Introduction
OK. Hi, everyone. I think we’ll get started. We only have a short 30 minutes here, so we want to make sure that we’re taking advantage of our time. So I think we’ll just start by welcoming you all to our second Kitchen Conversation, put on here by Exceptional Lives. Last week we had Carrie Alvarado talking to us about occupational therapy. And today, we have Zack joining us to talk about ABA therapy and how this all works now that we’re doing this through TeleHealth.
So Zack is joining us from the St. Nicholas center in Louisiana, and we will hear more from him in a few minutes. He’ll introduce himself and talk a bit about his work and how they’ve transitioned over the last couple of months. So Zack, you have control here. So maybe you can move to the next– there we go. OK. So we’ll just take a few minutes, I’m just going to go over some housekeeping things before we get started.
So first of all, this session will be recorded. So we are just going to be sure that we have closed captions on the full presentation. And then as soon as that’s ready, we’ll be having it up on our website. So please check back through our website. Or if you don’t already follow us on social media, or subscribed to our newsletter, please do that and we will send out an alert just as soon as it’s up. And feel free to share that with your community.
During the– during this presentation, your audio will be muted. We do have quite a bit of people joining us, which is fantastic. So we just want to make sure that Zack has enough time to get through all of his content, and then we’ll have time at the end and to answer your questions. If we don’t get to your question, then please don’t worry. We are keeping track of them, and we will get back to you through email. And I believe Zack is also going to share his email with us, or with you, so that you can follow up if you need to get in touch.
So on that note, at the bottom of the menu there you’ll see a Q&A function. If everybody can pull up– just click on that Q&A function, and you’ll see a window pop up. And when you do that, go ahead and type in a question that you have that you would like to discuss at the end, or that you would like to have answered during the presentation. And we have a couple of our staff here that will help Zack to get all of those questions and be able to answer them.
So if you can type in your questions there, that would be fantastic. And then we also have the chat function, which you all have been introducing yourselves. Thank you for doing that. During the presentation, if there are comments or reflections, observations, anything that you’d like to mention, please feel free to use that chat and we can continue that conversation with each other. So OK, Zack, we can go to the next one here.
Just a word about Exceptional Lives. I did speak a bit about Exceptional Lives last week. So when that– when that is up on our site, you can check that out if you didn’t already see it. If you’re new to Exceptional Lives, we are a not-for-profit free online resource. So we provide information to providers and families of a child with a disability to help them find the information that they need in a way that’s easy to understand.
So we do that through guides that we’ve created, a searchable resource directory that is state specific in Louisiana and Massachusetts, and we also have blogs, and we’ve also created an at home resource over the last couple of months to support families that are doing all of this from home. So feel free to go check that out. And again, subscribe to our newsletter so we can send you updates as they happen.
And then– so this is my– one of my little guys. I have three children, all of whom are receiving different services at this time. And this is my middle guy, who has cerebral palsy. And I’m showing this picture because this was pre-pandemic, when we were climbing on ropes and jumping into ball pits at every chance we could.
So how does this transfer to an online forum, now that we’re doing TeleHealth and we can’t access these services that we’ve been accessing in centers, or where we’ve been traveling to? So we asked ourselves as we are– as we are walking this walk as parents, and then really heard from the families that are following Exceptional Lives and that we speak to. And the questions that we heard were how does this work. My child is never going to sit still for more than 30 seconds, so how can you do this on a computer?
And is this even something that’s offered for me at this time? I haven’t heard about it, and how do I get this going? So that’s why we created this series, and we are thrilled to have Zack with us here today and he has some great things to share with you. So I think we should just get started. You can just answer that poll here, and then when that is finished up we will just move over to Zack.
Presentation
All right, guys. So first off, I want to say thank you to Exceptional Lives for having me on today. I really appreciate the opportunity to get to share kind of our experience. Just to give you a little bit more information about myself, I’m currently working at St. Nicholas Center for Children, which is a pediatric therapy center in southwest Louisiana, Lake Charles. And we primarily work with children with autism [Louisiana Autism Guide/Massachusetts Autism Guide] and developmental delays.
