Supporting Individuals with Autism via Telehealth: Lessons from Three Case Examples

Overview & Clinical Significance

Telehealth delivery of ABA services has transformed from a supplementary service option to a critical component of the service delivery landscape. The experiences of teams who have been conducting behavioral assessments and intervention support via telehealth since well before the pandemic provide invaluable lessons for behavior analysts navigating remote service delivery. The three case examples highlighted in this presentation, involving complex communication needs, severe self-injurious behavior, and vocational training, represent some of the most challenging clinical scenarios that behavior analysts encounter, and conducting this work via telehealth adds additional layers of complexity.

The clinical significance of telehealth in ABA extends far beyond convenience. For many individuals with autism, particularly adolescents and adults, access to professionals with specialized expertise is severely limited by geography. Families living in rural areas may be hundreds of miles from the nearest behavior analyst with expertise in functional analysis of severe behavior, augmentative and alternative communication assessment, or vocational programming. Telehealth bridges this geographic gap, enabling access to specialized consultation that would otherwise be unavailable.

The three case domains addressed in this presentation each carry distinct clinical significance. Complex communication needs represent one of the most important areas of intervention for individuals with autism, and the assessment and intervention approaches used in this domain require specialized expertise that is not uniformly available across geographic regions. Telehealth enables families to access communication specialists regardless of location.

Severe self-injurious behavior presents unique challenges for telehealth delivery. Functional analysis of severe behavior involves procedures that carry inherent risk and require careful clinical judgment about when and how to conduct assessment safely. Adapting these procedures for remote delivery requires creative problem-solving, strong collaboration with on-site personnel, and rigorous safety protocols.

Vocational training via telehealth addresses a critical need for adolescents and adults with autism who are transitioning to employment or community participation. This domain requires assessment and intervention in natural environments, which telehealth can facilitate through collaboration with on-site support personnel and the use of video technology to observe and coach in real-time.

Jennifer McComas's presentation draws on years of experience delivering these complex services remotely, providing practical guidance on technology problem-solving, clinical adaptation, and relationship building that is directly applicable to behavior analysts expanding or refining their telehealth practices.

Background & Context

The evolution of telehealth in ABA services has been shaped by technological advances, regulatory changes, and the practical realities of serving a geographically dispersed population. While the pandemic dramatically accelerated telehealth adoption, some teams had been developing telehealth models for years before 2020, accumulating experience and evidence that now informs best practices for the field.

Telehealth in ABA encompasses several service delivery models. Direct telehealth involves the behavior analyst working directly with the client via video technology, conducting assessments, implementing interventions, or providing instruction. Indirect telehealth involves the behavior analyst coaching a caregiver, teacher, or other on-site person who implements the procedures under remote supervision. Hybrid models combine direct and indirect approaches, using whichever modality is most appropriate for each clinical activity. The three case examples in this presentation likely involved significant indirect telehealth, given the complexity of the clinical scenarios and the need for on-site support.

The technology challenges of telehealth are substantial and often underappreciated. Reliable internet connectivity is not universally available, particularly in the rural communities where telehealth has the greatest potential to improve access. Video quality affects the clinician's ability to observe behavior accurately, which is foundational to behavioral assessment. Audio quality affects communication between the clinician and on-site personnel. Equipment malfunctions, software updates, and connectivity interruptions can disrupt clinical sessions and compromise data collection.

The regulatory landscape for telehealth in ABA has evolved significantly. State licensure requirements, insurance coverage policies, and practice act provisions governing telehealth vary across jurisdictions and have changed repeatedly in recent years. Behavior analysts practicing via telehealth must understand the regulations in both their own state and the state where the client is located, which may require licensure in multiple jurisdictions.

The clinical context of severe self-injurious behavior assessment via telehealth deserves particular attention. Functional analysis procedures, particularly those involving escape and attention conditions that may evoke challenging behavior, require careful safety planning. In traditional in-person service delivery, the clinician is present to respond to safety concerns directly. In telehealth delivery, the clinician must rely on on-site personnel to implement safety procedures, creating a different risk management calculus that requires extensive training, clear protocols, and robust communication systems.

The communication assessment context is similarly complex. Augmentative and alternative communication assessment involves evaluating motor capabilities, cognitive-linguistic skills, environmental supports, and communication partner responsiveness. Gathering this information remotely requires creative use of technology and strong collaborative relationships with on-site partners.

Clinical Implications

The clinical implications of telehealth service delivery span assessment, intervention, collaboration, and technology management. Each domain presents unique challenges and opportunities that behavior analysts must navigate thoughtfully.

