Increasing Access to Applied Behavior Analysis through ... · Sex Males 83% Females 17% Diagnosis...
Transcript of Increasing Access to Applied Behavior Analysis through ... · Sex Males 83% Females 17% Diagnosis...
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Increasing Access to Applied Behavior Analysis through Telehealth
Scott Lindgren, PhD
University of Iowa Children’s Hospital
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The Challenge
• There is a serious disparity in access to health care for people living in rural and other underserved areas.
• Reduced access to care is especially challenging for people with disabilities, who often require more complex, more specialized, and more frequent care.
• There are few practical strategies that can effectively overcome this “rural disadvantage” in access to services.
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Telehealth Can Help Meet this Challenge
• Telehealth is defined by HRSA as “Use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.”
• Telehealth has been shown to be an innovative and effective method for solving access problems that are based on geography and a shortage of rural providers.
• Telehealth can achieve cost savings while improving health outcomes.
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An Autism Problem
• Many children with autism spectrum disorders (ASD) have serious behavior problems (e.g., aggression, self-injury, noncompliance, destruction).
• These problems limit cognitive and social development and interfere with educational and therapeutic opportunities.
• Too many young children with ASD lack access to urgently needed behavioral services.
• Access to behavioral services is especially difficult in small towns and rural areas.
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How Can We Solve this Problem?
• We need to spread evidence-based ABA practices to all geographic areas.
• Behavioral interventions for ASD must
– Reduce challenging behavior
– Increase social communication and cooperative behavior
• Functional communication training (FCT) is the most widely used ABA intervention for the reduction of problem behavior in children with ASD and other DD
• We must use innovative methods to get ABA to underserved areas.
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Behavioral Treatment through In-Home Telehealth for Young Children with Autism
Co-PI: Scott Lindgren & David Wacker
Co-Investigators: Todd Kopelman, Kelly Pelzel, Debra Waldron
Behavior Consultants: John Lee, Patrick Romani, Wendy Berg, Alyssa Suess, Kelly Schieltz
Parents and children who have welcomed us into their lives
Supported by HRSA/MCH Grant R40-MC22644
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Poll Question
• Do you use Applied Behavior Analysis (ABA) to reduce problem behavior or build social communication skills in children with Autism Spectrum Disorder?
Yes ____
No ____
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What is ABA?
Definition: A systematic and experimental
approach for evaluating the effects of changes in
the environment on a person’s behavior
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Behavioral Procedures
Clinic & Home-Based ABA:
• Functional Analysis: Iwata et al. (1982/1994) procedures; multi-element design –Assessment: Goal is to identify function of
child’s problem behavior (e.g., escape, attention, tangible)
• Functional Communication Training: Carr & Durand (1985) –Treatment: Goal is to replace problem
behavior with appropriate communication that serves the same function
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Strategies Used for Behavioral Intervention in the Iowa ABA Studies
• Use functional analysis (FA) and functional communication training (FCT) to replace problem behavior with social communication
• Train parents to use FA/FCT with their children under the direction of a behavioral consultant
• Use telehealth to reach underserved areas
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In-Home ABA Project
(1996-2010) • Young children (12-72 months) with DD who engaged
in challenging behaviors
• Therapists drove to home and coached parents to conduct FA & FCT procedures (1 hr weekly)
• Social function identified in 84% of cases
• Treatment reduced challenging behavior by 90%
• High treatment acceptability
Wacker, Harding, Berg, Lee, Schieltz, Padilla, Nevin, & Shahan (2011). An evaluation of persistence of treatment
effects during long-term treatment of destructive behavior. Journal of the Experimental Analysis of Behavior, 96,
261-282.
