associated with the changes, but there are not yet data on long-term outcomes. Guidance from oversight organizations regarding the safety and efficacy of new delivery modalities for education have been quickly forged. It is no surprise that the socioeconomic gaps and gaps for special learners have widened. The medical profession and other professions that teach by incrementally graduated internships are also severely affected and have had to make drastic changes.

PREparedness, REsponse and SySTemic transformation (PRE-RE-SyST): a model for disability-inclusive pandemic responses and systemic disparities reduction derived from a scoping review and thematic analysis

Background

People with disabilities (PwD) have been facing multiple health, social, and economic disparities during the COVID-19 pandemic, stemming from structural disparities experienced for long time. This paper aims to present the PREparedness, RESponse and SySTemic transformation (PRE-RE-SyST): a model for a disability-inclusive pandemic responses and systematic disparities reduction.

Methods

Scoping review with a thematic analysis was conducted on the literature published up to mid-September 2020, equating to the initial stages of the COVID-19 pandemic. Seven scientific databases and three preprint databases were searched to identify empirical or perspective papers addressing health and socio-economic disparities experienced by PwD as well as reporting actions to address them. Snowballing searches and experts’ consultation were also conducted. Two independent reviewers made eligibility decisions and performed data extractions on any action or recommended action to address disparities. A thematic analysis was then used for the model construction, informed by a systems-thinking approach (i.e., the Iceberg Model).

Results

From 1027 unique references, 84 were included in the final analysis. The PRE-RE-SyST model articulates a four-level strategic action to: 1) Respond to prevent or reduce disability disparities during a pandemic crisis; 2) Prepare ahead for pandemic and other crises responses; 3) Design systems and policies for a structural disability-inclusiveness; and 4) Transform society’s cultural assumptions about disability. ‘Simple rules’ and literature-based examples on how these strategies can be deployed are provided.

Conclusion

The PRE-RE-SyST model articulates main strategies, ‘simple rules’ and possible means whereby public health authorities, policy-makers, and other stakeholders can address disability disparities in pandemic crises, and beyond. Beyond immediate pandemic responses, disability-inclusiveness is needed to develop everyday equity-oriented policies and practices that can transform societies towards greater resiliency, as a whole, to pandemic and other health and social emergencies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01526-y.

Parent-Mediated Home Intervention for Delayed Sleep-Onset and Night Waking in a Child With Autism Spectrum Disorder

We report the case of a 10-year-old boy with autism spectrum disorder who had difficulty initiating and maintaining sleep. Through home consultation, his parents were trained to implement a multicomponent sleep intervention that included (a) faded bedtime, (b) regimented pre-bedtime routines, and (c) elimination of positive social consequences contingent on sleep problems including unwanted co-sleeping. A critical element in the case was functional assessment of the conditions associated with poor sleeping and matching intervention to parent preferences. Compared to a baseline phase, intervention reduced night waking frequency and duration as well as the time required for the boy to fall asleep. Follow-up results one and 2 months post-intervention documented sustained improvement.

Spatial Disparities of COVID-19 Cases and Fatalities in United States Counties

This paper examines the spatial and temporal trends in county-level COVID-19 cases and fatalities in the United States during the first year of the pandemic (January 2020–January 2021). Statistical and geospatial analyses highlight greater impacts in the Great Plains, Southwestern and Southern regions based on cases and fatalities per 100,000 population. Significant case and fatality spatial clusters were most prevalent between November 2020 and January 2021. Distinct urban–rural differences in COVID-19 experiences uncovered higher rural cases and fatalities per 100,000 population and fewer government mitigation actions enacted in rural counties. High levels of social vulnerability and the absence of mitigation policies were significantly associated with higher fatalities, while existing community resilience had more influential spatial explanatory power. Using differences in percentage unemployment changes between 2019 and 2020 as a proxy for pre-emergent recovery revealed urban counties were hit harder in the early months of the pandemic, corresponding with imposed government mitigation policies. This longitudinal, place-based study confirms some early urban–rural patterns initially observed in the pandemic, as well as the disparate COVID-19 experiences among socially vulnerable populations. The results are critical in identifying geographic disparities in COVID-19 exposures and outcomes and providing the evidentiary basis for targeting pandemic recovery.

