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With the ongoing concerns regarding coronavirus (Covid-19) and recommendations for social distancing, ABA providers are quickly adapting to create new service delivery options for families.  Providers want to keep families and staff as safe as possible, while ensuring that clients continue to receive the care they need.  Telehealth allows patients to receive services remotely, making it an ideal way to minimize in-person interactions.  Every day, more insurance carriers are joining in approving this mode of service delivery for ABA clients. 

Who needs Telehealth? 

While some families are seeking continuity of the same level of services they were receiving previously, sheltering in place has actually increased the need for services for some.   Newly-diagnosed children and older individuals with aggression or self-injurious behavior cannot afford a break in services.  Children and adults who are struggling to adapt to the drastic change in routine of a sudden break from school or expected community activities may need more help than ever.   

How does Telehealth help my family social distance?

Using Telehealth decreases the number of people with whom your family will interact on a daily basis.  Although you may still choose to have services in your home, Telehealth provides the option to minimize the number of providers.  Direct service providers typically visit only a small number of homes.  Having a BCBA, who is responsible for supervising more families and staff, provide supervision and parent training via Telehealth allows those professionals to continue to serve many families without the risk of spreading germs between houses. 

How can Telehealth work within an ABA model? 

The model used for ABA is called real-time Telehealth or synchronous telemedicine.  This means that the health care provider and the patient are speaking and interacting in real time via audio or video communication.  Here are some examples of how real-time Telehealth might be used:

• The direct therapist is assigned to a minimum number of homes and takes precautionary measures to keep him/herself and the family low-risk.  Therapy proceeds as usual, with the BCBA observing sessions, taking data, making protocol modifications, and giving feedback through the use of a Telehealth platform. 
  
• In cases where direct therapy is not able to occur, another option could be an increase in parent education hours.  Some families might be prepared to continue the programming formerly implemented by the direct therapist, and some families will not be.  BCBAs can re-assess needs and design a parent-training program that meets the needs of the client within the constraints of the current family circumstances, whatever those may be.  This may mean changing goals, shifting priorities, and introducing different methods of managing behavior.    
  
• In some cases, direct therapy through Telehealth may be clinically appropriate.  Individuals who are able to readily attend and communicate with a therapist without physical redirection and who don’t require in-person reinforcement delivery may be able to make progress through Telehealth.  The feasibility of this would be determined by the BCBA.     

Are there privacy concerns? 

You have the right to expect your health care providers to protect your privacy no matter what modality your services are provided through.  There are many different types of Telehealth software specifically designed to be HIPAA compliant.  As with any healthcare service you receive, if you have privacy concerns, discuss them with your provider.  And always remember that whether or not you consent to services is entirely your decision. 

What should I expect?  How do I prepare?

The following are helpful in preparing to receive Telehealth services:  

• A strong Wi-Fi connection in your home
• A physical arrangement that minimizes disruptions and keeps other ambient noise to a minimum 
• A device that can be set up to properly view the therapy surroundings and the entire session (for observations and supervision) and moved to an area for 1:1 discussion, out of earshot of the client (for parent or therapist private discussion with the provider)
• Proper audio on your device.  Consider a mix of using device audio and headphones.  When a provider is observing the session, the device audio will capture all of the interactions going on.  When your child is taking a break and you and the provider need to speak, it may be best to use headphones for better sound quality and to reduce background noise. 
• Any other typical items you use during therapy: note-taking materials, etc.   

As with any type of therapy, it’s important to have excellent communication with your providers to share how the model is working for you.   A continuous open dialogue with your provider about your experience allows them to troubleshoot with you, ultimately making sure that this is an effective way for your family to receive ABA services.   

Continuity of services is important for both your child and your family, especially during this time of general disruption in routine.  Not only does this provide consistency in routine, it gives your child the opportunity to engage with others and to continue developing skills, and will ultimately support their adjustment back into a normal routine once this situation resolves. 

By Katherine Johnson, BCBA

The sudden disruption in routine due to COVID-19 is challenging for all individuals to manage as we adjust to a new, and hopefully short-lived, normal of staying at home and ceasing most of our regular activities. For families of individuals with autism and other disabilities, the disruption can be especially challenging.

Although families deal with planned schedule changes or transitions, such as school vacations and summer breaks every year, what we are currently experiencing is different. This is a sudden disruption to our everyday routines with the added pressure of trying to create a viable learning environment to accommodate home schooling or online learning as schools try to complete the year in a virtual environment.

This sudden disruption means that both teachers and parents have not had adequate time to prepare for distance learning and that children have unexpectedly been pulled out of school. Children rely on set classroom schedules and routines and seeing the same friends and teachers every day. Now add into the mix the cessation of center-based services, therapeutic interventions, and possibly in-home visits being limited or put on hold to help minimize the spread of Coronavirus (COVID-19) across the United States. This will likely cause confusion and uncertainty for many. Easing anxiety, setting up activities, and staying busy during these unexpected and possibly challenging times can help with this change.

