Telehealth with Young Learners and their Caregivers

Am I doing this right?

It’s early March and word starts going around about our services possibly moving to Telehealth due to the Covid 19 pandemic. My first thought was “OK cool, how do we do that?” Are we getting trained?” I like to think I have a good amount of #philosophicaldoubt. Telehealth sounds alright, I mean working from home and possibly in my PJ’s? I’m in! But how will we service our clients remotely? What should a telehealth session look like? 

Having been in the field for 5+ years, not once has telehealth ever been something I have been trained on or introduced to. However, as the situation with Covid 19 evolved, there began to be impact on service delivery throughout our county. I learned of various colleagues that had already transitioned to a telehealth platform and it was finally confirmed that we were making the switch to telehealth. 

As the remote work began, I worked closely with my supervising BCBA to prepare for this approach of service delivery. I remotely shadowed the first couple of sessions and got constant support and feedback from my supervisor. As I transitioned on to conducting the sessions independently, I began to stumble on to the nitty gritty challenges of conducting telehealth sessions that I did not anticipate. After just a week of conducting sessions remotely, I found myself feeling so defeated and drained after each session. But WHY?!? I had mistakenly anticipated this experience to be easier and I was not prepared for all of the variables that would be at play. 

My feelings mostly stemmed from the frustration of feeling limited about the ways that I could best support the families that I work with. It was difficult to implement and model strategies from the BIP when behaviors occurred through a screen and I found it incredibly difficult to provide real-time feedback and redirection and/or reinforcement as needed with immediacy through a screen. There are so many variables that are out my control when conducting telehealth sessions. For one, freezing screens are definitely a thing despite high speed internet.  Audio getting cut off has also proved to be an issue, along with the inability to account for all of the possible competing variables in the environment (toys across the room, and open door, environmental arrangements) that may arise during remote teaching. 

I also began to feel concerned about the experience that telehealth had become for caregivers and learners. From one day to another, home has become an environment where children are now required to sit and attend to different teachers and attend classes. Caregivers are suddenly presenting novel demands to their children. Everyone involved in the telehealth experience is going through a major transition and figuring it out as they go. I worried that caregivers would begin to feel discouraged or frustrated during this process too. If I was already feeling this way, I couldn’t imagine what it was like for the learners and their families. I wanted to be able to support in every and any way that I could and I came to realize, as you hopefully will as well, that it is all about shifting your perspective. I put my ABA thinking cap on and FINALLY had a lightbulb moment. I didn’t just begin providing ABA through telehealth- I had completely shifted from a direct intervention approach, to a facilitator role that would involve continuous real time collaboration.

There is NO right or wrong way to conduct a telehealth session and this is something extremely important that I’ve come to learn. While telehealth and all direct services look different for every single learner, something to keep in mind when we provide services is that we are all essentially working towards the goal of eventually not being needed by the client #independence. Am I right?! 

For those like myself working with the young learners, you know that they will likely have difficulty remaining seated and on task for longer periods of time. For this reason, caregiver presence is likely required for your learner during your telehealth sessions. This is an advantage! I mean, how often are caregivers likely to be actively present or participating during our home sessions? A majority of the time, most of us behavior techs as well as supervisors find ourselves actively seeking to increase caregiver involvement during our one on one session. During a typical home session, I do this by actively contriving opportunities for caregiver involvement through having them observe specific activities, participate in reinforcement delivery/ breaks or by running a familiar program. I have to admit, finding ways for parents to participate and contriving opportunities for successful interactions between caregivers and learners– is one of my favorite things to do!

So how do we do this in the time of Covid-19 and telehealth?  

Remote sessions already require more engagement from the caregiver’s part. This may include setting up devices and activities, facilitating transitions, making sure the learner remains seated and attending to what is being asked of the learner from the other side of the screen (us). Queue in, caregiver training and collaboration! 

I had to change my perspective about what the Telehealth experience is supposed to be or should be and changed the narrative to what I could turn the telehealth experience into for everyone involved! The goals put in place by the BCBA on the case already accounted for remote learning and were collaboratively created with the caregivers. My focus now was to translate them to the caregiver and support their implementation remotely through a screen, in an effective and empowering way. How could I do this remotely? How could I be as effective remotely as I felt I could be by being physically present? 

Below is a list of the ways that I modified my own behavior (wink, told ya my ABA cap thinking cap was on)  to align with a telehealth service delivery model. I have outlined tips that are currently helping me navigate the world of Applied Behavior Analysis (ABA) through telehealth and the novel challenges that this platforms brings with it.

• Preparing all materials and online resources BEFORE hand:

I give myself 5-10 minutes before my online session begins, to open any web pages or online platforms/ screen sharing resources I might use during my session. I have 4 different tabs ready at all times- each with a different preferred YouTube music video- ready for reinforcement delivery. I also open up different tabs for interactive books or games to have ready to share during the session as well. 

