Activities and lessons in the program are designed so the parent can complete the program within 60 calendar days. Our telehealth ABA parent training curriculum consists of the following four components:
An onboarding meeting. A group onboarding meeting is first conducted to provide an overview of the program. The meeting is hosted by a clinical supervisor and includes a brief introduction to the protocol, as well as providing technological coaching to ensure that parents can successfully use the software and platforms required for the program.
Five self-paced online skill development lessons. All five lessons are created and hosted via an online learner management platform called (Teachable 2020) for parents to complete in their own time. The platform we chose is not critical for the instructional design, and alternatives such as Desire2Learn (2020) and Moodle (2020) would be functionally equivalent. Each lesson covers several topics on basic behavior-analytic principles, skill teaching, and behavior management techniques (see the online training lessons that follow for detail). Each lesson is further divided into several modules. At the end of each module, there is a brief knowledge check. The knowledge check includes three to five multiple-choice questions. There are guided activities throughout the module to help parents adapt the lesson content into techniques they can use at home. At the end of each online lesson, there is an activity in which parents are required to record themselves using one technique they learned in the lesson.
Five individual consultations with follow-up coaching. Upon completing each lesson, and demonstrating adequate proficiency on quizzes, parents meet with a Board Certified Behavior Analyst (BCBA) or a senior clinician to receive individual live consultation throughout the program. Each of the five separate consultation sessions lasts 45 min, and each consultation is structured in relation to one online lesson (see the individual consultation that follows for detail). During the last consultation meeting, parents receive a behavior intervention plan they can implement at home. Afterward, parents receive weekly check-ins from the treatment team for additional coaching.
Competency-based contingency. Parents are required to complete one online lesson before they can schedule a meeting with the treatment team. Before scheduling the first meeting, the treatment team verifies that the parent has completed the first online lesson, which also includes required activities. A workbook is provided to each family, and parents are required to use the workbook to finish those activities. Parents are also required to submit the video in which they recorded themselves implementing techniques learned during the online skill development lessons. Once the treatment team verifies that all those conditions have been met, they reach out to the family to schedule one online consultation meeting. After the meeting, parents need to complete the next online lesson, along with all the activities, before they can schedule the second consultation. This continues for the third, fourth, and fifth online lessons/consultations. Once parents finish all five lessons, the treatment team provides them with the behavior intervention plan, and they begin receiving weekly check-ins. Figure 1 provides a flowchart that describes this process.
Before onboarding, the treatment team first conducts a risk analysis to determine whether there are immediate risks caused by maladaptive behavior. Clients are assigned to one of four tiers based on the history and complexity of their maladaptive behaviors. Clients assigned to Tier 1 demonstrate minimum maladaptive behavior. For these clients, the treatment team develops a behavior intervention plan for one common problem behavior. The family receives one 30-min phone call or meeting per week during the follow-up coaching. Clients assigned to Tier 2 demonstrate some maladaptive behavior. Although these behaviors are more frequent, they do not pose immediate risks and can often be redirected. These families receive behavior plans for two or three maladaptive behaviors and receive two 30-min phone calls or meetings per week during the follow-up coaching. Clients assigned to Tier 3 demonstrate several maladaptive behaviors, and these behaviors are consistent across multiple settings. However, these behaviors do not pose immediate risks (e.g., no self-injurious behavior or severe property destruction). These families receive behavior plans for two maladaptive behaviors and receive two 30-min phone calls in two settings (e.g., in the home and in community outings). Clients assigned to Tier 4 demonstrate severe maladaptive behaviors that pose immediate risks. These families continue to receive in-home services or receive crisis management services.
Program overview and technological coaching
During the program overview, the clinical supervisor explains the structure of the program to the parent. The clinical supervisor briefly presents the content in each online lesson and explains the requirement of completing the online lesson and activities before scheduling individual consultations. The clinical supervisor also demonstrates how to use the online platform and provides examples of different types of activities in online lessons. The clinical supervisor then provides brief technological coaching on the online meeting software (e.g., Zoom, GoToMeeting). Specifically, the supervisor explains (a) how to find the link to join the meeting; (b) what material to prepare before the meeting; (c) how to configure the computer, the webcam, and the microphone in the meeting software; and (d) how to share files, videos, or the computer screen during the meeting. Finally, a workbook is given to the parent, along with a prerecorded video on the technological tutorial. The technological tutorial video covers the same content as in the coaching session on the online meeting software so parents can reference the video as needed throughout the curriculum.