We’re pretty unique in that we have occupational, speech, and applied behavior analysis therapy all in the same building. This kind of affords us the opportunity to get a collaborative approach, and kind of put together the best programs for each individual child. So it’s St. Nicholas Center, so we’re center-based. So when COVID came on, obviously, we had to kind of turn on a dime and do some things that we– wasn’t typical practice for us.
We had some school-based services, we have some center-based services. And we’ve done some in-home, but it’s always in-person. So TeleHealth was not something that we were experts at. And I’ll go ahead and say it now, we’re still not experts at it, but we’re adapting to it and we’ve learned some strategies. And I hope that you guys can take some of these things away and find them useful with– when you’re working from home.
One of the things we noted right off the bat is that a lot of our kids are what we call comprehensive cases, so they’re 35 to 40 hours per week in center. We wanted to try and approximate that, but clearly that’s a lot of hours. And we know families have a lot going on, many of you guys are still working from home. During the school year, you’re basically being the teacher in the home setting. So you’ve got all this on your plate.
So we knew we wouldn’t– we weren’t going to necessarily get close to that 30 to 40 hours that we were at, but we also didn’t want to see our kids regress. We wanted to make sure that our kids that we were serving were getting basically everything they needed and the priority goals done. One of the ways we looked at doing this was increasing our parent training.
So what we typically would do, and what our typical practice was, two to three hours per month we would basically do parent training. This was going to be insufficient now because we weren’t going to be able to have them work with the kids directly 35 to 40 hours. So looking at that, we knew that we were going to have to involve the parents more in what we call the line technician role in applied behavior analysis, which is working directly with the kids.
So we looked at having our parents go from two to three hours per month doing parent training, to now we’re looking at two to three hours per week. So was a big shift for us, and I’m sure our families– it was a big shift for them. And there was a mixed kind of reception to moving to TeleHealth. Some providers adapted to it quicker, or some BCBAs adapted to it quicker. Some parents were nervous. I mean, we were basically going into the home environment. And so it was a lot to get used to.
So with these new normals came new expectations. We knew, like I said, families were working from home. Many times they were filling the role of the teacher, and now we’re asking them to complete these ABA programs in the home setting. So it’s a lot. And with that we can’t have the same expectations, we’ve got to set some new expectations of what is best practice.
So today what we’re going to cover is how can we create schedules and make modifications to the environment to have really good clean cut ABA sessions with parents running them. And then what do those sessions need to look like kind of style. What are some considerations, and then how can we assess the barriers and fix those? And then what– you know, for us we found some silver lining that I’d like to share with you guys. So what is the value of the whole experience?
So one of the first things we did as a center was, when we knew we were closing or moving– or moving to TeleHealth, we looked at some take home folders. And within the take home folders, we would put together the behavior intervention plan and some data sheets. These were all modified so that the parents– you, as parents, could use them. So kind of a what are the priority goals, and then how to work on those. And then problematic behaviors, how do we do– how do we deal with those in the home setting?
So basically a home style behavior intervention plan, and home style data sheets. Once we had that in our family’s hands, then we looked at, OK, what are some specific windows of time for each family that we can actually run sessions. We found that many families were already doing some playtime with their kids, or maybe doing some teaching time with their kids.
And so instead of adding another additional thing, we would work out session times within the natural flow of their day. Trying not to add another stressor, just trying to maximize the teaching time that they are already doing. We found that to be more effective. Some of the things we’ve done is help them create a visual schedule. While this is helpful to the child, it’s also helpful to the family just to have some routine, and some predictability, and structure in their day.
Some kiddos are not quite on the level yet. They don’t have currently in the repertoire to follow a full visual schedule, and so we may look at creating some times within the sessions to do– to do breaks, or kind of breaking down the session to where it’s not one hour straight of teaching, or two hours straight of teaching. Many of our kids, as I’m sure you guys can relate to this, have issues delay– delaying reinforcement and being able to wait for rewards.