Assessment via telehealth requires adaptation of standard procedures. For functional analysis of severe self-injurious behavior, the behavior analyst must train on-site personnel to implement assessment conditions safely and accurately. This involves detailed written protocols, video modeling of condition implementation, practice sessions with feedback, and real-time coaching during the assessment itself. The behavior analyst observes via video and provides moment-to-moment guidance while the on-site person implements the procedures. Data collection may be conducted by both the on-site personnel and the remote clinician simultaneously, allowing for reliability checks.

The clinical implications for communication assessment include the need to evaluate the client's communication in naturalistic contexts while observing via video. The behavior analyst may need to direct the on-site partner to present various communication opportunities, observe the client's responses from a different visual angle than would be available in person, and make clinical judgments based on video observation that may not capture all relevant behavioral details. Supplementing live video observation with recorded segments that can be reviewed multiple times can improve assessment accuracy.

Intervention implementation via telehealth relies heavily on the competence and compliance of on-site personnel. The behavior analyst designs the intervention, trains the implementer, and provides ongoing coaching and feedback via telehealth. This indirect service delivery model requires the behavior analyst to develop strong training skills, including the ability to provide clear written and verbal instructions, model procedures via video, observe implementation remotely and provide real-time corrective feedback, and motivate and support implementers through the challenges of learning new procedures.

Technology problem-solving is a clinical skill in telehealth practice. When technology fails mid-session, the clinician must have contingency plans. These might include alternative communication methods such as phone calls if video fails, offline activities the on-site partner can implement independently if the connection is lost, and clear protocols for when to pause the clinical activity versus when to proceed with reduced technology support. Building technology troubleshooting into session planning rather than treating it as an unexpected disruption improves the reliability and quality of telehealth sessions.

Rapport building via telehealth presents unique challenges, particularly with individuals with autism who may have difficulty engaging with a person on a screen. Strategies for building rapport remotely include using high-interest activities and materials during initial sessions, maintaining a consistent visual presentation such as background and lighting, using exaggerated facial expressions and gestures to compensate for the reduced visual information available through video, and gradually increasing the duration and complexity of interactions as rapport develops.

Collaboration and rapport with families via telehealth requires intentional effort. Families may feel that telehealth is less personal or less effective than in-person services. Addressing these concerns openly, demonstrating competence through effective clinical work, and maintaining regular communication beyond scheduled sessions helps build trust and sustain the therapeutic relationship.

Ethical Considerations

Telehealth service delivery raises several ethical considerations that behavior analysts must address proactively. The BACB Ethics Code for Behavior Analysts (2022) does not address telehealth explicitly in every code, but the principles underlying the codes apply regardless of service delivery modality.

Code 2.01 (Providing Effective Treatment) requires behavior analysts to provide services that are effective and in the client's best interest. When delivering services via telehealth, behavior analysts must assess whether telehealth is an appropriate modality for each client's needs. Some clinical activities may require in-person delivery for safety or effectiveness reasons, and the behavior analyst has an obligation to recognize these limitations and arrange for in-person services when necessary.

Code 1.05 (Practicing Within Scope of Competence) has specific implications for telehealth. Competence in telehealth delivery is a distinct skill set that includes technology proficiency, remote training and coaching skills, adaptation of clinical procedures for remote delivery, and understanding of telehealth regulations. Behavior analysts who transition to telehealth without developing these competencies may be practicing outside their scope.

Code 2.11 (Obtaining Informed Consent) requires that clients and families understand the nature of services, including the telehealth delivery modality. Informed consent for telehealth should address the technology requirements and potential limitations, the differences between telehealth and in-person service delivery, confidentiality considerations specific to telehealth including data security and the risk of unauthorized persons being present during sessions, the contingency plan for technology failures, and the circumstances under which in-person services would be recommended instead.

Code 2.04 (Third-Party Involvement in Services) is relevant when on-site personnel serve as intermediaries between the behavior analyst and the client. Clear agreements about roles, responsibilities, and the scope of the on-site person's involvement must be established and communicated to all parties.

Code 2.14 (Selecting, Designing, and Implementing Assessments) requires that assessment methods be appropriate for the client and the context. Behavior analysts must evaluate whether the assessment procedures they plan to use can be validly adapted for telehealth delivery. If the validity of an assessment procedure is compromised by remote administration, the behavior analyst should acknowledge this limitation in their assessment report and consider supplementary methods.

