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Preliminary Findings in a Randomized Clinical Trial of a
Virtual Training Program for Parents of a Child with Autism Kevin C. Luczynski, Ph.D., BCBA-D University of Nebraska Medical Center’s Munroe-Meyer Institute Center for Autism Spectrum Disorders Co-authors: Wayne W. Fisher, Andrew Blowers, Stephanie A. Hood, Aaron D. Lesser, Mychal A. Machado, Maegan Pisman, & Megan E. Vosters Funding Source: Grant Number AR from the Autism Research Program, which is a component of the Congressionally Directed Medical Research Programs within the Department of Defense Good Morning…..
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Wayne Fisher, Ph.D. Kevin Luczynski, Ph.D. Stephanie Hood, Ph.D.
Aaron Lesser, Ph.D. Cathleen Piazza, Ph.D. Mychal Machado Ph.D. The parent-training program that I am discussing today was informed by the vision of Dr. Wayne Fisher, was supported by Dr. Cathleen Piazza, and was the result of notable efforts of two cohorts of dedicated, talented doctoral students. One of them Maegan Pisman and she is here today, who in addition to training some of the parents, has the important role of organizing the recruitment process. Maegan Pisman, M.S. Andrew Blowers, M.S. Megan Vosters, M.S.
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*******This symposium existsbecause of important advances in video and audio communication technologies over the last 5 to 10 years.
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Laptops are more affordable than ever and they are sufficiently powerful to continuously transmit quality video and audio ….. while …… simultaneously running other software, for instance, a screen recorder to capture live video being displayed on the computer screen.
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More families than ever have access to a broadband-internet connection.
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Wireless routers over the last 5 years can take full advantage of increased bandwidth and broadcast the wireless signal though out a family’s home, which allows the use of streaming, wireless video cameras that can record at a resolution with 1,080 pixels.
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And cloud storage is game changer, and the University of Nebraska Medical Center has business agreements with Box and Microsoft Onedrive that permits file-sharing between multiple individuals. Pictures or scanned copies of data-collection sheets, graphs, instructional protocols, and video recording of instructional periods can be organized easily, shared, and stored securely. *****Now, let’s make sure we have the right expectations….
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Dr. Deb Roy We are all not going to be able to follow the video-recording application done of Dr. Deb Roy from MIT.
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Before the birth of his son, he put high-resolution fisheye cameras in every room of his house, and recorded every vocal utterance his son emitted from birth to 3 years of age….including the surrounding context.
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Wireless Video Camera Webcam Bluetooth Earpiece Laptop
High-Definition Webcam Bluetooth Earpiece Laptop Nevertheless, we can serve families in important ways with simply……
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Dose of EIBI > 25 hr The desired intensity of EIBI services is high
The growth in the prevalence of Autism Spectrum Disorders has led to intense demand for effective early intensive behavioral intervention services (National Autism Center, 2009). There are at least 10 peer-reviewed studies that have reported clinically significant improvements in IQ following EIBI services, with the median IQ gain being about 20 points. Although the dose and type of EIBI programing varied across the studies, the main findings were that, ONE, the number of hours of treatment per week is significantly correlated with gains in IQ scores and, TWO, that the dose of services should be 25 or more hours.
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Dose of EIBI > 25 hr The desired intensity of EIBI services is high
Limited number of credentialed therapists relative to the need Although there is a growing a need for services delivered at a high intensity, there is also a shortage of therapists to meet that demand. This shortage is worse for families who reside in rural communities.
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Incorporate Parents in Treatment Services
One part of the solution is to…. In some cases, as the primary behavior-improvement agent, In other cases, to promote the transfer of skills taught by a credentialed behavior analyst across the day and settings.
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Clinic to Clinic Fiber Optic Network Clinic Near Parent
In-clinic Trained Assistants In terms of teaching parents effective assessment and treatment procedures for problem behavior, Dr. Wacker’s team has produced pioneering virtual care (telehealth) research.
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In 2013, 20 parents and 20 children took part in an large study that demonstrated the use of remote coaching to teach parents to accurately implement functional analysis methodology that lead to the identification of behavioral function. In a related study, parents were taught how to implement functional communication training with high accuracy and corresponding increases in the target communication response and decreases in problem behavior were shown.
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Clinic to Clinic Clinic to Home Virtual Private Network
Form1 Fiber Optic Network Clinic Near Parent In-clinic Trained Assistants Virtual Private Network Parent’s Home Only Remote Coaching
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One example of this application is Dr. Suess and colleagues publication. Parents were successfully taught, in the context of their home by a behavior analyst located remotely at a clinic, to implement functional communication training to address problem behavior.