And so we use visual cues, token boards, break cards, and things like that within our sessions to kind of basically break up the work versus playtime. And so it becomes very predictable, and so there’s a nice routine there for our kids to learn from. So as an example of what a day might look like for one of our kids working with our families, many times we’ll set up a guided practice.
And what guided practices for us is a BCBA supervised session time. So when you’re looking at this 10:00 to 11:00 guided practice, that was a time when that family, particularly, already were doing some teaching and doing some play with their kids. So we just basically asked if we could do the session then and do the coaching while the natural teaching is already going on.
And what we like to do is set up some play time and some more fun activities directly after the session, so you’re kind of rewarding that working session with some more fun activities. So you see, like, you have guided practice, then you have lunch, you have independent practice, and then you have gross motor play, which might be going outside or doing something fun.
And in independent practice, oftentimes we utilize that time as when the BCBA would kind of step back or even not be present. So if they’ve been working on some skills and they just want to try it at home, and what that would be. They would work through the data sheets and teach, and then in the next guided practice session the BCBA would be present to kind of look at the data, and go over it, and work with the family on how everything’s progressing.
So we found that, you know, some guided sessions and some sessions where the parents are running it was kind of the best way to lay out the day. So having a nice structured schedule was a nice way to kind of get the flow going and kind of create a routine. If you notice, one thing to point out is, this is 10:00 to 2:00. We’re not trying to mimic the 8:00 to 5:00. So we’re not trying to do 30 to 40 hours of comprehensive care, we’re trying to focus on prioritizing treatment plan goals.
So what are the main things that I need? Do I need to focus on communication and problematic behavior reduction? Are those are the things that are more important? And so it’s 10:00 to 2:00. And there’s a lot of break times and more leisurely activities built in there. Families have a lot, so we’re not trying to overwhelm them. So what does a session look like?
At St. Nick’s, we found that two methods work pretty well. One is parent led with the BCBA as a coach. So you can kind of see the visuals there, but basically this is for our younger, more active kids. Maybe they’re developing communication or early learners, so they– you’re doing more play-based sessions. Maybe they don’t have within their repertoire currently the ability, because part of TeleHealth is being able to attend to a laptop, or an iPhone, or an iPad.
If that’s currently not in their repertoire, then the BCBA is not really able to lead this session via technology. So you’re going to have to have the parent lead it and the BCBA just do the coaching from an iPad. Typically, before we start these sessions, we ask the family to kind of see if there’s a room or a section of the house where we can structure the room to basically have a more productive session.
Many of the kids go more for this model are working on what we call manding, which is like requesting to get your needs met within your environment. So we ask parents to maybe put the highest preferred items, or what typically functions as a reinforcer, either up on the shelves or in some bins. So they’re visible, but maybe they have to go through the parent and practice communication to get to those items. So this is kind of one structure.
In this format, the BCBA may be, you know, basically propped up on an iPad or a laptop. And as the parent is running the mand trials, or running the tact trials, or whatever it may be, the BCBA is providing coaching and supervision. This looks much like a session would look in a clinic setting where a BCBA is providing feedback directly to a line technician, which is the people who typically work directly with kids.
In this model, the parents are extensions. So they’re providing the instructions and providing the consequences, and the BCBA is coaching. A second method we’ve looked at is BCBA led, and the parents are more facilitators in this role. Now, with this setup, you want to have a child that is basically– has learner readiness to attend to a screen for two to three minutes. OK?
So if you’re lucky enough to have that, then that would be the type of session where you could actually have the BCBA run the targets, and parent maybe provides the reinforcement or the prompting. The parents are observing, and the BCBA is modeling in this format. So one of the things in this format for the model is, basically the BCBA is training and demonstrating the program.
One of the things we found that really has been a super effective application of this is something called Boom Cards, and I’m going to demonstrate that for you guys here in a second. But with this, the BCBA can actually do the reinforcement through, like, a token system or something like that in some of the prompting through a screen. So it’s really kind of neat. We typically use Boom in conjunction with Zoom, but you can do it with FaceTime, and you can do it with some of those other applications as well.