Brief acceptance and commitment training (ACT) session
During the onboarding meeting, the clinical supervisor conducts a brief ACT session. The ACT session lasts about 30 min and is delivered to parents and caregivers in a group setting. For each activity, the clinician reads from a script to facilitate the guided group activity. These activities aim to increase parents’ present moment awareness, clarify their values, and promote value-driven behaviors. Table 1 summarizes the protocol used in the ACT session. The activities are adapted from the ACT toolkit organized by Ahles and Jenkins (2018). The page number to the right of the activity indicates where a detailed description and materials needed can be found within the toolkit. After these five activities, the clinician concludes the onboarding meeting. The ACT component in this model also includes a weekly text message, which will be discussed in the progress monitoring portion of the model.
Online Training Lessons
There are five self-paced online lessons in this program. Parents are required to complete these lessons in sequential order. Each lesson is further divided into different modules. At the end of each module, there is a brief knowledge check, each containing three to five multiple-choice and/or true-or-false questions. Throughout the module, there are various activities. Parents are required to use the workbook to write down their answers to these activities. See Figure 2 for an example. At the end of each lesson, there is one cumulative activity named “Do-It-Yourself,” where parents are required to record themselves using one technique they just learned in the lesson. Table 2 summarizes the contents covered in each lesson, along with the required activities. Note that the course content outlined there should be used as a reference, and clinicians should make case-by-case decisions as to whether the content is appropriate.
Preparing course material
When preparing course materials, clinicians need to pay attention to avoid using certain behavior-analytic terms, as they can be technical and confusing. For example, instead of using the term “Premack Principles,” clinicians can use “Grandma’s Rule.” Instead of using the term “prompt,” clinicians can use “give hints during teaching.” Instead of using the terms “tangible,” “escape,” “attention,” and “automatic” to describe the function of behavior, clinicians can use “behave to get something,” “behave to get away from something,” “behave to get attention,” and “behave because it just feels good.” See Figure 3 for examples of slides explaining functions of behavior.
The clinician should also prepare abundant examples and scenarios so parents can easily understand the course content. For example, Lesson 1 mentions that the same behavior in different contexts could cause different outcomes, and people may define the same behavior differently. It then gives the following scenario:
For example, you are sitting in your car listening to music while you are stopped at a traffic light. If the traffic light is red, everyone behind you will wait patiently because you’re following the law. If the traffic light is green, people behind you will get mad and honk their horns, and you might just cause a small traffic jam. As you can see, although it is the same behavior, under different circumstances, people respond to it differently. From your perspective, you didn’t notice the light change because you got carried away by the music. You were just not paying attention to the traffic light. The person behind you, however, who just woke up 10 minutes ago, rushing to work because he’s about to be late, thought you did that because you were looking at your phone. He becomes really angry since he’s already shown up late 2 days in a row. You can see how easy it is for different perspectives to lead to different accounts of the same behavior. This is why defining behavior is really important, so we can be on the same page and know what everyone else is talking about.
When demonstrating specific techniques (e.g., redirection, prompting), clinicians can prepare videos to model the skill. For example, Lesson 4 discusses various prompting techniques that parents can use during teaching. After providing the definition and examples for each type of prompt, a video is shown to the parent where a clinician models how to deliver the prompt. Clinicians can also use a longer video to demonstrate a complex behavioral principle. For example, when the clinician teaches how to conduct structured teaching, parents were educated on the following three areas: how to set up the environment, how to deliver the discriminative stimulus, and how to deliver the reinforcer. Although this seems intimidating, the clinician can first present a video that contains all of these components and ask parents to watch the entire video before diving into those three areas. As the clinician explains what parents need to do in each area, the clinician can re-present clips from the same video, pausing and highlighting how the video is in line with the course content they just went through.
Besides preparing examples and video modeling, the clinician should also prepare abundant visual aids to increase user-friendliness and to help highlight important information. For example, clinicians can present different pictures of completed activity schedules and token boards in Lessons 2 and 3.
Format and delivery
Once the course content is finalized and the material has been prepared, the clinician can begin assembling the online lesson in its final form. The following steps are suggested as the optimal workflow:
Prepare the text content. The first step is to prepare the text to be displayed on each page. Because the deliverable also serves as a handout that parents can refer to, these texts should be complete sentences, rather than bullet points. When preparing the content, also consider how the page is divided. Be concise, and limit the text to no more than 150 words per page.
Develop the layout using Microsoft PowerPoint. Once the text content is ready, start putting materials together using Microsoft PowerPoint. First, select a layout that is appropriate for the content. Then, copy and paste the text onto the slide and insert the picture prepared earlier. Use the “Design Ideas” function in PowerPoint to browse automatically generated layouts. Make changes as necessary. The font size for each page’s title should range between 28 and 32. The font size for the content should range between 18 and 22. See Figure 4 for examples of finished PowerPoint slides.
