Digital health should augment (not replace) autism treatment providers

Supporting emotion regulation in children on the autism spectrum: co-developing a digital mental health application for school-based settings with community partners

OBJECTIVE

KeepCalm is a digital mental health application, co-designed with community partners, that incorporates wearable biosensing with support for teams to address challenging behaviors and emotion dysregulation in children on the autism spectrum.

METHODS

We followed a user-centered design framework. Before app development, we conducted design workshops, needs assessment interviews, a systematic review, and created an Expert Advisory Board. Once we had a working prototype, we recruited 73 participants to test and help improve the app across five testing cycles.

RESULTS

Participants rated the app across testing cycles as highly acceptable, appropriate, feasible, and with good usability. Qualitative data indicated that KeepCalm helped teachers (a) be aware of students' previously unrealized triggers, especially for nonspeaking students; (b) prevent behavioral episodes; (c) communicate with parents about behaviors/strategies; and (d) equipped parents with knowledge of strategies to use at home. We learned that in order to make the app acceptable and appropriate we needed to make the app enjoyable/easy to use and to focus development on novel features that augment teachers' skills (e.g., behavioral pattern and stress detection). We also learned about the importance of maximizing feasibility, through in-person app training/support especially regarding the wearable devices, and the importance of having aides involved.

CONCLUSION

Our findings have informed plans for wider-scale feasibility testing so that we may examine the determinants of implementation to inform adaptations and refinement, and gather preliminary efficacy data on KeepCalm's impact on reducing challenging behaviors and supporting emotion regulation in students on the autism spectrum.

Helping Practitioners Stop, Drop, and Roll: Suggestions to Help Improve Responses to Intense Clinical Events

Community practitioners inconsistently implement evidence-based interventions. Implementation science emphasizes the importance of some practitioner characteristics, such as motivation, but factors such as practitioners' emotion regulation and cognitive processing receive less attention. Practitioners often operate in stressful environments that differ from those in which they received training. They may underestimate the impact of their emotional state on their ability to deliver evidence-based interventions. This "hot-cold state empathy gap" is not well studied in mental health care. In this Open Forum, the authors describe scenarios where this gap is affecting practitioners' ability to implement evidence-based practices. The authors provide suggestions to help practitioners plan for stressful situations.

Video-based interventions promoting social behavioural skills for autistic children and young people: An evidence and gap map

Background

Video-based interventions (VBIs) are an approach that can be used to promote social behavioural skills for autistic children and young people. Despite an abundance of literature in this area, previous evidence syntheses are limited by their exclusive search strategies and eligibility criteria. Therefore, there is a lack of comprehensive evidence syntheses to provide insight on whether these interventions work, for whom, and in what circumstances. Evidence and Gap Maps (EGMs) are used to collate vast literature on a broad topic area such as this, highlighting areas for synthesis, and identifying gaps for future research.

Objectives

To identify, map and synthesise existing primary research on VBIs promoting social behavioural skills for autistic children and young people, creating a live, searchable and publicly available EGM.

Search Methods

Searches were conducted in electronic databases (n = 8), web search engines, and other repositories including published papers and grey literature. The search strategy was developed around two concepts including (1) terms related to autism, and (2) terms related to VBIs. Searches were conducted in May 2021.

Selection Criteria

All primary studies evaluating the effectiveness of VBIs in promoting social behaviours for autistic children and young people aged 3-18 were included in the EGM.

Data Collection and Analysis

Search results were imported into Eppi-Reviewer where duplicates of identical studies were removed. Titles and abstracts were then screened by two independent reviewers. Potentially eligible full texts were located and also screened by two reviewers. Data were then extracted on study design, participant characteristics, type of intervention, type of outcome, and country of study, by one of three reviewers. EPPI-Mapper was used to create the interactive EGM.