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Clinic to Clinic Clinic to Home Clinic to Home Virtual Private Network
Form 1 Clinic to Home Form 2 Fiber Optic Network Clinic Near Parent In-clinic Trained Assistants Virtual Private Network Parent’s Home Only Remote Coaching Virtual Private Network Parent’s Home In-home Naive Assistants Who is instructed by the behavior analysts to engage in a variety of child responses that are representative of those a parent might encounter implementing the target skill in practice.
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Extended studies on virtual training programs by…
Method included a… Randomized-clinical trial Virtual-training program with a variety of EIBI procedures Extended studies on virtual training programs by… Evaluating the effects of the training using competency measures verified via direct observation Results indicated … Technicians implemented a variety of behavioral protocols with high procedural integrity Fisher et al. conducted a randomized-clinical trial to evaluate virtually training adults in a variety of behavior-management and skill-acquisition programs. The 40-hr virtual training program included e-Learning modules that were complimented by in-home role-plays with the adult and their adult friend who served as a confederate child. Results demonstrated that… these adults implemented academic-based and play-based teaching procedures with high procedural integrity.
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Inclusion Criteria At least 19 years of age
Child that met diagnostic criteria for ASD No prior training in ABA No prior coursework in behavior analysis No ongoing EIBI services Internet connection in the home We enrolled parents based on the following criteria. Next, I’m going to describe the steps in our evaluation.
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Parent-Training Evaluation
We enrolled parents in dyads. P 2
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Parent-Training Evaluation
Pre-Tests P 1 Next, we conducted the pre-tests. P 2
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Wireless Video Camera High-Definition Laptop Webcam Teaching
Stimuli Bluetooth Earpiece We sent parents a wide-angle a web camera (Logitech c525 or c615), Bluetooth headset (Plantronics Voyager Pro), wireless video camera, the materials needed for the pre-test, and a laptop if needed. ……. Via UPS.
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Parent’s Home
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Parent’s Home The parent was asked to recruit an adult friend.
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(encrypted connection)
Parent’s Home Expert in Clinic Research in Clinic Synchronous Instruction (encrypted connection) A researcher was live from the medical center with audio and video using software such as GotoMeeting.
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(encrypted connection)
Parent’s Home Expert in Clinic Research in Clinic Synchronous Instruction (encrypted connection) The adult friend wore a Bluetooth earpiece. The other audio connection involved the Bluetooth earpiece worn by the confederate, which allowed the behavior analyst to give verbal instructions to the confederate without the parent hearing.
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Parent-Training Evaluation
Pre-Tests P 1 Behavioral Implementation of Skills for Work Activities Touch Dog The first pre-test is called Behavioral Implementation Skills for Work Activities, and it is a direct-observation measure designed to assess the parent’s skill at implementing teaching procedures in a discrete-trial format. We provided the parent with a set of pictures of common objects and animals to teach the confederate receptive-identification skills. P 2
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Behavioral Implementation Skills for Work Activities
Trial 1 Trial 2 Trial 3 Trial 4 Trial 5 Trial 6 Trial 7 Trial 8 Trial 9 Trial 10 Trial 11 Trial 12 We instructed the confederate to respond to the technician in prescribed ways across 20 trials Trial 13 Trial 14 Trial 15 Trial 16 Trial 17 Trial 18 Trial 19 Trial 20
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Behavioral Implementation Skills for Work Activities
Correct Response Trial 1 Trial 2 Trial 3 Trial 4 Trial 5 Trial 6 Trial 7 Trial 8 Trial 9 Trial 10 Trial 11 Trial 12 A correct response occurred on 4 trials Trial 13 Trial 14 Trial 15 Trial 16 Trial 17 Trial 18 Trial 19 Trial 20
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Behavioral Implementation Skills for Work Activities
Correct Response No Response Incorrect Response Trial 1 Trial 2 Trial 3 Trial 4 Trial 5 Trial 6 Trial 7 Trial 8 Trial 9 Trial 10 Trial 11 Trial 12 A no response and incorrect response occurred on 3 trials a piece. Trial 13 Trial 14 Trial 15 Trial 16 Trial 17 Trial 18 Trial 19 Trial 20
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Behavioral Implementation Skills for Work Activities
Correct Response No Response Incorrect Response Problem Behavior Trial 1 Trial 2 Aggression Trial 3 Trial 4 Stereotypy Trial 5 Neg. Vocalization Trial 6 Trial 7 Echolalia Trial 8 Trial 9 Trial 10 Disruption Trial 11 Echolalia Trial 12 Five different topographies of problem behavior were programmed (2 instances of aggression, stereotypy, negative vocalizations, echolia, and disruptions). Although not depicted here, we also assessed how the caregiver would perform following additional errors within a trial (e.g., following an initial incorrect response, no response, and problem behavior, we programmed prompted incorrect and correct responses). The behavior analyst’s responsibility during these assessments was to promote high procedural fidelity on the part of the confederate child. Trial 13 Neg. Vocalization Trial 14 Trial 15 Disruption Trial 16 Trial 17 Trial 18 Aggression Trial 19 Trial 20 Stereotypy
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We randomly assigned 20 parents to either the technology-enhanced training group or the waitlist-control group, resulting in 10 technicians assigned to each group. We used two methods to analyze the parent’s performance on the BISWA and BISPA. The percentage-of-trials method was calculated by dividing the total number of trials with a correct response (e.g., an instance of delivering reinforcement following a correct response) with the total number of trials.