Prepare the voice-over script. Once the slide is ready, begin preparing the script for the voice-over narrative. This is the script that you will read out loud as you guide parents through the online lesson. This script should be very similar to the content on the slide to avoid confusion. You can add a few sentences to smooth the transition between slides. However, all important information should appear in writing on the slide.
Record audio files. Once the voice-over script is ready, begin recording the audio file. Place the microphone in front of your chin. Record one file for each slide of the presentation. Once you hit the record button, wait for 3 s before beginning to speak. Read out the voice-over script with an appropriate volume and speed. Once you finish reading the script, wait for 3 s before stopping the recording. Name the file appropriately to avoid confusion.
Combine the PowerPoint slides with the audio recordings. Before combining the files, first export all PowerPoint slides as JPEG pictures. Open the PowerPoint file with Microsoft PowerPoint, select “File,” and then “Export.” Change the file format to JPEG. Make sure the box before “Save Every Slide” is checked. Type 1600 in the box after “Height.” Navigate to the location where you want the file to be stored, and click “Export.” Use the video editing software of your choice to combine the picture and the audio. For example, if you are using the Photos app on your PC, first launch the app and select the “Video Editor” tab at the top. Click “New video project,” and type in the name for the file (e.g., L1S1 for Lesson 1, Slide 1). Click OK to continue. Click the “+ Add” button, and select “From this PC.” Select the picture of the slide, and click “Open.” Locate the corresponding audio file, and write down how long the audio lasts. Right-click on the picture in the storyboard, and select “Duration.” Change the duration to match the length of the audio. Click “Change” to save the setting. Click “Custom audio” at the upper right-hand corner, and select “Add audio file.” Select the corresponding audio recording, and click “Open.” Click on the audio file you just added, and move the orange-colored bar on the screen so you cut out the 3-s blank recording at the beginning and the end. You can click the triangle-shaped button to test whether the audio is working properly. Once you are done, click “Done.” Click “Finish video” in the upper right-hand corner, and select “High” for the video quality. Click “Export,” and select the location where you want the file to be saved. Click “Export,” and the computer will begin rendering the video. Once the system finishes processing, you will see the file in that location. Repeat the previous steps until all pictures and audio files are combined. Other software that can be used includes Adobe Premiere, iMovie, and Final Cut Pro. Please keep in mind that these steps were performed using PowerPoint version 16.37. Older/newer versions of any of this software will likely have minor discrepancies to the steps we outlined previously.
Upload course content as videos to the online platform. Once all the videos are ready, upload the video to your online platform (e.g., Moodle, Teachable, Blackboard). Depending on the platform, you may enable settings such as requiring parents to watch the entire video before they can move on to the next webpage, requiring the online lessons to be completed in sequential order, logging their progress by showing you what content they have gone through, and logging their percentage of correct responding during knowledge checks. In the example of the current study, a navigation panel is presented to the left of the screen so parents can keep track of their progress. There are four types of webpages: the lecture slide, activities, module knowledge checks, and the Do-It-Yourself. On the lecture slide webpage, parents are required to finish watching the video before they can move on to the next part. If they log out before completing the lesson, they will be taken back to where they left off the next time they log in. They can pause and resume the video anytime they want. On the activity webpages, parents are required to pause the video and use the provided workbook to write down their answers. For example, an activity might ask parents to identify potential functions of the behavior in the given scenario. Parents then write down their answers in the blank box. A knowledge check webpage appears at the end of each module. During these checks, multiple-choice and/or true-or-false questions appear one at a time on the screen, and parents are required to complete them before moving on to the next module. Parents receive corrective feedback if they answer the question wrong. A Do-It-Yourself webpage appears at the end of each lesson. The page contains specific instructions for parents to record themselves using one technique covered in the lesson. After completing this activity, parents contact the treatment team and schedule their individual consultations. Figure 5 provides one example for each of these webpages.
As mentioned earlier in the competency-based contingency section, once parents finish one online lesson and complete the required activity, they contact the treatment team and schedule one individual consultation. Each consultation lasts 45 min, and the clinician follows a semistructured checklist to conduct these meetings.
All consultations are conducted via online meeting software (e.g., Zoom, GoToMeeting, Skype). Before each meeting, the clinician reviews parents’ progress on the online lessons. If parents make mistakes during the knowledge check, that topic will be discussed in greater detail. Each session begins with a brief review of the online lesson content. The clinician asks parents to share their activity answers, and can clarify any misunderstandings. The clinician also discusses parents’ behavioral concerns in relation to the material in the online lessons. For example, the parent learns about the definition of behavior and its potential functions. During the discussion, the clinician asks the parent to describe the child’s maladaptive behavior. If the parent gives a subjective description, the clinician re-presents the course content and guides the parent to develop a definition that is objective. The clinician also discusses the potential functions of behavior with the parent. This serves two purposes. On the one hand, parents deepen their understanding of the course content. On the other hand, it informs the clinician of potential intervention plans. As parents progress through the program, the content of each consultation changes accordingly. Table 3 presents an outline of how behavioral concerns are discussed in relation to the course content.