Main Results

The current EGM contains 438 studies reporting on 394 single subject research designs, 25 randomised controlled trials, 15 non-randomised group designs, and 8 pretest-posttest designs. Included studies evaluated VBIs in all male (n = 238), mixed gender (n = 172) or all female (n = 17) samples. VBIs employed included video modelling (n = 273), video self-modelling (n = 82), point-of-view modelling (n = 61), video prompting (n = 57), video feedback (n = 12) and computer-based video instruction (n = 4). The most frequently used models were adults (n = 191) and peers (n = 135). In relation to social outcomes, almost half evaluated social engagement (n = 199) with limited studies looking at safety (n = 9) and community (n = 7) skills.

Authors' Conclusions

This EGM provides a valuable resource for policy-makers, practitioners, researchers, funders and members of the public to access evidence on VBIs promoting social behavioural skills in autistic children and young people. The map has identified areas of sufficient research where evidence can undergo synthesis. In addition, important gaps in the evidence were highlighted and suggest further research is warranted in all female samples and less frequently evaluated types of VBIs and social outcomes. Evidence included in this EGM will be further explored via systematic review and meta-analysis on control group designs.

Mental health service users' experiences of telehealth interventions facilitated during the COVID-19 pandemic and their relevance to nursing: An integrative review

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Service users report telehealth interventions to be useful in terms of access and convenience however, a preference for face-to-face interventions remains. Nurses are using telehealth interventions in clinical practice however, further research is necessary in this area as the evidence of their involvement is limited. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This paper highlights the use of telehealth interventions should augment rather than replace face-to-face care provision.

ABSTRACT

INTRODUCTION: The Covid-19 pandemic saw the swift implementation of physical and social distancing that impacted the way in which mental health services were facilitated. Consequently, telehealth/e-health interventions are increasing in use.

AIM

This integrative review aims to explore existing literature regarding mental health service users' experiences of telehealth interventions facilitated through the COVID-19 pandemic, to determine the visibility of nursing involvement in the facilitation of telehealth interventions and to use these experiences to inform nursing practice.

METHOD

A methodical search of eight (n = 8) academic databases was undertaken using CINAHL, SCOPUS, EMBASE, PsycINFO, Web of Science, Cochrane, MEDLINE and Academic Search Complete between January 2020 and January 2022.

RESULTS

A total of 5133 papers were screened by title and abstract of which (n = 77) progressed for full-text screening. Five (n = 5) papers met the inclusion criteria for this review and results were mapped onto the four meta-paradigms of nursing: person; where the findings discuss the acceptability of telehealth interventions; environment; where the findings highlight barriers and facilitators to the use of telehealth interventions; health; where the findings discuss staff time and logistical issues relating to telehealth interventions and nursing; where the findings centre around the therapeutic relationship.

DISCUSSION

This review highlights there is a paucity of direct evidence relating to nursing involvement in the facilitation of telehealth interventions. However, there are benefits to the use of telehealth interventions that include increased access to services, less perceived stigma and increased engagement which are relevant to nursing practice. A lack of individual contact and concerns relating to infrastructure indicates a fondness for face-to-face interventions remains high.

IMPLICATIONS FOR PRACTICE

There is a need for further research on the role of the nurse in the facilitation of telehealth interventions, specific interventions used and outcomes of such interventions.

A Digital Mental Health App Incorporating Wearable Biosensing for Teachers of Children on the Autism Spectrum to Support Emotion Regulation: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

As much as 80% of children on the autism spectrum exhibit challenging behaviors (ie, behaviors dangerous to the self or others, behaviors that interfere with learning and development, and behaviors that interfere with socialization) that can have a devastating impact on personal and family well-being, contribute to teacher burnout, and even require hospitalization. Evidence-based practices to reduce these behaviors emphasize identifying triggers (events or antecedents that lead to challenging behaviors); however, parents and teachers often report that challenging behaviors surface with little warning. Exciting recent advances in biometric sensing and mobile computing technology allow the measurement of momentary emotion dysregulation using physiological indexes.

