Overview of Telehealth & Technology

for Individuals with ASD and Their Families

Dr. Lou Vismara Consultant, Sen. Darrell Steinberg

louis.vismara@sen.ca.gov

Ph: (916) 651-4189 Fx: (916) 327-8867

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Technology & Innovations in the ‘Digital Age’

Definitions and Concepts•Interactive Distance Education(case conference; didactic; training; virtual “hands-on”)•Asynchronous Distance Education(lectures; pre-recorded information)•Web-based Information•Asynchronous “Store-and-Forward”(images; data; evaluations; audiovisual clips)•Remote Communications•Registries & Data Management

Implementation: Planning & Strategic Approaches 1.Resource & need assessment2.Strategic & operational plan for technology-based program3.Evaluate “technology” and other telehealth platforms4.Integration of “technology” with other programs & services5.Information evaluation & outcomes assessment

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How are technology and innovations being used in today’s healthcare environment?

Tele-Healthcare (categories) Real-time Interactive ServicesRemote MonitoringStore-and-Forward

General health care deliveryElectronic Health RecordsHealth Information ExchangeClinical decision supportClinical EducationPatient Support & EducationPharmacy & laboratory systemsElectronic medical recordsDisaster response support

Specialist care delivery

Experimental services

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Quick Facts about Tele-Healthcare:

77% of families have internet access

80% of internet users gather health information online (specific diseases; treatments; doctors; hospitals)

Underutilized: < 10% of California consumers ~ telehealth session

Only 13% of medical practices use electronic health records

V.A. telehealth program for vets with chronic conditions reduced hospital admissions by 19% and total bed days of care by 25%

California prisons provided 9,000 telehealth consultations : >$4 M savings

Diabetes outpatient visits reduced by 49%

Congestive heart failure hospitalization costs reduced by 47.5%

Tele-medicine annual savings: $4.2 B nationally; $511 M California

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What are impacts of technology and innovations on today’s healthcare outcomes?

• Increases access to healthcare services

• Improves healthcare outcomes

• Reduces healthcare costs

• Improves disparities in providers

• Improves training & education of providers

• Improves supports for patients & families

• Improves organizational productivity

• Helps the environment

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Why do we need innovative programs for the evaluation and treatment of ASD?

Increased demand for autism servicesAutism = 1 in 110 (>70% increase from prior 2002

Limited number professionals (<5,000 BCBA~ASD experience)

Limited collaboration and integration

Unclear treatment paths & responsibilities

Disparities in services

Parents & caregivers are often “traumatized”

Shrinking budgets

“insanity”: keep doing the same thing and expect a different outcome

Overview of Assistive Technology & ASD(“Telepractice Review” by M. Boisvert; Developmental Neurorehabilitation,

Dec. 2010; 13(6) 423-432)

Definition: Any item, equipment, or product that is used to increase, maintain, or improve functional capabilities of individuals with ASD

Functional Classification Communication skills Social interaction skills Attention skills Motivation skills Organizational skills Academic skills Self-help skills Independent daily functioning skills Understanding of environment

Delivery of Services & ProgramsNo discussion of facilitated or augmented

communication

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The U.C. Davis MIND InstituteApplications of Technology & Innovative Programs

A parent-founded & inspired research institute dedicated to finding: the cause(s), better treatments and ultimately a cure(s) for autism and other neurodevelopmental disorders

Includes 48 senior researchers &faculty,86 research fellows38 major research projects270 employees160 volunteers

U.C. Davis Center for Health Technologywww.ucdmc.ucdavis.edu/cht/

“Enhancing Mental health Services for Children with ASD in Rural Communities”

www.media.americantelemed.org/conf/2008/Presentations

1. Overview of Telehealth 2. Tertiary care center & target communities3. Practical considerations for implementation of

services4. Telehealth-enabled ASD training/services5. Principles of culture, ethics, legal &

professional considerations

Recommendations for Reviewing Websites: Authority Accuracy Objectivity Comprehensive & inclusive Current & Up-to-date

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The MIND Institute Early Start Denver Model Lab

Mission of the ESDM Program•To understand patterns of growth and change in young children with ASD & other disorders.•To prevent or minimize the disability through early detection, early intervention, and family support.•To prepare for careers in research & clinical care•To increase public awareness and knowledge

Research Projects•Intensive Treatment for Toddlers with Autism (Early Steps) •Initial Investigation of Prevention of ASD in Infants at Risk (Infant Start) •Remote ESDM: Expanding the Reach of Toddler-Treatment in ASD