Organization helps me focus on the learner and what is happening on the other side of the screen. This way, I can provide feedback and not miss any teaching opportunities; It also makes it a shorter process to deliver potential reinforcement through a shared screen when immediacy is important and a tangible item is not accessible.

• Taking notes!

I use a digital data collection system to take program data. However, I always have a notebook and pen in hand ready to jot down any feedback that I want to include for review during caregiver debrief. This may include specific praise that I want to deliver to the caregiver about a way that they handled something during the session; such as giving a clear and concise instruction, delivering praise to the learner throughout an activity or following through. I also separately write down key words under, “Next time” for things we can practice during the next session. For example, “I noticed today ****** ran towards the door a lot! Next time we can try having him sit furthest from door and close the door before we start the activity just in case” 

Before I got in the habit of doing this, I found myself recalling things that I forgot to note with the caregiver HOURS AFTER SESSION WAS OVER! Writing them down, gives me a permanent product to refer to and remind me about information or feedback that I plan on giving the caregiver.

• Checking in, planning the activities and debriefing with caregiver before session #collaboration:

Just like with our home sessions, it is so important that we check in on our kiddos through caregivers prior to transitioning the learner into session and diving into session activities. Any information is information that we may need to gather before planning the structure of a session. For example, has the learner had lunch? Did they use the restroom? Did they sleep well and how has their day been? During Covid-19 times, it is likely that the learner has had other telehealth sessions (speech, occupational therapy, physical therapy, etc.) throughout their day. If the learner has had to sit for 2 FULL HOURS for a session directly before their session with you, you more than likely do not want to begin session with a table top activity #setthemupforsuccess. Throw some gross motor or sensory activities in there! Wooohoo!

If we don’t check in, you may find your learner begins to demonstrate some aversiveness to table time, engages in elopements to the fridge, or has a potty accident if they did not go before session.

I use this information to collaboratively plan the structure and schedule of the session with the caregiver and it has been so beneficial in setting the tone for smoother transitions. I like to present a couple of ideas about the order of activities to the caregiver following the debrief and I always ask for their thoughts. This way, we can plan the schedule of activities together and anticipate the materials as needed.

I also discuss the goals that we can target for each activity and I get the caregiver’s input on what they would like to target. For example, if we decided we should start with a puzzle, I follow up with, “These are the things we can work on while we use a puzzle! (i.e color ID, receptive labeling, or choice making). Which do you think we should focus on first?”

Collaboratively planning the structure of the session with caregivers and deciding on a clear goal to focus on for each activity before it is presented to the learner has helped create a smoother flow of session for everyone involved #AntecedentStrategies #Priming

1. Delivering feedback and behavior support:

This part will look different for everyone, as all goals and programs are tailored to each individual learner’s needs. Through my experience this is the part that will take some adjusting to. The thing I struggled with the most at the beginning of my telehealth service delivery experience was this- “WHEN & HOW DO I STEP IN?!?!” 

When providing telehealth services to my young learners, the name of the game has been collaboration. Three months ago, at the start of my telehealth service delivery experience, I found myself internally struggling on how and when to deliver feedback to caregivers using the telehealth platform. I could not give any reliable feedback if I could not pinpoint the function of the behavior accurately. Remote service is tricky because as mentioned before, there are multiple competing variables of which we as practitioners cannot control for or are unaware of (such as a scent in the room, siblings playing nearby, a preferred toy in nearby view, or an open bag of chips nearby). I came to discover that it was a huge challenge attempting to provide feedback or guide caregivers through moments in which the learner engaged in excessive or inappropriate behaviors. 

During face to face service delivery, I have the ability to jump in, implement and model reactive strategies and then debrief caregivers. However, virtual service delivery is a whole other ballgame. I had the biggest urge to be able to somehow jump through the screen and physically be there to model the intervention for the caregivers! But this is telehealth. And this is where it becomes important to adjust our expectations of what telehealth should look like. 

As ABA providers, we are trained to observe and account for all the variables, to assess for the functions of a behavior and implement necessary protocols in accordance with the BIP. What if you can’t see what preceded or followed a behavior? What if you are not able to see the competing variables because they are out of frame, as is the case with telehealth?

When behaviors are involved it has continued to prove difficult to guide caregivers through de-escalation. Picture a young child engaging in crying behavior, and screaming loud enough to drown out your voice coming in through the audio. What do we do then?

• I try to step in when I know I can be heard. As is typical in an escalated situation, I like to keep in mind that my feedback may not be received or may even be tuned out if everyone involved is escalated. How do I know this? I had to learn this technique after I tried to hop in and coach a caregiver through a tantrum the first week and it was such a mess!  #trialanderror
• I speak through the screen and offer my feedback to either the learner or the caregiver only as needed. The caregiver may attempt to implement strategies familiar to them or turn to you (the screen) for guidance- In which case I jump right in and give the caregiver short and clear instructions on how to best proceed. You may have that kiddo in your caseload that knows if they give their caregiver hugs and kisses, they may not have to complete the demand. This is where telehealth is the advantage!! I get to be present during those interactions and redirect the learner and caregiver. How great is this for generalization of skills and behavior protocols!