Confidentiality considerations under Code 2.07 (Confidentiality) are heightened in telehealth. Video sessions may be visible to others in the client's or clinician's environment. Recordings of sessions create additional confidentiality risks. Data transmitted over the internet may be vulnerable to interception. Behavior analysts should use HIPAA-compliant video platforms, educate families about maintaining a private environment during sessions, and establish policies about session recording.

Code 3.12 (Advocating for Appropriate Conditions) may require behavior analysts to advocate for telehealth policies and funding that support access to services. When telehealth is the only way for a client to access needed services, advocating for insurance coverage and regulatory support for telehealth delivery serves the client's interests.

Assessment & Decision-Making

Developing a structured decision-making approach to telehealth service delivery requires behavior analysts to evaluate multiple factors including clinical appropriateness, technology readiness, safety considerations, and collaborative capacity.

The first decision point is whether telehealth is appropriate for the specific client and clinical activity. Factors favoring telehealth include geographic barriers to in-person service, client comfort with technology, the presence of a competent on-site support person, and clinical activities that can be validly conducted remotely such as parent training, consultation, and some assessment procedures. Factors that may argue against telehealth include safety concerns that require a trained professional to be physically present, client behaviors that cannot be accurately observed via video, the absence of a reliable on-site partner, and technology infrastructure that cannot support reliable video connection.

For functional analysis of severe behavior via telehealth, the decision-making process must include a thorough risk assessment. Questions to address include whether the on-site person has been trained to manage the target behavior safely, whether there are clear criteria for pausing or terminating an assessment session if behavior escalates beyond safe limits, whether the video technology provides sufficient visual clarity to observe behavior accurately, whether there is a backup communication method if the video connection fails during a session, and whether the on-site setting has been assessed for environmental safety.

Technology readiness assessment should evaluate internet bandwidth and reliability at both the clinician's and client's locations, hardware quality including camera resolution, microphone quality, and screen size, familiarity of all participants with the video platform, and backup technology options in case of primary system failure. A technology test session before beginning clinical services can identify and resolve many issues proactively.

Training readiness assessment for on-site personnel should evaluate their understanding of the clinical procedures they will be implementing, their ability to follow real-time coaching from the remote clinician, their competence in data collection, their understanding of safety protocols, and their communication skills for describing in-session events that may not be visible on camera. Multiple training sessions with practice and feedback should precede the initiation of clinical services.

Ongoing decision-making during telehealth service delivery should be guided by data. Behavior analysts should monitor treatment progress, comparing telehealth outcomes to expected outcomes for in-person delivery. If progress is not meeting expectations, the behavior analyst should evaluate whether the telehealth delivery is a contributing factor and consider modifications to the telehealth approach, supplementary in-person sessions, or transition to in-person services if telehealth is proving inadequate.

Documentation of telehealth decision-making should include the rationale for selecting telehealth as the service delivery modality, the assessment of risks and mitigation strategies, technology specifications and contingency plans, training provided to on-site personnel, and ongoing evaluation of telehealth effectiveness.

What This Means for Your Practice

Whether you are new to telehealth or experienced with remote service delivery, the lessons from these case examples offer practical guidance for improving your telehealth practice.

Invest in your technology competence. Learn the features and limitations of your video platform. Test your equipment regularly. Develop troubleshooting skills for common problems such as poor video quality, audio echo, connection drops, and screen sharing failures. Have contingency plans for every session, knowing what you will do if the technology fails at different points in the clinical activity.

Develop your remote training and coaching skills. The ability to effectively train an on-site person to implement behavioral procedures via video is a distinct clinical competency. Practice giving clear, concise verbal instructions while observing the implementer on screen. Develop visual aids, written protocols, and video models that support remote training. Build in practice opportunities and feedback loops that ensure the on-site person can implement procedures accurately before beginning clinical sessions.

Build collaborative relationships intentionally. In telehealth, you depend on on-site partners more than in traditional service delivery. Invest time in building rapport with caregivers, teachers, or other support personnel. Communicate clearly about roles and expectations. Express appreciation for their participation. Address their concerns and frustrations promptly. A strong collaborative relationship is the foundation of effective telehealth service delivery.

Plan for safety in every telehealth session, particularly when conducting assessments or interventions that may evoke challenging behavior. Ensure that on-site partners are trained in safety procedures, that environmental safety has been assessed, that clear escalation protocols are in place, and that you can communicate with on-site personnel even if the video connection fails.

Advocate for your clients' access to telehealth services. If insurance coverage, regulatory barriers, or organizational policies limit your ability to provide needed services via telehealth, use your voice to advocate for change. The clients who benefit most from telehealth are often those with the fewest alternatives, and your advocacy can make a meaningful difference in their access to specialized services.