So I’m going to give you a quick demonstration of what it would look like to run a one on one session with the parent observing as the BCBA. So this is the website for Boom. It’s wow.boomlearning.com, and it’s free to sign up. You can be a teacher on here, and it’s free. The store has many free programs, and you can actually put in a lot of your ABA programs. And as parents, you know, if your BCBA is putting programs in there, you can work on this.
And a lot of times, it’s more fun to do this than maybe some tabletop stuff, too. I typically go to the studio feature. And what’s unique about the studio feature is you can make your own. So I actually put in the programs for my kids in there. And so I can work on them through the screen, but also the parent can work on them as well. So I’ll demonstrate one of those real quick.
I have a kiddo that’s learning how to label, or tact, side words. And so what that would look like is– you can actually create a token board on here. So, you know, maybe he’s working for some YouTube. This kiddo likes electronics a lot, so he’s working for YouTube, he’s looking at the screen. One of my suggestions is to reinforce for, you know, basically looking at the iPad screen and working, sitting, any of those learner readiness behaviors, because learning from TeleHealth is unique and new to many of the kids.
And so even reinforcing the setup behavior is not a bad idea. So maybe I say, OK, thanks for coming to work with me and tell me what you want to work for. You get the first dinosaur. And I can actually move on the screen the icon, he can see that he’s gained a token. So just to show you, I could say, you know, what’s this. They say four, that’s right. It gives them a nice reinforcing sound there, potentially, and then I can give him another dinosaur.
You can also use the remote control feature on Zoom, and the kiddo can actually move their own tokens, or the parent can move their tokens if you wanted to, you can also put a YouTube video on the iPad, so then watching the iPod and taking the instructions from the iPod becomes reinforcing as well. So those are some of the things– those are two ways we did it. Which, just to go back real fast– so one is parent as extension, so the parent is basically running the session with the BCBA coaching.
And the other is the BCBA leading the session with the parent facilitating. Maybe when they get all their tokens, they may provide the reinforcement. And this is a good way to teach families about reinforcement schedules, and how to train those. So some considerations and barriers to look at is that not all parents are basically ABA technicians. We usually train 40 hours initial, and then there’s ongoing training and that’s their job.
So parents have a lot of other things to consider, there’s a lot on their plate, and so our expectations need to be changed based on that. We need to understand that, as a group, we need to collaborate, coordinate, and basically find those most important goals to work on so that we can together– I mean, I haven’t really separated out the BCBA and the caregiver throughout this presentation because, to me, it’s a reciprocal relationship that whenever that goes well, the child is going to benefit the most.
So I think collaborating, and prioritizing your most important goals, and working on those during those coaching sessions is most important. The silver lining for us is we’ve had– you know, it started off a little messy. We had to figure out, like, what mode are we actually going to use. We had some families that had some technological issues. We’ve had Wi-Fi drop a few times in certain situations.
But through the messiness, you really can see some great outcomes. We’ve had families that are working on mand training and maybe– some of them have taught their child a new vocal mand and they’re the ones responsible. They can directly see, oh my gosh, I just got my kid to say a new word. There’s also the fact that we can look into the environment.
I had one kiddo that really liked to watch– play video games, and YouTube was playing on a TV elsewhere. So he was working to play video games, but YouTube was on. So he was fine just watching the YouTube. So being able to say, hey, look maybe we pause the YouTube to the parent and just leave that off, and then we can have him work for the video games, it will make it more reinforcing.
So just those little environmental variables and those many successes that the families are having has really made it a rewarding experience, too, and that’s kind of the silver lining that we’ve seen. And the last thing I just want to say on this is I know– you know, I’m working from home and I was doing TeleHealth, and I had my two kids home, and, I mean, the toys were stacked up. There was food plates left out, it was crazy, it was chaotic.
When we come into your home as BCBAs, we’re there to help. We don’t want to add another stressor. We understand that right now life is uncertain, and there’s a lot of things going on. We’re there to help, and we just want to basically see the kids succeed, and do what we can for you guys. All right.