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In-Vivo In Home
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Eligibility Criteria for ABA Telehealth
Autism Spectrum Disorder diagnosis Significant challenging behaviors (e.g., aggression, destruction, self-injury, repetitive behaviors, severe tantrums) within 50 miles of participating CHSC clinic (clinic-based) OR anywhere in Iowa (home-based)
Children 18 to 83 months of age with:
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ABA Telehealth Procedures
• Weekly 60-min telehealth sessions from UI Children’s Hospital to regional clinics or homes
• Parents conducted all sessions with telehealth coaching from behavior therapist
• Parents completed practice sessions each week
• All sessions recorded, coded, and graphed
• Participation lasts up to 9 months
• RCT design for in-home project:
–Assigned to immediate or delay (control) group
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Regional Clinic Telehealth
• CHSC regional sites:
– Equipped with videoconferencing hardware (i.e., computer, camera, tv monitor)
– Received live image and audio from therapist
– Toys, picture cards, and other materials provided for each clinic
– Parent assistants/family navigators present in clinic room to provide support
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View from UI Children’s Hospital
• Hospital site connected to regional clinic site or home through a secure network
• Hospital site: – Telehealth lab equipped with
desktop computers and videoconferencing software
– FA and FCT sessions recorded for subsequent data coding
– 6-s partial-interval audio was embedded into 5-min sessions
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Clinic-to-Clinic Telehealth (2009-2012)
• Similar procedures to prior in vivo project but delivered via telehealth
• Evaluation and treatment in clinic setting
• Focused on young children (ages 2 - 6) with ASD who were engaging in severe challenging behaviors
• 6-month involvement (1 hr/wk visits)
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Clinic-to-Clinic Telehealth
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Clinic-to-Clinic Results • Social function identified in 90% of cases, 90% average
reduction in challenging behavior
• All children showed > 64% reduction in problem behavior;
83% showed > 90% reduction in problem behavior
• High treatment acceptability by parents
• Consultants could spend more time coaching families and less time in travel
• Decreased costs (Average weekly cost of telehealth =
$58 per participant vs. $335 if therapists traveled weekly)
Wacker, Lee, Padilla, Kopelman, Lindgren, Kuhle, Pelzel, & Waldron (2013). Conducting functional analysis of problem behavior via telehealth. Journal of Applied Behavior Analysis, 46, 31-46.
Wacker, Lee, Padilla , Kopelman, Lindgren, Kuhle, Pelzel, Dyson, Schieltz, & Waldron (2013). Conducting functional communication training via telehealth to reduce the problem behavior of young children with autism. Journal of Developmental and Physical Disabilities, 25, 35-48.
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In-Home Study Participants
In-Home (N=54)
Sex
Males 83%
Females 17%
Diagnosis
ADOS Autism Spectrum Cut-off 33%
ADOS Autism Cut-Off 67%
Developmental Status
Developmental Disability 57%
Age
Mean 54 months
Range 21-85 months
Distance from Iowa City
Mean 120 miles
Range 3-310 miles
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County Coverage via Home Telehealth
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In-Home Functional Communication Training Results
• 17 participants have completed FCT treatment
• Mean reduction in challenging behavior: 85.6%
• 15 participants had ≥ 90% reduction
• Only 2 non-responders
• Parents were able to implement procedures with acceptable fidelity
Suess, Romani, Wacker, Dyson, Kuhle, Lee, Lindgren, Kopelman, Pelzel, & Waldron (2013). Evaluating the treatment fidelity of parents who conduct in-home functional communication training with coaching via telehealth. Journal of Behavioral Education.
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A Family Using Teleheath at Home
• Tera
– 5 years old
– Autism Spectrum Disorder
– Destructive Behavior (aggression, property destruction)
• Mother and Father
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Summary of ABA Telehealth Results
• Social functions were identified through functional analysis for over 90% of children
• Most children with ASD show escape and/or tangible functions
• FA was completed in an average of 4-5 visits
• FCT was completed in an average of 8-10 visits
• An average reduction in problem behavior of at least 85% has been achieved in both clinic and home settings
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Behavioral Telehealth Successes
• Reduction in problem behavior through telehealth averages over 85%, which is comparable to ABA provided in vivo when therapists visit the home
• Treatment acceptability ratings by parents at end of treatment were at least as high as when therapists went out to the home (Clinic=6.47, Home=6.75 of 7)
• Average weekly cost of delivering telehealth was $58 per participant, compared to $335 if consultants traveled to provide coaching on site or in home
• Treatment fidelity based on parent behaviors has been acceptable and produces positive changes in child behavior and communication
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Challenges for ABA Telehealth
• Not all parents have the confidence and interest needed to learn ABA methods
• Not all families are comfortable with communication through teleconferencing
• Technical problems with equipment and internet connections can interfere with completing sessions
• For clinic-based telehealth, families must still find the time and transportation to attend clinic sessions
• Even though telehealth can extend the reach of behavioral consultants into underserved areas, there are still not enough trained behavior analysts to meet the need for ABA services
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Take-Home Messages
• Function-based behavior analysis and treatment are highly effective for children with ASD.
• As little as 1 hour/week of behavioral consultation can teach parents how to reduce challenging behavior and increase social communication significantly.
• Telehealth can extend ABA expertise to rural, underserved areas.
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Peace and Joy (An Autism Haiku)
Hopes dashed and rooms trashed
until parents restore peace,
turning pain to joy!
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Photographs by Timothy Archibald at timothyarchibald.com
(Used with permission)