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Use of Telemedicine to Provide Ongoing Consultation to Care Providers
by David P. Wacker and Anjali Barretto
Since 1985, the Biobehavioral Outpatient Service has operated in the Department of Pediatrics at the University of Iowa Hospital School for children and adults who have developmental disabilities and engage in challenging behavior. The focus of the clinic is to assess challenging behavior via functional analysis methods and then to develop interventions based on functional communication training. We have conducted evaluations of approximately 127 children and adults this past year, most involving evaluations of self-injury or aggression.
Two practical concerns have emerged about the services we provide in the outpatient clinic. First, only about half of the patients show any problem behavior in the clinic. This is not too surprising, given the novelty of the situation, the uniqueness of the day, and other factors such as the undivided attention the patient often receives from care providers. Second, families often travel over 100 miles one way to attend the clinic. This length of travel can put added stress on an already stressed family and often precludes any follow-up through the clinic. Although we are strongly committed to the functional approach we are using in the clinic, we believed that our method of delivering that approach needed to be changed.
In 1997, we were given the opportunity to deliver the same functional model used in our clinic via telemedicine, which utilizes interactive video. In Iowa, studios with interactive video capability are located in most high schools and regional hospitals. It seemed possible to us that the functional model used in our outpatient clinic could be conducted over interactive video, with the major benefits being the cost and time savings to families.
The Telemedicine Process
Telemedicine services at University Hospital School include both initial and follow-up evaluations. In addition, we conduct discharge conferences, wrap-up sessions following outpatient evaluations, and consultation with local school teams. The initial evaluations are similar to those conducted in our outpatient clinic and focus on identifying environmental variables maintaining problem behavior. These types of evaluations consist of a descriptive assessment (e.g., A-B-C interview) followed by a brief functional analysis. A typical initial evaluation lasts 90 minutes (the same duration as an in vivo clinic evaluation), with the first 15 minutes being devoted to conducting an A-B-C interview to gather information about environmental events surrounding the target behavior. This information is then used to formulate a hypothesis regarding the function(s) of the target behavior. We then conduct a brief functional analysis to test this hypothesis. Following the assessment, we conduct a brief wrap-up (via telephone or as part of the session) to summarize the results of the assessment and to provide recommendations for intervention. We have conducted four such evaluations over the past year in collaboration with Des Moines Public Schools in Iowa located over 100 miles from our clinic. We have up to 10 more evaluations scheduled for this school year, each of which will consist of both a descriptive assessment (A-B-C assessment) and a functional analysis.
Some of our initial consultations consist of interviews with care providers to identify possible environmental variables maintaining target behavior and the initiation of ongoing assessment in the home or classroom. Based on the information obtained during the interview, we provide recommendations, devise observation forms to gather relevant information over a period of time, and demonstrate their use. These data are then sent to us by fax, e-mail, or regular mail. We review the data and provide consultation on our interpretation of the outcomes of these observations.
Follow-up evaluations consist of ongoing consultation by our clinic team. These types of evaluations may occur after an initial evaluation has been conducted via telemedicine (as described above) or following on-site clinic or inpatient evaluations. Our experience and that of the families have convinced us that the vast majority of follow-up evaluations can be conducted using telemedicine. Surveys of both participating families and those who attended the on-site clinic rated the quality of service about the same. However, the cost saving to the family is substantial for telemedicine. Given equal quality and increased cost savings, we believe that telemedicine should be used even more.
To date, we have consulted with over 40 families via telemedicine and have conducted approximately 100 evaluations (both initial and follow-up). The duration of consultation has been from one session to fourteen sessions over a two-year period. As part of the funded project we agreed to conduct 25 evaluations, but we actually conducted just over 75 more evaluations simply because as professionals we were very satisfied with the quality of service we could provide and because of the enthusiastic response by consumers of the service. Additionally, the use of telemedicine has made it very possible for local service providers to “attend” the evaluations. With consent from the family, educational consultants and medical staff routinely “join in” from area studios (multiple sites can participate). As a result, we currently enjoy a very strong professional relationship with educational and medical teams.
To further highlight the telemedicine service, we provide a example of its use with one child, Karl, who was diagnosed with autism and deafness. This example demonstrates how useful telemedicine can be with the most challenging cases. It also shows how families and professionals can work more closely together over extended time periods, even when physically located many miles apart.
Karl’s Story
Karl* was eight years old when we began working with him and lived with his parents and sister in a town about 75 miles from University Hospital School. In March, 1988, Karl was referred to the Biobehavioral Outpatient service by his family physician and his parents for an evaluation of self-injury (e.g., head banging, eye poking), aggression (e.g., hitting others), destruction, stereotypy (e.g., key twirling), and lack of independent toy play. During the initial evaluation in our outpatient clinic, we conducted a brief functional analysis to identify the environmental variables maintaining Karl’s challenging behavior. While in clinic, Karl’s parents conducted the sessions with assistance from clinic staff. The result of the functional analysis showed that self-injury served several social functions (e.g., to gain preferred items or to escape nonpreferred activities). We also observed that Karl wandered around the room and resisted his parents when they attempted to engage him in an activity. Based on these results, we recommended a treatment package that included structured work and play situations, choice making, functional communication training, and extinction. We demonstrated these procedures in clinic and described them in written recommendations to the family.
We believed that ongoing follow-up would be helpful, as numerous changes to treatment would be needed. In essence, we viewed the treatment package recommended from the clinic evaluation as a baseline plan upon which we would build. Our first follow-up evaluation was scheduled for April, 1998, to determine the efficacy of our initial plan. All those involved in Karl’s care (e.g., his parents, in-home therapist, teacher, speech therapist, family physician) “attended” this session from the local school and hospital. During this follow-up evaluation, Karl’s parents and the in-home therapist raised several good questions regarding problem behavior that occurred in specific situations. This led to a series of routine follow-up evaluations over the course of a two-and-one-half year period. Karl’s parents also videotaped situations that were problematic, which helped us provide them with other recommendations. They also sent us videotapes of Karl’s progress, which was remarkable. Overall, during the initial treatment and the follow-up he moved from self-injury, aggression, destruction, stereotypy, and lack of independent toy play to engaging in up to 30 minutes of independent play, using a communication device, following hitting with appropriate touching and signing for the preferred item, and self-scheduling activities during breaks. This was in large part due to the extensive follow-up available to Karl that would not have been possible without telemedicine.
Summary
Our hope is that telemedicine will bridge the gap between families, local service teams, and highly specialized professionals in addressing the needs of individuals with challenging behavior. In this way, all families can have more immediate access to professionals who have specialized expertise.
*Pseudonym
David P. Wacker is Professor of Pediatrics and Special Education, and Anjali Barretto is a PhD student in special education and a Research Assistant with the Department of Pediatrics, University Hospital School, University of Iowa, Iowa City. Both may be reached at 319/353-6450.
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