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Participants in the treatment group improved from an average of 15
Participants in the treatment group improved from an average of 15.3% during the pretest to an average score of 90.8% during the posttest, whereas caregivers in the control group showed no improvement from pretest (11.9%) to posttest (11.3%). For the BISWA (right panel)…
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The percentage-of-components-mastered method was calculated by, first, determining the number of mastered components (e.g., for the component of reinforcement delivery, was reinforcement delivered correctly on 90% of the opportunities in which a correct response occurred) and, second, dividing the total number of mastered components by the total number of components.
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Parent-Training Evaluation
Pre-Tests P 1 Behavioral Implementation of Skills for Work Activities Behavioral Implementation of Skills for Play Activities P 2
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Behavioral Implementation Skills for Play Activities
Joint Attention Initiates Conversation Functional Play Describes Emotions Initiates Play Problem Behavior Trial 1 Trial 2 Aggression Trial 3 Trial 4 Trial 5 Neg. Vocalization Trial 6 Stereotypy Trial 7 Trial 8 Echolalia Trial 9 Aggression Trial 10 Trial 11 Disruption Trial 12 In the same manner, we also assessed the parent’s skills during a play-based, naturalistic training context in which the goal was for the technician to increase the social and play behavior and decrease problem behavior. Trial 13 Trial 14 Trial 15 Echolalia Trial 16 Neg. Vocalization Trail 17 Stereotypy Trail 18 Trial 19 Disruption Trial 20
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Parent-Training Evaluation
Pre-Tests Group Assignment (randomization) P 1 Matched Control Once participants completed the BISWA and BISPA assessments, they were matched into pairs (based on how closely in time they completed the pretests) and then randomly assigned to either the test or control group. P 2 Test
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Technology – Enhanced Training
Parent-Training Evaluation Pre-Tests Group Assignment (randomization) Technology – Enhanced Training P 1 Matched Control Parents were assigned to the test group completed the technology-enhanced training curriculum immediately and participants in the control group were placed on a waitlist and did not receive training until their matched partner completed the training curriculum and both participants in the dyad completed the posttest. P 2 Test
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Parent-Training Evaluation
Module Number 1 2 3 4 5 6 7 8 The E-training curriculum consisted of 8 multi-media modules (each lasting about 40 to 70 min). The content of the modules was designed to provide an overview of a behavior-analytic framework of child behavior and instructional models of strategies through pictures, video, or both…
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Parent-Training Evaluation
Module Number 1 2 3 4 5 6 7 8 Technicians accessed each module and completed a quiz from the University of Nebraska Medical Center’s Blackboard, which is a content delivery service universities and colleges commonly use.