A Demonstration of Caregiver-Implemented Functional Analysis of Inappropriate Mealtime Behavior via Telehealth

Treatment for pediatric feeding disorders is imperative, so clinicians should alter the assessment and treatment process, making it is possible for caregivers to deliver via telehealth. Clinicians must first demonstrate that caregivers can conduct initial assessments in this format. We extended the literature on functional analysis of inappropriate mealtime behavior by demonstrating that caregivers can implement functional analysis procedures via telehealth to identify maintaining variables of inappropriate mealtime behavior. Clinicians determined that escape, attention, and tangibles and escape maintained inappropriate mealtime behavior during solids and liquids meals, respectively.

Behavioral Affect in Children with Autism Spectrum Disorder during School Closures Due to the COVID-19 Pandemic in Japan: A Case-Controlled Study

Children with autism spectrum disorder (ASD) could experience more stress due to the changes consequent to school closures because of the coronavirus disease 2019 (COVID-19) pandemic. This study investigated differences in behavioral affect between children with ASD and typically developing children (TD). We conducted an online survey with mothers. The data of 84 children with ASD and 361 TD children aged 6 to 18 years were analyzed. Children with ASD were more frustrated due to the changes in their schedule and engaged more in restricted and repetitive behavior. Children with ASD had different types of behavioral affect compared to TD.

Lockdown-Related Disparities Experienced by People with Disabilities during the First Wave of the COVID-19 Pandemic: Scoping Review with Thematic Analysis

People with disabilities may be disproportionally affected by the COVID-19 pandemic. We synthesize the literature on broader health and social impacts on people with disabilities arising from lockdown-related measures.

METHODS

Scoping review with thematic analysis. Up to mid-September 2020, seven scientific databases and three pre-print servers were searched to identify empirical or perspective papers addressing lockdown-related disparities experienced by people with disabilities. Snowballing searches and experts' consultation also occurred. Two independent reviewers took eligibility decisions and performed data extractions.

RESULTS

Out of 1026 unique references, 85 addressed lockdown-related disparities experienced by people with disabilities. Ten primary and two central themes were identified: (1) Disrupted access to healthcare (other than for COVID-19); (2) Reduced physical activity leading to health and functional decline; (3) From physical distance and inactivity to social isolation and loneliness; (4) Disruption of personal assistance and community support networks; (5) Children with disabilities disproportionally affected by school closures; (6) Psychological consequences of disrupted routines, activities, and support; (7) Family and informal caregiver burden and stress; (8) Risks of maltreatment, violence, and self-harm; (9) Reduced employment and/or income exacerbating disparities; and (10) Digital divide in access to health, education, and support services. Lack of disability-inclusive response and emergency preparedness and structural, pre-pandemic disparities were the central themes.

CONCLUSIONS

Lockdown-related measures to contain the COVID-19 pandemic can disproportionally affect people with disabilities with broader impact on their health and social grounds. Lack of disability-inclusive response and emergency preparedness and pre-pandemic disparities created structural disadvantages, exacerbated during the pandemic. Both structural disparities and their pandemic ramifications require the development and implementation of disability-inclusive public health and policy measures.

A Measure for Supporting Implementation of Telehealth Direct Therapy With Treatment Integrity

As telehealth direct therapy sessions are being increasingly provided for safety reasons during the COVID-19 pandemic, it is critical to ensure that sessions are implemented with integrity by direct service providers. Although existing research addresses the efficacy of the telehealth model, there is no literature on integrity measures tied to this service model. Without a framework or point of reference, clinicians new to the field of telehealth direct therapy may not be able or willing to attempt to implement it. The Telehealth Therapy Treatment Integrity Measure is designed to delineate components of effective telehealth direct therapy, including aspects of both instruction that should be generalized from in-person sessions to telehealth direct therapy sessions and new elements that are unique to telehealth direct therapy. A description of how the measure can be used to support the training, both initial and ongoing, of direct service providers is included. This measure can support clinicians in ensuring that direct service providers are working within their scope of competence when providing telehealth direct therapy.