Being transparent about the situation:

Easing any anxiety your child may be experiencing, due to the changes in schedules and routines, is the first step to settling in to a “new” temporary schedule. Children will perceive the added stress and anxiety in the environment and so it’s important to explain to your child what is happening in their world. Keep it simple with basic information and present the facts at the level appropriate for your child’s age and ability to absorb this type of information.  Even though you may be concerned yourself, it is important to model calmness when talking about the virus. Children pick up on your social cues and how you respond to new things. If they have questions, answer them. Don’t be afraid to talk about it. Remind them that they are safe. And, remind them that this will end and they will return to school and to their favorite activities.

There are a variety of websites with information on how to talk to your child about the coronavirus. This website offers a social story about the change in schedule due to the Coronavirus as well as a printable PDF.

An increase in sensory needs, anxiety and meltdowns:

Individuals with Autism Spectrum Disorder generally have increased sensory needs and it is likely that those needs will not be met during this challenging time. Expect to see an increase in anxiety, depression and perhaps OCD. Additionally, since autistic individuals frequently have trouble communicating verbally, often the only sign that your child is experiencing anxiety is through external expressions such as meltdowns and increased self-stimulatory behaviors. It is likely that you may see new behaviors in which your child may not have engaged in previously.

It is important to provide the space for your child to express his concerns. Russell Lehmann, motivational speaker and author reminds us that outbursts and meltdowns are the expression of inner pain, overwhelm, confusion, stress and anxiety. Simply, be present with your child and listen more than you talk. Validation of their experience and a safe space to release their emotions is important in helping to move through it. Helping children take long deep breaths throughout the day will calm the nervous system (both yours and theirs) and help to mitigate the build-up of stress and emotion.

Establishing routines:

It helps to create a routine at home that provides consistency and predictability. If your child does better with visual schedules, there are great resources available to you on the internet that can help you create your own daily written or visual schedules. We tend to take for granted that we know what is coming based on the time of day (12 means lunch is near), but many of our children can’t associate time of day with certain activities. Creating a schedule will help allow them to see what’s coming next throughout their day and may help to lessen some challenging behaviors that may emerge due to their lack of routine.

If this feels overwhelming, try creating mini-routines for different parts of the day; a waking routine, a morning play routine, a “schooltime” or learning routine,  a lunch routine etc. This is also a great opportunity to create and teach hygiene routines such as handwashing.

If you are receiving in-home ABA, seek help and advice from your BCBA to assist you in developing a daily schedule that will help meet your family’s needs. There are also greater resources available, via Telehealth, to receive parent training from your BCBA.

Staying busy, especially during your child’s typical school, daycare or ABA-service hours is the next step. The solidarity of many world-wide educational and additional sites offering free online resources is remarkable during this time of uncertainty. Educational sites, as well as museums, zoos, and even Disney are offering virtual treats for children of all ages. There are free options for temporary internet service if your family needs it. This is also a time to connect with your children in new ways- cooking or baking, playing cards and boardgames, taking a walk, making up games, and learning life skills. Alternate your schedule between electronic activities, written work, crafts or projects and playing inside or outside when available. Use transition warnings (timers, first/then statements and choices) whenever possible throughout the day to help navigate and manage their new schedules.

Remain calm, set up a new daily routine and stay busy. And remember that patience, not perfection, is the key. Know that this is going to be hard- taking it moment to moment makes it more manageable. These tips should help minimize the effects of these sudden and unexpected events on your child and your family. Stay safe and healthy.

By: Ronit Molko, Ph.D., BCBA-D and Sally Burke, M.S. Ed., BCBA

As we’ve mentioned before, communication, in general, is complex. So, for a child with Autism Spectrum Disorder (ASD), any improvements in social skills will mean improvements in other related areas, such as communication.

For example, in communicating, the child needs to be approachable—and understand what that entails—then needs to understand when it’s his or her cue to speak or communicate.

Conversely, if the child wants to communicate something, he or she needs to learn how and when to approach others to initiate the conversation.

So, if you can work on practicing social skills at home, you will be way ahead of the game so-to-speak for advancing in communication skills as well.

There are lots of games and activities you can do at home to work on a child’s social skills, and you can have some fun with them. Obviously, which exercises you choose to try will be a function of the child’s age, interests, and where he or she is on the spectrum. But here are a few suggestions.

Role Play:

1. You can spell out an open-ended situation, such as “What do we do when the doorbell rings?” or “What do we do if we’re lost?” And then play through different scenarios because there are probably several right answers.
2. You could write down several different situations on pieces of paper and draw them out of a jar at random.
3. Set up a concrete situation like the child wanting to buy something that costs $1.99. One person can be the storekeeper and one can be the buyer. Then exchange roles.
4. Please note that all children can benefit from these types of role playing games, not just children with Autism Spectrum Disorder (ASD).