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Parent-Training Evaluation
Module Number 1 2 3 4 5 6 7 8 Ethics & Vulnerable Pop. Verbal Behavior Response Prompting Nat. Environmental Tx’g Compliance The modules included… Ethics, Least Restrictive Environment, and Vulnerable Populations…An Introduction to Verbal Behavior…Response Prompting…Natural Environmental Teaching…Compliance…Preventing Problem Behavior…Putting it Together I—which involved Integrating Structured Teaching Strategies, and…Putting it Together II—which involved Integrating Play-Based Training Strategies. We delivered modules to parents one at a time, and in sequence, because the parents had to answer 8 of 10 questions correctly on a multiple-choice quiz before gaining access to the next module. Preventing Problem Bx Putting it Together I Putting it Together II
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Parent-Training Evaluation
Module Number 1 2 3 4 5 6 7 8 Ethics & Vulnerable Pop. Verbal Behavior Response Prompting Nat. Environmental Tx’g Compliance Six of the modules, denoted by the orange bars, included in-home, scripted role-plays that the technicians completed after they finished the PowerPoint component of the module and passed the knowledge test. We scheduled the role-plays at times convenient to the parents schedule. The expert attempted to schedule role-plays during typical work hours, but many occurred late in the evening or on weekends. The expert, parent, and confederate child connected via the virtual-meeting link in a manner identical to the setup for the pretests described previously. Preventing Problem Bx Putting it Together I Putting it Together II
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And, on a personal note with a 7-month year old, I can understand how such flexibility is likely a preferred and important feature of the training program.
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(encrypted connection)
Parent’s Home Expert in Clinic Research in Clinic Synchronous Instruction & Feedback (encrypted connection) At the beginning of each role-play, parents were instructed to implement the target skills based on the teaching information provided in the module. As with the pretests, we identified a variety of behaviors for the confederate child to exhibit that were tailored for each module. Essentially, we used components of behavioral skills training (BST) during role-plays.
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Technology – Enhanced Training
Parent-Training Evaluation Pre-Tests Group Assignment (randomization) Technology – Enhanced Training Post-Test P 1 Matched Control After training had been completed by the parent in the test group, we conducted posttest assessments with both parents in the dyad using the same methods as described for the pretests. P 2 Test
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Parent’s Satisfaction with …
Web-Based Technology Parent’s Satisfaction with … In my opinion, as important as measures on effectiveness, is the extent to which parents found this training model to be socially acceptable. After the post-test was completed, parents were asked to provide ratings and narrative responses across several aspects of the training program.
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Web-Based Technology Parent’s Satisfaction with …
Accessing Virtual Meeting and Initiating Audio and Video Reliability of Audio & Video during Role-Plays Blackboard to Deliver e-Learning Modules and Quizzes
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Web-Based Technology Parent’s Satisfaction with …
Accessing Virtual Meeting and Initiating Audio and Video Reliability of Audio & Video during Role-Plays Blackboard to Deliver e-Learning Modules and Quizzes
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Web-Based Technology Parent’s Satisfaction with … Accessing Virtual Meeting and Initiating Audio and Video Reliability of Audio & Video during Role-Plays Blackboard to Deliver e-Learning Modules and Quizzes “Without question, dealing with Blackboard's poor design was the worst part of the training program.”
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E-Learning Content in Modules
Parent’s Satisfaction with … The Amount I Learned Design Quality & Organization of Modules Role-Plays as a Training Component Amount and Type of Content in e-Learning Modules
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Consultant (BCBA) Parent’s Satisfaction with …
Communications with Consultant Consultant’s Ability to Answer Questions Parti
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Scheduling Parent’s Satisfaction with …
Flexibility of Meeting and Role-plays Completing the Program at Preferred Pace
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The Overall Training Program
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Conclusion and Implications . . .
One of the first RCTs using web-based training of parents that includes competency measures No traveling, which saves time and money Training can be provided anywhere, given sufficient internet access This method of training could be adapted for other skill areas Future Research: Pyramidal training when spouse serves as confederate child (with parents). TRANSLATING Modules in to Italian and we are going to a cross-continent evaluation, for which we will be watching the providing real-time guidance to the Italian who will immediately translate what we said to the Italian parent. Exciting.
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Future Directions . . . Cross-continent evaluation of the virtual training program with parents, and include a stimulus generalization assessment with the parent’s child. Future Research: Pyramidal training when spouse serves as confederate child (with parents). TRANSLATING Modules in to Italian and we are going to a cross-continent evaluation, for which we will be watching the providing real-time guidance to the Italian who will immediately translate what we said to the Italian parent. Exciting.
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Our virtual training program, and others like it, are needed because there is a limited number of credentialed therapists to provide the recommended 25+ hr of EIBI services and many families in need of services are not located in areas for which service provision is practical or consistent. Thus…
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Future Directions . . . Cross-continent evaluation of the virtual training program with parents, and include a stimulus generalization assessment with the parent’s child. Train-the-trainer evaluation via a pyramidal model. Are the in-home scripted role-plays necessary to the effectiveness and social validity?
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