Health Risks and Consequences of a COVID-19 Infection for People with Disabilities: Scoping Review and Descriptive Thematic Analysis

This study aims to synthesize the literature on any disproportionate health risks or consequences of a COVID-19 infection for people with disabilities. Scoping review with a descriptive thematic analysis was carried out. Up to mid-September 2020, seven scientific databases and three preprint servers were searched to identify empirical or perspective papers. Snowballing searches and expert' consultations also took place. Two independent reviewers were used for the screenings and data extractions. Of 1027 references, 58 were included, 15 of which were empirical articles. The thematic analysis showed that: (1) People with disabilities living in residential or long-term care facilities were more likely to have greater infection rates; (2) Intersecting mediators of greater infection risks were multiple (e.g., lack of accessible information); (3) People with disabilities often face greater health problems when infected; and (4) Unethical disadvantages in the rationing of lifesaving and critical care can be experienced by people with disabilities. Conclusions: Beyond any health-related vulnerabilities (e.g., comorbidity rates), multiple yet modifiable environmental factors can provide disproportionate health risks and consequences of a COVID-19 infection for people with disabilities. Public health and policy measures must prevent or reduce modifiable environmental risks.

An intensive telehealth assessment and treatment model for an adult with developmental disabilities

Over the last decade, the provision of applied behavior analysis (ABA) services within a telehealth delivery format has had a flourishing literature base. Research has demonstrated that caregivers can successfully conduct functional analyses and functional communication training to treat challenging behavior with coaching from practitioners via telehealth. Previous limitations include research that has only been conducted with children, typically in 1hr, weekly meetings, so the utility of providing ABA therapy via telehealth across the lifespan is unknown. Additionally, the effects of a more intensive treatment format delivered via telehealth has not been evaluated. The purpose of the current study was to coach caregivers to conduct the assessment and treatment process for a young man with developmental disabilities using an intensive-outpatient model in a telehealth format. Functional analysis procedures led to the development of a function-based treatment to reduce challenging behavior and increase functional communication. Caregivers demonstrated high procedural integrity across all phases of the study and found the intervention highly acceptable and effective. Areas for future research and directions are discussed.

Telehealth parent coaching to improve daily living skills for children with ASD

Children with autism spectrum disorder often display deficits in daily living skills. Behavior analysts can use telehealth, such as videoconferencing technology, to deliver interventions to families of these children. Given the COVID-19 pandemic and the common barriers to accessing behavioral interventions, it is imperative to evaluate the effectiveness and practicality of delivering behavioral interventions via telehealth. This study evaluated the efficacy of a parent-implemented intervention with coaching via telehealth to improve daily living skills. Children ranging in age from 5 to 9 years participated in the study with 1 or 2 of their parents serving as the primary implementer(s). Parents implemented the intervention with fidelity and the intervention yielded increases in independent daily living skill completion for all 4 participants.

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.

Use of an Online Training with Virtual Role Play to Teach Preference Assessment Implementation

Identification of reinforcers is critical to the effectiveness of behavioral interventions. Stimulus preference assessments (SPA) are a frequently used method to identify putative reinforcers. Given the fluctuating nature of individual preferences, there is need for efficient training of providers that may regularly implement SPAs. The present study evaluated the utility of a web-delivered training with virtual role play to train SPA implementation. This study builds upon previous literature by utilizing a larger sample and incorporating role-play, a component often omitted from other efficient methods of training. Study 1 trained 40 undergraduate students to implement an SPA via web or in vivo. Results suggest both trainings were equivalently effective, and the web-delivered training reduced trainer time by approximately 25 min. Live role-play and feedback was still necessary with web-delivered training, consistent with suggestions that rehearsal and feedback is a vital component of training. Results also suggest web-delivered training may identify areas of weakness following training. A follow-up clinical pilot showed that the web-delivered training was also effective at training eight novice providers to competently implement the SPA with children with ASD in a special education school. This study demonstrates that web-delivered training with virtual role-play is likely another efficient training method for implementation of behavioral procedures.