OBJECTIVE

We present the framework and protocol for a pilot trial that will test a mobile digital mental health app, the KeepCalm app. School-based approaches to managing challenging behaviors in children on the autism spectrum are limited by 3 key factors: children on the autism spectrum often have difficulties in communicating their emotions; it is challenging to implement evidence-based, personalized strategies for individual children in group settings; and it is difficult for teachers to track which strategies are successful for each child. KeepCalm aims to address those barriers by communicating children's stress to their teachers using physiological signaling (emotion dysregulation detection), supporting the implementation of emotion regulation strategies via smartphone pop-up notifications of top strategies for each child according to their behavior (emotion regulation strategy implementation), and easing the task of tracking outcomes by providing the child's educational team with a tool to track the most effective emotion regulation strategies for that child based on physiological stress reduction data (emotion regulation strategy evaluation).

METHODS

We will test KeepCalm with 20 educational teams of students on the autism spectrum with challenging behaviors (no exclusion based on IQ or speaking ability) in a pilot randomized waitlist-controlled field trial over a 3-month period. We will examine the usability, acceptability, feasibility, and appropriateness of KeepCalm as primary outcomes. Secondary preliminary efficacy outcomes include clinical decision support success, false positives or false negatives of stress alerts, and the reduction of challenging behaviors and emotion dysregulation. We will also examine technical outcomes, including the number of artifacts and the proportion of time children are engaged in high physical movement based on accelerometry data; test the feasibility of our recruitment strategies; and test the response rate and sensitivity to change of our measures, in preparation for a future fully powered large-scale randomized controlled trial.

RESULTS

The pilot trial will begin by September 2023.

CONCLUSIONS

Results will provide key data about important aspects of implementing KeepCalm in preschools and elementary schools and will provide preliminary data about its efficacy to reduce challenging behaviors and support emotion regulation in children on the autism spectrum.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05277194; https://www.clinicaltrials.gov/ct2/show/NCT05277194.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45852.

Making Progress Monitoring Easier and More Motivating: Developing a Client Data Collection App Incorporating User-Centered Design and Behavioral Economics Insights

Data collection is an important component of evidence-based behavioral interventions for children with autism, but many one-to-one aides (i.e., behavioral support staff) do not systemically collect quantitative data that are necessary for best-practice client progress monitoring. Data collection of clients' behaviors often involves labor-intensive pen-and-paper practices. In addition, the solitary nature of one-to-one work limits opportunities for timely supervisor feedback, potentially reducing motivation to collect data. We incorporated principles from behavioral economics and user-centered design to develop a phone-based application, Footsteps, to address these challenges. We interviewed nine one-to-one aides working with children with autism and seven supervisors to ask for their app development ideas. We then developed the Footsteps app prototype and tested the prototype with 10 one-to-one aides and supervisors through three testing cycles. At each cycle, one-to-one aides rated app usability. Participants provided 76 discrete suggestions for improvement, including 29 new app features (e.g., behavior timer), 20 feature modifications (e.g., numeric type-in option for behavior frequency), four flow modifications (e.g., deleting a redundant form), and 23 out-of-scope suggestions. Of the participants that tested the app, 90% rated usability as good or excellent. Results support continuing to develop Footsteps and testing its impact in a clinical trial.

Practitioner and Service User Perspectives on the Rapid Shift to Teletherapy for Individuals on the Autism Spectrum as a Result of COVID-19

Prior to COVID-19, research into teletherapy models for individuals on the autism spectrum was slowly progressing. Following the onset of COVID-19, teletherapy became a necessity for continuity of services, however, research was still emerging for how to translate best practice autism support to the online environment. The aim of this research was to gain insight into the rapid shift to teletherapy for practitioner and service users and the implications for the broader disability sector. Survey responses were collected from 141 allied health practitioners (speech pathologists, occupational therapists, psychologists, educators, and social workers) from four Australian states and territories. A total of 806 responses were collected from service users following an individual teletherapy session. Five themes were identified during the qualitative analysis; (1) technology-love it or hate it; (2) teletherapy as a "new normal"; (3) short term pain, for long term gain; (4) the shape of service delivery has changed; (5) is teletherapy always an option? Data from the quantitative analysis provided further insights into the first two themes. While COVID-19 has brought forward significant advances in telehealth models of practice, what is needed now is to delve further into what works, for who, and in which context, and explore the potentiality, efficiencies, and scalability of a post-pandemic hybrid approach. This will inform practice guidelines and training, as well as information for service users on what to expect.