These results showed that functional analyses were successfully conducted using telemedicine technology. The brief functional analyses were completed in the children's local environments. Moreover, the children's primary care providers conducted the analyses. Based on recent legislation (Part C of the Individuals with Disabilities Education Act, PL 105-17, 1997) requiring that early intervention services be provided in the child's natural environment, the use of telemedicine may increase the social validity of the applied behavior analysis service delivery as well as the efficiency of the procedures.
For each child, involvement of the local team during the functional analysis was important because the results obtained were different than what they had expected. It is possible that the results would not have been as convincing for the local team had we obtained them in our clinic without the team's participation. For example, the local team hypothesized that Charlie's disruptive behavior was maintained by automatic reinforcement. This was not supported by the obtained functional analysis results, which showed a negative reinforcement (escape) function. For Daisy, the local team was surprised that she engaged in self-injury to escape physical therapy. Because the physical therapist conducted the assessment, no concerns were raised regarding the physical therapy procedures employed.
These results are similar to those of earlier reports (Harding et al., 1999
; Iwata et al., 2000
) that showed that functional analysis procedures are not overly difficult to learn or to administer. The advantage of telemedicine is that necessary consultation can be provided in a cost-effective manner (e.g., there are no travel or time expenditures). During both evaluations, intermittent consultation, mostly in the form of reassurance that the procedures were being conducted correctly, was needed.
Throughout the project period (1997 to 2000), the BBS completed over 75 telemedicine evaluations such as those described above. A summary of initial and follow-up evaluations in the BBS clinic as well as telemedicine evaluations conducted by the service during this 4-year period is shown in . New evaluations conducted in the outpatient clinic comprised the majority of cases, followed by follow-up clinic evaluations, and finally ICN evaluations. Throughout this period, the number of return evaluations conducted in the clinic decreased. This decrease may be accounted for by the increase in the number of ICN evaluations, which suggest that follow-up services may be a practical use of telemedicine. For example, assessments such as functional analyses that are conducted in clinic settings can be described to an entire local service team in an efficient manner via telemedicine during a follow-up evaluation. In addition, the ICN is applicable to initial screening and follow-up consultation. In approximately 25% of referred cases, we were able to provide sufficient initial and follow-up consultations to avoid costly trips to the clinic for the children and their families.
Summary of new and return evaluations conducted in clinic and ICN evaluations conducted during the 1997–2000 period.
At present, the UIHC holds a multiyear contract with the Iowa Department of Education to provide ICN consultations for teachers, childhood service providers, and families both prior to and following initial clinic evaluations. During 2005, the BBS conducted 200 telemedicine consultations, with the majority being descriptive assessments and initial screenings. In almost half these cases, we were able to forgo subsequent clinic visits through treatment recommendations that were directed via the ICN and implemented by the local teams.
In summary, the use of telemedicine by experienced applied behavior analysts appears to be an efficient method for conducting brief functional analyses, follow-up consultations, and descriptive screenings to assess severe behavior disorders. Telemedicine services permit experts in functional analysis and function-based treatments to consult directly with local service teams and care providers in the assessment and treatment of problem behavior. Presently, insurance companies have not covered telemedicine evaluations conducted by behavior analysts in Iowa. However, contracts through agencies such as the Iowa Department of Education have been successfully obtained to fund these services. As technologies expand to include systems such as Web-based interactive video, even more options will be available to expand the delivery of functional analysis and function-based treatment services for children with behavior problems.