The Many Faces of Covid-19 at a Glance: A University Hospital Multidisciplinary Account From Milan, Italy

In March 2020, northern Italy became the second country worldwide most affected by Covid-19 and the death toll overtook that in China. Hospital staff soon realized that Covid-19 was far more severe than expected from the few data available at that time. The Covid-19 pandemic forced hospitals to adjust to rapidly changing circumstances. We report our experience in a general teaching hospital in Milan, the capital of Lombardy, the most affected area in Italy. First, we briefly describe Lombardy's regional Covid-19-related health organizational changes as well as general hospital reorganization. We also provide a multidisciplinary report of the main clinical, radiological and pathological Covid-19 findings we observed in our patients.

Supporting Children With Neurodevelopmental Disorders During the COVID-19 Pandemic

Families of children with neurodevelopmental disorders are especially vulnerable during the COVID-19 pandemic. Physical distancing requirements and closure of schools and services in the context of the COVID-19 pandemic are likely challenging to everyone but may be particularly impactful for families with children with neurodevelopmental disorders ([NDDs], eg, intellectual disability, attention-deficit/hyperactivity disorder [ADHD], autism spectrum disorder [ASD]). Although a small number of children may experience less stress or anxiety due to reduced social and academic expectations,¹ for many children with NDDs, and particularly those with ASD, carefully developed behavioral and environmental supports, and consistent and predictable routines and expectations, are vital for their mental well-being.² Consequently, abrupt discontinuation of these supports during quarantine and prolonged isolation creates a real risk for behavioral exacerbations in this vulnerable population.^3-6 Possible consequences for family members include physical and mental strain,⁷ whereas for the child with an NDD, increased emotional distress and challenging behavior may create safety concerns and the need for hospitalization.^4,6 Children with NDDs may be at increased risk for COVID and COVID-related complications,⁸ emphasizing the need for preventive and/or crisis behavioral health care availability outside of emergency and hospital settings.

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.

Comparison of Telehealth-Related Ethics and Guidelines and a Checklist for Ethical Decision Making in the Midst of the COVID-19 Pandemic

Applied behavior analysis (ABA) services have been provided primarily in the fields of health care and education across various settings using an in-person service delivery model. Due to the COVID-19 pandemic, the necessity of and demand for ABA services using telehealth have increased. The purpose of the present article was to cross-examine the ethical codes and guidelines of different, but related fields of practice and to discuss potential implications for telehealth-based ABA service delivery. We reviewed the telehealth-specific ethical codes and guidelines of the American Psychological Association, the American Academy of Pediatrics, and the National Association of Social Workers, along with the related ABA literature. These organizations addressed several useful and unique ethical concerns that have not been addressed in ABA literature. We also developed a brief checklist for ABA practitioners to evaluate their telehealth readiness by meeting the legal, professional, and ethical requirements of ABA services.

ABA Finding Its Heart During a Pandemic: An Exploration in Social Validity

The COVID-19 pandemic has presented practitioners of applied behavior analysis (ABA) with new and uncharted challenges. Upholding ethical responsibilities while navigating an international public health crisis has opened areas of uncertainty that have no precedent. Although there is general guidance on how to respond ethically from the Behavior Analyst Certification Board (BACB) in their publication specific to the COVID-19 crisis (BACB, 2020, March 29, Ethics Guidance for ABA Providers During COVID-19 Pandemic, retrieved from https://www.bacb.com/ethics-guidance-for-aba-providers-during-covid-19-pandemic-2/), there remains a huge responsibility on the individual practitioner to make potentially life-changing decisions. In that regard, practitioners are urged to ensure that they rely on socially significant and valid decision-making processes. The goal of this article is to provide an exercise in accounting for stakeholder feedback and connecting with patients and families regarding their input on the acceptability of treatment during the COVID-19 pandemic. The exercise is in the form of a structured parent interview to help practitioners account for the setting variables and social validity of treatment during a crisis. It is our ethical responsibility to remember this critical dimension of our science and practice.

