ABA Services and Telehealth

Applied Behaviour Analysis (ABA) is an evidence-based approach for teaching skills and addressing learning challenges in individuals with Autism Spectrum Disorder (ASD) and related conditions. While ABA was traditionally delivered in person, demand for telehealth services increased significantly during COVID-19 due to restrictions on face-to-face sessions. I currently provide telehealth supervision and consultation services as a behaviour analyst to an ABA center in Saudi Arabia, whilst being based in England, UK.

What is ABA Telehealth?

Telehealth is defined as the use of telecommunications and information technology to provide access to assessment, diagnosis, intervention, consultation, supervision, education, and information across distance (Nickelson, 1998). During ABA telehealth, it is vital that clinicians follow the ethical code of their licensure board and comply with all regulations, the Health Insurance Portability & Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act whilst using telehealth (CASP 2021). Additionally, providers should conduct a risk assessment to assist with determining if telehealth is safe and appropriate for the patient and family (CASP 2021).

Types of ABA Telehealth services (CASP 2021)

1. Caregiver Mediated Services:

In this model, the behaviour analyst provides coaching and feedback remotely to a parent/caregiver using both synchronous modalities (e.g., real-time videoconferencing with the caregiver implementing treatment protocols directly to their child) and asynchronous modalities (e.g., caregiver reported data toward goal progress, asynchronous store-and-forward video of caregiver/child interactions).

2. In-person Direct Services with Telehealth Clinical Direction:

A partial telehealth model in which a trained behaviour technician delivers services in-person to the client and the behaviour analyst provides synchronous or asynchronous clinical direction remotely. Synchronous clinical direction might involve real-time protocol modifications or performance feedback by the behaviour analyst using a HIPAA compliant videoconferencing platform. Asynchronous clinical direction might involve the behaviour analyst reviewing video or data from a session with or without the behaviour technician present and providing feedback and clinical direction.

3. Telehealth Direct Services:

Clients with the necessary skills can receive services directly through synchronous videoconferencing or audio sessions with providers (e.g., behaviour analyst, behaviour technician). These telehealth services may occur 1:1 or in social skills groups and can be combined with asynchronous methods for improved remote monitoring, such as tracking patient-reported progress toward goals.

Benefits of ABA telehealth

Telehealth enables continued access to ABA, particularly in remote areas with few qualified professionals. This approach enables practitioners to maintain continuity of care, supporting clients’ progress and wellbeing when traditional, in-person sessions are not feasible. It also reduces burnout of staff, who previously may have had to travel for hours each way to visit clients in very remote locations. This approach significantly increases access to healthcare, reducing health inequalities, particularly in areas where in-person ABA services are unavailable. This method also saves valuable travel time for both families and professionals.

Globally, telehealth proves especially valuable during situations such as pandemics. If face-to-face sessions are suspended due to social distancing requirements, telehealth ensures that services can continue without disruption.

Financial Advantages

Beyond improving service reach, telehealth also offers notable financial benefits. The costs associated with providing ABA services are reduced, as there are no travel costs for both families and staff members.

Global and Domain Effectiveness

ABA telehealth has been successfully implemented worldwide, including in countries such as the United States, United Kingdom, Canada, Albania, and across Europe. Research supports telehealth methods being successful in delivering behavioural interventions for sleep difficulties (McLey et al 2020), training parents to implement functional communication training with their children (Lindgren et al 2020), successfully completing assessments, targeted interventions and specific teaching techniques (Tomlinson et al 2018).

Parent Acceptability

Importantly, research indicates that parents report a high level of acceptability for ABA interventions delivered via telehealth. This positive perception further supports the ongoing adoption of telehealth modalities within behaviour analytic practice (Unholz-Bowden et al 2020, Tsami et al 2019)

Limitations of Telehealth

While telehealth offers significant advantages in expanding access to ABA services, it is important to acknowledge its limitations. Firstly, effective participation in telehealth requires families to have access to a computer and a reliable internet or phone connection. This prerequisite can be a barrier for low-income families who may lack the necessary technology, potentially excluding them from remote services.