Note that Table 3 should be used as a reference. If parents have specific behavioral concerns or if the maladaptive behavior is complex, the clinician should focus more on coaching parents as to how to use specific techniques to address those concerns. The clinician uses a checklist during each consultation. See Figure 6 for an example.
Behavior management plan and coaching
During the fifth consultation, the clinician presents a behavior management plan that parents can use in their homes. The focus of the plan will vary depending on the complexity and severity of the maladaptive behavior, as outlined previously in the risk analysis section. These behavior plans should be brief and use non-behavior-analytic terms. Clinicians should prioritize techniques parents already learned throughout the program. The clinician explains the behavior management plan to parents and provides video modeling. After the fifth meeting, parents receive weekly coaching from the clinician. During these coaching sessions, the clinician follows up on the child’s progress, answers parents’ questions, and makes modifications to the behavior management plan.
Weekly ACT message
Parents receive weekly text messages from the clinic. Besides reminding them to continue the online lesson, the message also briefly describes an ACT activity. These messages aim to increase parents’ present moment awareness and promote value-driven behavior. For example, the text message could read as follows:
Hi, this is [name of the agency]. Just a reminder that once you’ve finished the next online lesson, you can reach out to us to schedule your individual consultation. Additionally, enjoy some mindful moments this weekend! When we think of being mindful, we may think of sitting in a calm, quiet room with no distractions, but that’s not always how life is! Sometimes you are in a big crowd or a loud place and may feel the need to slow down and find your way back to the present moment. Throughout the week, when things get busy or hectic, try to focus on the present moment by taking a few deep breaths and focusing on what is going on around you.
Because all sessions are conducted remotely, and parents may meet with different clinicians due to scheduling conflicts, a detailed session note is of great importance. On the session note, clinicians provide detailed descriptions of what content was covered in the meeting and what examples were used to elaborate on behavioral principles. Clinicians also take note of specific questions raised by parents and document the answer they provided during the session. Clinicians also write down items that need to be followed up with parents in the next session. This information can help the clinical team maintain consistency across sessions. Different clinicians can use the same example to explain different behavioral principles. This will also increase rapport with parents, as they would not need to repeat similar information to different clinicians. Figure 7 provides an example of the session note template.
Briefing, debriefing, and supervision
In the 60-day telehealth ABA parent training curriculum described in this example, most clinicians are senior master’s-level graduate students enrolled in the Behavior Analysis and Therapy Program. The credential and level of competency needed for clinicians providing consultations should be individualized depending on the depth and complexity of the case. Each family is assigned one case manager and can meet with any member of the treatment team based on availability. Before each meeting, the clinician is required to review all previous session notes and attend a 10-min briefing with the case manager. The case manager reviews the family’s information and provides specific directions on what the clinician needs to focus on in the meeting. After the meeting, the clinician is required to debrief the case manager on what happened during the meeting. The case manager is in charge of developing the behavior management plan under the supervision of a BCBA. The BCBA holds a weekly group supervision meeting and also meets with case managers individually as needed.
Advice on service delivery via telehealth is increasingly prevalent during the current pandemic (CASP, 2020; Rodriguez, 2020). As a science rooted in objective measurable outcomes, it is critical that the advice we give is also effective in producing the outcomes we are expecting. Furthermore, the rise of ACT-related additions (Murrell & Scherbarth, 2006; Pahnke, Lundgren, Hursti, & Hirvikoski, 2014) to the typical behavioral training approaches for employees (Bethay, Wilson, Schnetzer, Nassar, & Bordieri, 2013), clients (Enoch & Dixon, 2017, 2019), and parents (Blackledge & Hayes, 2006; Poddar, Sinha, & Urbi, 2015) necessitates even more proof of concept before inferring such material is warranted for inclusion in enhancing telehealth outcomes.
The previous content details the model of our telehealth ABA parent training curriculum. It includes five self-paced online lessons and details individual consultations parents receive as they move through the program. The content structure covers the majority of behavioral principles and techniques parents need in order to set up the home for the child’s success. The individual consultations complement the online lessons. They deepen parents’ understanding of the course content and allow behavior analysts to have a detailed discussion on parents’ concerns. The brief ACT session during the onboarding meeting, along with the weekly ACT messages, frequently reorients parents to the present moment and enhances parental adherence. Detailed examples are provided so practitioners can replicate this model. Study 2 presents the preliminary data that support the effectiveness of this model. Limitations and suggestions for improvement are also discussed.