Developing and Enhancing Adherence to a Telehealth ABA Parent Training Curriculum for Caregivers of Children with Autism

The current COVID-19 pandemic poses unique challenges to the delivery of applied behavior analysis (ABA) services, and there has been a growing demand for evidence-based practices on how to develop a telehealth ABA service model. The current article provides a detailed technological guide on how to develop a telehealth ABA parent training curriculum. Our model also includes a series of brief acceptance and commitment training (ACT) protocols to enhance parental adherence. We provide the details for replicating our telehealth model and also demonstrate its effectiveness. To begin, a step-by-step guide on how to develop this curriculum is presented, as well as protocols used in a 60-day telehealth ABA parent training program. Afterward, we describe a randomized controlled trial design to examine the effectiveness of this protocol. Thirteen families from the southern Illinois region participated in the curriculum before the COVID-19 outbreak. Obtained data indicated training was effective to teach skills, and parents with supplemental ACT material made significantly more progress than those in the control group, t(11) = 2.36, p = .038. Halfway through the training, the outbreak of COVID-19 occurred, and parents in the ACT group were more likely to continue the program, whereas parents in the control group were significantly more likely to postpone their participation, χ² = 6.96, p = .008. Social validity measures indicated that parents rated the curriculum favorably. Limitations and suggestions for practitioners are discussed.

Creating an Automated Health Attestation System During the COVID-19 Pandemic with Microsoft 365

Identifying and isolating individuals infected with COVID-19 are critical steps in stopping the spread of the coronavirus. Until widespread testing and contact tracing systems are implemented, alternative methods must be considered. One way that organizations can protect employees and clients is by creating their own automated health attestation systems. These systems could be used to reduce the spread of the coronavirus by asking providers and consumers to self-identify COVID-19 exposure, as well as to help mitigate liability for organizations by asking providers and consumers to agree to follow relevant policies and acknowledge the risks inherent in providing or receiving services. The purpose of this article is to outline the steps for creating this type of health attestation system using Microsoft Office 365.

Reopening the Doors to Center-Based ABA Services: Clinical and Safety Protocols During COVID-19

In the wake of the coronavirus (COVID-19) pandemic, U.S. organizations that provide applied behavior analysis (ABA) programs to individuals with autism spectrum disorder have implemented a variety of safety precautions to minimize the spread of the virus, often shifting center-based services to the home or telehealth. Considered essential workers, ABA providers are exempt from government directives to close, so they have both the freedom and the great responsibility to make their own decisions about how best to keep their clients safe while continuing to provide medically necessary services. In the coming weeks and months, ABA providers will be faced with the decision about whether to reopen centers. This article does not address that decision, except to acknowledge the urgency to reopen, both to help clients and to remain solvent. Political rhetoric and contradictory public information further complicate this daunting decision. Because ABA providers do not have legal guidance to shift the burden of such decisions to local and state regulators, the burden is theirs alone. The unprecedented nature of the COVID-19 pandemic means that no decision is clearly wrong or right, and every decision has consequences. Although ABA providers do not have their own state guidance, many states have issued guidelines for childcare providers whose operations have continued throughout the pandemic. This article analyzes that guidance, identifies common variables potentially relevant to ABA organizations, highlights clinical considerations and procedural compliance, and provides ABA organizations with the tools to make the best decision for their clients, in their community, and on their timeline.