Another challenge associated with telehealth is the potential for technical difficulties. Issues such as unstable internet connections or malfunctioning devices can disrupt sessions and negatively impact the delivery of services. To mitigate such risks, families and staff must be familiar with setting up and operating the relevant technology and equipment prior to commencing sessions. This technical readiness is essential for ensuring smooth and effective interactions.

Additionally, providers must assess whether the patient has the appropriate prerequisite skills to participate in the different telehealth models. For example, a client for whom the technician will deliver services via synchronous, real-time videoconferencing will require prerequisite skills such as joint attention, discrimination, follow instructions, echoic skills, ability to sit at a desk, and low levels of challenging behaviour (CASP 2021).

Language barriers limit telehealth, especially internationally. In my role supporting clients in Saudi Arabia, some clinic staff speak only Arabic, so a bilingual colleague currently translates during sessions. We are seeking a real-time Arabic-English translation app to improve communication and telehealth effectiveness.

Cultural Considerations in International Telehealth Delivery

When delivering telehealth services across different countries, it is essential to consider cultural norms, values, and local policies. While cultural sensitivity is important in all clinical settings, providing services remotely can introduce additional complexities related to communication, professional roles, and service delivery expectations.

Practitioners may need to adapt how services are delivered to align with local customs, regulations, and family practices. This can include modifying observation methods, planning sessions carefully to account for who will be present in the wider environment, and collaborating closely with local staff or caregivers to ensure services are both culturally respectful and clinically effective. Thoughtful planning and flexibility are key to maintaining ethical and meaningful support across diverse cultural contexts.

Conclusion – Expanding Access Through ABA Telehealth Support

When qualified ABA staff are not locally available, telehealth support effectively broadens access to behaviour analytic services by connecting professionals with individuals and families facing geographical or resource barriers.

ABA telehealth support delivers effective training, supervision, and consultation remotely, making quality behaviour analytic services accessible to more people. This approach maintains engagement and skill development for caregivers and staff when in-person support is unavailable, enhancing equity in healthcare.

About the Author

Catherine Bacon, BSc, MSc, BCBA, is a Consulting Specialist for The New England Center for Children – Gulf Consulting Division. Based in the UK, she provides telehealth consultation and supervision to a non-profit ABA provider in Saudi Arabia with multiple branches. Catherine brings extensive experience in clinical leadership and supervision and aims to support the availability of accessible, compassionate, ethical, high quality ABA services across the globe.

References

1. Council for Autism Service Providers (2020a). Organizational guidelines and standards: Telehealth chapter. Retrieved from https://casproviders.org/wp-content/uploads/2020/03/CASP_ALS_Booklet_v1_1.3.20.pdf
2. Council of Autism Service Providers (2021). Practice Parameters for Telehealth-Implementation of Applied Behavior Analysis: Second Edition.. Wakefield, MA: Author
3. Lindgren, S., Wacker, D., Schieltz, K., Suess, A., Pelzel, K., Kopelman, T., Lee, J., Romani, P., & O’Brien, M. (2020). A randomized controlled trial of functional communication training conducted via telehealth for young children with autism spectrum disorder. Journal of Autism and Developmental Disorders. Advance online publication. https://doi.org/10.1007/s10803-020-04451-1Nickelson, D. (1998).
4. McLay, L., Sutherland, D., Machalicek, W., & Sigafoos, J. (2020). Systematic review of telehealth interventions for the treatment of sleep problems in children and adolescents. Journal of Behavioral Education, 29, 222-245. https://doi.org/10.1007/s10864-020-09364-8
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7. Tomlinson, S. R. L., Gore, N., & McGill, P. (2018). Training individuals to implement applied behaviour analytic procedures via telehealth: A systematic review of the literature. Journal of Behavioral Education, 27(2), 172–222. https://doi.org/10.1007/s10864-018-9292-0
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