Great. Thank you so much, Zack, that was excellent. And I love– I love how you just ended that, that you’re coming into the home and you’re there to help. You’re not looking to add another stressor. I know it’s hard, as a parent, having people come in even through TeleHealth, and you’re worried that your other kids are running through with their– in their underwear or, like, there’s a mess everywhere. So everybody’s– you know, everybody’s dealing with a lot right now.
Right. My dog has jumped on many Zoom calls.
Yeah. OK. So we have a question here from Louisiana. Are there other– are there any parish school systems in Louisiana which are using specific ABA therapy in the school system?
I can speak to our parish, and right now we’re– I’m in Calcasieu. So, no. I actually– St. Nick’s works within the dioceses, so it’s more of the private schools that we’re able to go into. I’m not aware– I can get back to you on that. But as far as for us, we’re primarily working within the dioceses right now for school settings.
OK. And another question here. Can the program be shared from BCBA to other staff? Yeah, go ahead.
OK. So do you mean the– are you talking about the Boom Card programs? I’m thinking that’s what they’re talking about. If so, you can create a universal username and password for your organization, or maybe your company, and then you can create kind of a library of things to use. One thing you’d have to look at as a BCBA would be the personal health information aspects of it. So you may not want to share program to program if it’s specific to one child.
But I would say you could create one for your organization and have a pool of different programs in there, sure.
That’s a great way to communicate for therapists also. Yeah, OK. Another question here. My son is turning 12 in July, he was diagnosed in November. All the help that we started working on was put– was put on hold in March. That’s– yeah. And how can I– how can I get the training in ABA as a parent?
There’s a lot of resources out there. CentralReach produces a lot of research– resources. I would say– honestly, you guys’ website would be pretty good for that, too. Navigating Exceptional Lives’ website would be able to give you some different options. I think that’s your best route. CentralReach has programs that parents can actually utilize in the home setting while you’re waiting for services.
But, like I say, Exceptional Lives actually has a nice way of kind of sorting what programs you need.
Yeah, and we can follow up on that also with specific information– help you find information in your area. OK. And Jackie says, can we request ABA type accommodations well– while homeschooling? OK. So can you request that while you’re at home at this point?
Yeah. I mean, you can do– well– so we primarily work through insurance funding. So I can speak to the fact that I know we have some kids that are homeschooled that also receive ABA services through Blue Cross and Blue Shield and things like that. As far as, like, how to request that? I’m not sure how to go about that, if I’m being honest. But I know you can receive applied behavior analysis and be homeschooled simultaneously.
OK. And finally, have you heard– maybe you could share some tidbits from parents who have– who you’ve been working with. Like, how do they make it work? And what makes it– what are some challenges, or what tips do they have for us, as parents, to try to make this work?
Sure. You know, pretty much unanimously most parents like the Boom Card sessions. They found those to be more valuable because there’s visuals in it. As far as making the session times work, parents who are open with us as far as on their schedules and things like that, we can be pretty flexible as BCBAs and say, well, we can do sessions around your typical day and when you find areas that are working for you.
And I think that, based on your availability as a parent is how you need to prioritize your goals or your BCBAs. So if you’re only able to do two or three hours per week because, I mean, we have lives and there’s things going on, then you need to maybe condense the amount of goals from the treatment plan and really hit the ones that are super priority. And I think if, you know– if you’re open with your BCBA and you can have that collaborative process, then you’ll be able to narrow down.
OK, maybe if we work on communication we’ll get some of these other areas for free. And so I think just really prioritization of goals with the time that you have is super important.
Conclusion
Great. OK thank you, Zack. So I think we’ll finish this up here, and I’m going to take the screen sharing from you here for a second. OK. OK. OK, so Zack thank you so much for being here and sharing all of your ABA wisdom as we’ve transitioned into this– this TeleHealth world, and really have learned a lot about how this works, and about ourselves, and what we’re– how we’re able to do this with our children that we’ll bring with us when we transition back.
So thank you so much for your time, and thank you all for being here. We’ll be back next week with a mental health counseling session. Well, how we do mental health counseling through TeleHealth session. And you can see more information on our website regarding TeleHealth, or regarding this webinar series, and you can just take our poll here, and we will see you next week. Thanks so much.