The Role of Compassion and Ethics in Decision Making Regarding Access to Applied Behavior Analysis Services During the COVID-19 Crisis: A Response to Cox, Plavnick, and Brodhead

Cox, Plavnick, and Brodhead (2020, "A Proposed Process for Risk Mitigation During the COVID-19 Pandemic") published a position statement in the emergency section of Behavior Analysis in Practice in response to the COVID-19 crisis. They argued against a blanket interpretation that in-person applied behavior analysis services for all patients should continue during the pandemic. They strongly argued that the risks of continued services are almost always prohibitive and that only in rare cases would the continuation of in-person services be warranted. Colombo, Wallace, and Taylor (2020, "An Essential Service Decisions Model for Applied Behavior Analytic Providers During Crisis") soon thereafter published a response to the article pointing out the potential dangers associated with the position of the article by Cox et al. They included a detailed decision model to assist providers in making nuanced and informed data-based decisions that provide the opportunity to honor the ethical responsibility for not abandoning patients. We echo the importance of the Colombo et al. response and add points of response centered on balanced ethical decision making informed by compassionate family-centered care.

Some actions for behavior analyst licensing bodies to consider in response to the COVID-19 pandemic

The COVID‐19 global pandemic has had a significant impact on the practice of applied behavior analysis (ABA). Practitioners and caregivers have had to adapt quickly as physical distancing, stay‐at‐home orders, and shelter‐in‐place directives have become commonplace. As the field copes with the changes produced by the COVID‐19 outbreak, many behavior analytic practitioners are seeking guidance from regulatory bodies to ensure they are practicing legally and ethically. This article outlines some actions that the regulatory bodies that manage state behavior analyst licensure programs may consider to assist ABA practitioners and consumers during this unprecedented time. Additionally, suggestions are offered as to how state licensing bodies might prepare to support the practice of licensees during future events that present challenges similar to the current pandemic.

School's Out for COVID-19: 50 Ways BCBA Trainees in Special Education Settings Can Accrue Independent Fieldwork Experience Hours During the Pandemic

Due to the COVID-19 pandemic and nationwide executive orders closing schools, many trainees completing their supervised independent fieldwork in educational settings lost the ability to accrue hours linked to restricted activities of a therapeutic and instructional nature with students (i.e., clients). Given the impact on trainees of the pandemic restrictions, we present 50 suggestions for trainees in school settings to continue to accrue hours for both restricted and unrestricted activities throughout the course of the COVID-19 pandemic.

An Essential Service Decision Model for ABA Providers During Crisis

In the United States, applied behavior analysis (ABA) is broadly recognized as a medically necessary treatment for individuals diagnosed with autism and related disorders (Association of Professional Behavior Analysts, 2020, Guidelines for practicing applied behavior analysis during COVID-19 pandemic, Retrieved from https://cdn.ymaws.com/www.apbahome.net/resource/collection/1FDDBDD2-5CAF-4B2A-AB3F-DAE5E72111BF/APBA_Guidelines_-_Practicing_During_COVID-19_Pandemic_040920.pdf). We argue that this designation should not be called into question in light of a particular disaster and that it is critical to consider that an interruption of services can have long-lasting effects on the treatment of the individual (practitioners are ethically obligated to uphold the continuity of services while doing no harm). This dilemma might be ameliorated by a decision model that considers the prioritization of immediate needs, the vulnerability of clients, and the competency of service providers. Just as the medical field prioritizes immediate needs during crisis situations and defers routine appointments (e.g., physicals, checkups), the ABA field can make similar evidence-based decisions. The purpose of the current article is to provide a decision model for ABA practitioners who find themselves questioning the need for essential service delivery during the current COVID-19 pandemic. The impact of this model goes beyond the needs of this crisis and can be applied to any emergency situation where services are at risk of interruption.

The impact of the COVID-19 pandemic on children with autism spectrum disorders

In the unprecedented disruption and social isolation of the COVID-19 pandemic, families around the world are faced with questions of how their children can thrive in these conditions. On top of the ubiquitous challenges for all children, this public health crisis imparts unique difficulties for children with special health needs. We identify children with Autism Spectrum Disorder (ASD) as being particularly vulnerable to negative impacts of the COVID-19 pandemic. In this paper, we examine why children with ASD are uniquely vulnerable, recommend strategies to mitigate these stressors for children with ASD and their parents, explore the potential challenges of reintegration into society as conditions improve, and examine the obligations of healthcare and community stakeholders to support these families.