BCBA ethical guidelines state that a cookie-cutter approach should never be used, and all treatments should be tailored and individualized to each client’s specific needs. That being noted, please keep in mind that I am only sharing tips that have been effective for me through my own trial and error, on my own behavior. These are strategies that I constantly practice and pull from my behavior tech toolbox when deemed appropriate.

Food for thought: Young learners are more than likely used to having fun and playful interactions with their caregivers free of demands when they’re at home. You can assure that it is a difficult transition for everyone in the home to have these interactions completely change from fun and free of demands, to 8-hour days, jam packed with demands and structured activities. This is a BIG change! It’s ok to relax the structure of the session, and keep it fun!

• Facilitating activities:

After lots of trial and error, and many rough sessions that I’m sure left the caregivers and I more exhausted, we FINALLY found a middle ground on how to best support the learner using the telehealth model to facilitate activities and conduct most of the session.

The winner by far was direct and indirect vocal prompting! I begin by narrating what’s happening, enticing the learner towards the activity that is starting. I definitely have to be more animated than usual, and if you know me that’s a whole lot of animated. The caregiver begins the activity, engages and interacts with the learner through play. Then, through the screen I begin to contrive opportunities by indirectly prompting the caregiver and the learner. For example, see below:

“OH, you’re doing an animal puzzle! I see tons of animals! Let’s talk about them!” I would then follow up by directing myself towards the caregiver and giving them a thumbs up paired with, “Let’s work on identifying animals now. You can hold up one at a time, and ask “what is this?”

Of course, the approach, instructions and programs targeted through telehealth would all vary by learner and case. But the message that I am trying to convey to any one reading this is: “Be flexible with your expectations!”

• Asking questions at the end of debriefs:

Encouraging caregiver input can facilitate the telehealth experience. Many of us are used to the debrief/ check in interactions before and after sessions, however during home sessions caregivers are typically not responsible for conducting the entire session. At the end of my sessions, I like to ask the caregiver that I just worked with if they have any questions about today’s session.

I had a caregiver once, respond with asking me if I could provide her specific phrases to use during play-based activities. I had been modeling and giving instructions for choice making targets to the caregiver such as, “Ok, now let’s hold both choices up and ask her to pick one”, however this caregiver asked if I could tell her exactly what to say to the learner because it was tough for her to deliver short and clear instructions.

I proceeded by modifying my feedback approach to what worked for this caregiver. Modifying my feedback delivery helped tremendously in keeping a good flow of session and having better communication during session. I had originally refrained from narrating to the caregiver exactly what to say, as it is something that doesn’t make everyone comfortable and some may find it unpleasant. Receiving this feedback and knowing this about the caregiver, helped our therapist/ caregiver relationship tremendously and it has helped us collaborate more effectively to best support the learner. 

Making the best of the situation:

Telehealth is novel to most of us and it will absolutely be an adjustment to our typical method of service delivery. Most of our work with young learners in ABA is play based! We get to know our learners through engaging them in play, we also teach through play using Natural Environment Teaching (NET) strategies. As ABA providers, we are likely to intuitively implement proactive and reactive strategies. However, it would be unfair of us as practitioners to expect our caregivers and learners to be able to initiate learning opportunities the same way that we do as ABA providers. Modify your approach as needed, have fun and ensure your learner does too! 

After the first week, when I felt defeated, I knew I’d have to adjust or modify something in my own approach. I immediately communicated this to the BCBA on the case. I expressed the things that were proving difficult and asked her if she could hop in so she could observe and model some more. Don’t ever feel nervous or intimidated to ask for more feedback. I do it all the time! It is the way that we become effective and the best way we can support our learners. Like I said, collaboration is the name of the game.

If you currently continue to provide telehealth services due to the pandemic or for any other reason, keep on keeping on! It is not easy navigating the curveballs that come our way when providing services remotely. I mean, I still haven’t been able to figure how to get my computer to stop freezing mid-session, even after installing a new internet in my upstairs home office! 

Continue showing up and being the bada** techs that you are! These are weird times, but nothing can take away from the positive impact you make in your learners lives daily. Whether remotely or physically present- YOU GOT THIS BOO!

About the Author

Jenny is a Registered Behavior Technician (RBT) based in LA, who discovered this field in Spring of 2015 and like many of you fell in love. She recently graduated from Pepperdine University Graduate School of Education and Psychology with a Master of Science in Behavioral Psychology with a focus in Applied Behavior Analysis as part of the Quarantine Class of 2020. Jenny currently works as a clinical lead in the center-based setting providing on field training to other RBT’s and has 5 years of experience providing direct intervention in the home and school setting. She is currently studying to sit for the Board Certified Behavior Analyst Exam. Jenny spends most of her weekends running, hiking with her 8-month old pup and going on coffee runs with friends!