Distance Supervision of ABA Programs
Supervising Applied Behavior Analysis (ABA) in-home programs from a distance presents unique challenges for supervisors and therapists. It’s easy to lose the personal connection when the supervisor is not physically present to provide face-to-face contact. Since parents rarely see the supervisor, they may not be aware of what is going on behind-the-scenes to keep the program functioning. Insurance companies, who know little about Behavior Analysis, know even less about Distance Supervision of ABA programs. From their perspective, “applying behavior analysis” means a Behavior Analyst is sitting at the table working directly with the child..
Despite the challenges, “remote” or “distance supervision” will become a necessity as more states pass mandated insurance coverage for children with autism. Most Board Certified Behavior Analysts (BCBAs) reside in highly populated urban regions, leaving many under-served geographical regions and even under-served states. There will be a high demand for services in these areas, since ABA therapy is written into the mandate in many states. When supervising therapists in another region (or state), program development and analysis is critical, but many insurance companies will not allow billing for these activities.
Three Tier Consulting, Inc. has been providing “remote supervision” for clients in underserved regions for the past two years. Our system uses relatively inexpensive distance technology to stay connected with the therapists, supervise treatment sessions in “real time” and assess client progress.
Hardware & Software
Every supervised program has a digital video camera to record each session. We use the JVC Everio MS 120, and they work perfectly for the purpose. There are newer, more expensive video cameras out there now, but second hand MS120’s may now be purchased on Ebay for about $100. This camera allows a low-enough resolution to permit 10 hours of video on a single 8 GB SD card (many of the newer cameras only allow higher-resolution, more memory demanding video). Since most of my programs run 10 hours per week (after school), the therapists send the video cards once per week.
The therapist records sessions for two purposes: The most important reason is that it allows relatively speedy review of sessions. By fast forwarding through potty breaks, snacks, and smoothly run programs, supervisors can review 10 hours of video in about 2 hours. The second reason is accountability. Often behavioral issues arise unexpectedly. Having a recording of incidents allows for later review of the sessions to identify antecedent issues.
The second piece of equipment used in the program is a netbook computer with internet access. Most families have wireless internet in their homes and if they don’t, we provide a router and set up wireless access. The Acer Aspire One netbook computer costs about $250 at Wal-Mart. Some insurance companies require supervision to occur “live” during the
session. Skype is free video conferencing software that allows live supervision. Additionally, therapists must meet with the supervisor online via Skype once per week to discuss observations and problem-solve session issues. The new business version of Skype allows conference calling so multiple therapists may join the consultation simultaneously from different locations.
The final piece of equipment used is a scanner. Therapists scan the data sheets from the program once a week so the supervisor may analyze and discuss program progress during the weekly consultation. Scanned datasheets are converted to PDF using free conversion software (Primo PDF). These datasheets are uploaded to a cloud-based storage system. Our company uses Dropbox as the cloud storage service. It is relatively inexpensive ($100.00/year for 50 gigabits of storage). The therapists can set up a Dropbox account for free (with two gigabytes of storage). For text documents and a small number of scanned documents, two gigabytes is sufficient. One problem with Dropbox is that it is not Health Insurance Portability and Accountability Act (HIPPA) compliant. To ensure the safety and confidentiality of client documents, no identifying information is included on the data sheets. Additionally, all files are encrypted in the Dropbox folder. These two actions ensure client confidentiality even though Dropbox itself is not HIPAA-compliant storage.
Evaluation & Program Review
Program evaluations are completed upon intake and updated every six months for all clients. The assessment tools vary, depending on the level of the child. Most of the children in our program are between the ages of three and seven. Therefore, we frequently use two early childhood assessments: The “Assessment, Evaluation, and Programming System for Infants and Children” (AEPSi) and the “Verbal Behavior Milestones, Planning, and Placement” (VB-MAPP). The AEPSi is a broad assessment that measures children’s progress in six key developmental areas: fine motor, gross motor, cognitive, adaptive, social-communication, and social. Data is collected and stored via a HIPAA compliant subscription service. The VB-MAPP is based on B.F. Skinner’s model of Verbal Behavior and is focused on skill areas which are frequently challenging for children with autism and developmental disabilities. While the VB-MAPP is not an online assessment, protocols and downloadable datasheets are available at the AVB Press Website.
In addition to the formal assessment tools, a structured parent interview is conducted to determine behavioral issues that interfere with interactions with the family and peers. Once behavioral challenges are determined, the behaviors are rated using the Motivation Assessment Scale (MAS), the Problem Behavior Questionnaire (PBQ), or Questions About Behavior Function (QABF), to develop a hypothesis about the reason the behavior occurs and to create a Positive Behavior Support Plan.
Benchmarking programs for higher functioning children with Asperger Syndrome and Pervasive Developmental Disorders-Not Otherwise Specified is a bit more difficult. Many of the challenges encountered by these clients are related to social issues. Components of the AEPSi and VB-MAPP provide some evaluation of this area, but we supplement the assessment of these clients with the Social Skills Rating System (SSRS); a detailed assessment of social domains benchmarked on typically-developing children. Another useful tool is the sociogram, which identifies the degree of social integration or isolation the child experiences in the school environment. Finally, direct observation of the client in social contexts to track social initiations, conversations, imaginative play, and structured play provide valuable information in setting program goals. This component of distance supervision requires the Behavior Analyst to directly observe the client in person.
Weekly Program Review
Every week, we transfer the videos from the memory cards (SD cards) to a dedicated hard drive. Then the supervisor completes a review session of videos from the preceding week. Two forms are completed each supervision session. The first is a generic session observation form to take notes and record incidents that occur during the sessions. The form provides records of time (into the session), the behavior, the goal (from the treatment plan) and recommendations and ideas for the therapist. The second form documents “treatment fidelity” and provides detailed feedback regarding teaching procedures. Some insurance companies require documentation of supervision using their own forms. This is handled by transferring the relevant data from the two forms described above. For example, Health Net/Tricare North, requires the use of the BACB supervision form.
After two years of distance supervision, we have worked out many challenges of setting up and maintaining effective programs for children in remote locations. The initial investment for hardware, software, protocols and program materials is about one thousand dollars. Adequate supervision also has an up front cost, since more supervisor feedback and in-person interaction is required when programs first start. Once the programs are established, they require 10-12 hours per month of supervision time. For insurance sponsored programs, Behavior Analysts are often placed in a difficult position; many insurance companies will not authorize 10-12 hours of supervision per month. Additionally, some insurance companies will not authorize hours spent developing programs or reviewing program data and video. Although our supervisors end up contributing several unpaid hours each month, we have streamlined the process to provide effective supervision within insurance constraints.
For a complete summary of the process of setting up In Home ABA programs, see IN HOME ABA PROGRAMS.
For Military Families interested in receiving in home ABA services, see REMOTE DEMO SERVICES.