Play Cards:

There are hundreds of card games available from the simplest to the most sophisticated and plenty of books devoted to the subject. All require someone to understand when it is their turn to play and when they must sit back and allow someone else to play. Players also have to learn how to act if they don’t want others to know what’s in their hand and bluffing!

This is useful because card playing can involve just two persons or as many as four or even six. In four-handed games, a savvy adult can easily play two hands.

Easy games include War, Concentration (trying to make matching pairs with all the cards face down), and Go Fish.

Slightly harder games include straight 10-card Gin, Whist (a precursor to bridge for four players), and 5-card draw poker.

If your kids are card sharks, then try Texas Hold’em, a variety of poker, or Canasta. You can make card playing more interesting once the child or children understand the games by playing for (fake) money: pennies or popsicle sticks or marbles or chips or chits you make yourself during your craft time.

Card playing also teaches skills like matching like things (pairs), counting (which card has a higher value), and can be a lifelong hobby. Another benefit is that cards are very portable, so you can take your games and activities with you anywhere, and you don’t have to be a great conversationalist to play cards if you master the social skills involved.

Hint: You could also try introducing Mahjong, which is similar to the card game Gin, except you play with tiles, and it’s always four-handed.

The Smell or Taste Game

Try blindfolding your child—if he or she is amenable to it—and having them do some blind smell or taste tests.

Peel and cut up several different types of apples and ask the child to rate them and try to identify them—when it’s his or her turn.

Have them smell some common herbs or spices from your cupboard, and again, try to describe them or rate them or identify them with pictures or words or numbers when it’s his or her turn.

All of these exercises teach a child to watch for cues that it’s his or her turn and how to initiate his or her turn to play or speak. You can all have a lot of fun, and there’s nothing expensive about any of these suggestions.

The holidays are as joyful as they are stressful, or is it the other way around?

The stress of the holidays, visiting family members, and all that comes with the season can be a lot to deal with under any circumstances.  When caring for a loved one with autism or other developmental challenges, this time of year can feel overwhelming as it creates disruption to the routines and structure of your family’s life.

Here are some helpful strategies to lessen your child’s anxiety and increase your family’s enjoyment of the holiday season:

Shopping:

Holiday shopping, and especially last minute trips to huge department stores, can be over stimulating and stressful for individuals who cannot tolerate too many sounds, bright lights or large groups of people.  If you do take your child shopping with you, allow enough time to gradually adapt to the intense holiday stimuli that stores exhibit at this time of year. Planning multiple short shopping trips is a good idea, and be prepared to leave before you have completed your list if your child can no longer tolerate the environment.

Decorating:

Individuals with autism typically struggle with changes to their environments. Keeping this in mind, decorate your home in gradual stages, rather than changing everything at once. Include your child by having him interact with the decorations and do some of the decorating himself. Some children may be disturbed by decorations with flashing lights and music. Allow your child to experience these in a store or in a quiet place first to determine if he can tolerate them, and how many.

Family Routines:

Maintaining your typical family routines as much as possible during the holiday season will result in fewer behavioral disruptions and less anxiety for the family as a whole. This is often tough to do with travel, visitors in your home, and long family gatherings. If your child can predict and understand what is going to happen, he will manage the celebration far better. Writing a story or using some visual supports (photos, drawings) to show how the day will unfold will allow him to practice some social behaviors. A visual schedule will also give you a tool to use for reference during the day, reminding him what is going to happen next (when he will get to open toys etc). This type of system creates independence and structure within a typically more unstructured setting.

Gifts:

Gifts are tempting to all of us.  Create opportunities to teach (and remind) that gifts will be opened during specific times during the family ritual of getting together. For families celebrating a holiday such a Hanukkah, where children may receive gifts on multiple nights, try using a visual schedule to show your child which nights he will get to open a gift and which nights he will not. We suggest waiting until just before the holiday to put gifts out to reduce the temptation for opening them. You can also practice a family ritual of taking turns opening gifts so your child learns to wait his turn and learns to predict when it is his turn to open a gift.

Your child may not be inclined to share their toy or may immediately want to play with another child’s toy. This can cause disruption and chaos so plan ahead, perhaps selecting one toy to be shared while the others are set aside or bring another new toy with you to share with the other children.

Make it Your Own:

It is important to identify what the meaning of the holiday is for you and your family and how you want to honor that- your special ritual, celebration, event. Once you have identified what that looks like, you can begin practicing ahead of time with your child and your family and extended family members what you and your child will need to make that event successful. We hope that some of the tips we have provided will help you and your family experience a peaceful, joyful and meaningful holiday season.