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The MIND Institute Early Start Denver Model Distance Intervention Project

Based on ESDM curriculum & teaching approach(attention; motivation; sensory-social; play; dyadic;non-verbal & verbal communication; imitation; speech)

Computers/laptops web cameras

Initial evaluation; specific goals; 12 week program

Video conference parent training: 1/hour/week(review; parent-child play; feedback; new skill; practice)

Final Assessment & Comparison with Center-Based Therapy

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Results of the MIND InstituteESDM Distance Intervention Program

• High degree of fidelity (6 hours)

• High degree of parental satisfaction

• Wider range of observed activities

• Achieved 95% of goals

• > joint attention, social & shared interests

• Verbal: (spontaneous) pre=3.44/ post=29.9

(prompted) pre=3.87/ post=9.43

• Vocabulary: pre= 107.6/post=237.1

• Adaptive behavior (Vineland) pre=77/post=82

• No differences from center-based therapy12

The MIND Institute ESDMQuality of Participation & Outcomes Involves:

Quality of parent-child sharing

Parents Click on Selected Topic

The MIND Institute Virtual Reality LabDr. Peter Mundy

PRELIMINARY STUDY:•3-D simulated classroom •Nine avatar peers•Multitasking activities•Controlled interventions

PRELIMINARY RESULTS:•Joint attention~learning•Joint attention improves >age•Joint attention delayed with HFA•Joint attention/HFA improved post virtual training

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The U. C. Davis MIND Institutewww.ucdmc.ucdavis.edu/mindinstitute/

MIND VideosDistinguished Lecture SeriesMinds Behind the MIND Lecture SeriesSummer Institute on Neurodevelopmental DisordersSpecial Lectures and ConferencesMIND Educational VideosIn the CommunityVideos By Topic 

RESOURCESDisabilities and Conditions Adulthood & TransitionAdvocacy Assistive TechnologyDevelopment Early InterventionEducation Family Resource CentersHealth & Wellness International ResourcesLocal, State, & Federal  Occupational TherapyRegional Centers ResearchSpeech & Language Sports & RecreationSupport Groups Videos-MIND InstituteOther Services 

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The MIND Institute Tele-Autism Program

Major Goals & Objectives1. Technology based “system of care” for ASD   2. Access, comfort, efficacy, and satisfaction

(clinical & research) 

3. Establish “telecompetence”

Video-conferencing

Multi-media platforms

Written/video learning modules

“Store & forward” technology

Data management & Multi-disciplinary communication

Communities of practice

Resource information center

New therapeutic modalities17

Computer-Assisted Interventions

Software programs Drill & practice Tutorial Improved language & social

interactions Increased motivation Off-computer activities

Keys to success Predictability Animation Multiple exemplars Variety in methods Non-repetitive trials Customization

Possible pitfalls: Generalization Boredom &/or frustration Limited research

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Autism Learning Platform

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Examples of Proprietary Companies

TeachTown Corp.Software treatment ABA program

– Over 500 lessons for children – video game rewards

Platform for synchronization between home and school and therapists office; progress reporting, communication/notesTools for rapid development of new contentExpert mode to customize curriculum

Animated Speech Corp.Team Up with Timo is a language learning suite that features an engaging animated tutor to teach

– Vocabulary lessons – Stories and related games to teach narrative skills

and language in contextLesson Creator:

– A tool for teachers, parents and therapists to create individualized vocabulary lessons

Lesson Exchange: enables posting and exchanging of lessons

TeachTown: Basics• A research-based, computer-aided instructional software program • Uses evidence-based best practices from Applied Behavior Analysis (ABA) • Includes 500 on computer lessons with 300 highly motivating off computer activities to promote generalization • Teaches thousands of concepts that improve performance in six key learning domains

TeachTown: Social Skills• A video modeling-based curriculum• Infuses engaging animated characters that teach socially valid skills in each episode • The targeted skill in each episode is further developed through a series of lesson plans, classroom activities, and homework assignments • The animated characters become another voice in the classroom to support teachers

What Does TeachTown Offer to Classrooms?TeachTown products teach academic & social skills

required to be successful in Pre-K, Kindergarten and 1st grade

A US Department of Education funded study with LAUSD:During this 3-month study TeachTown students had significant gains

compared to control groups

What is the Scientific Data to Support Efficacy?

Web-based Curriculum & Technology

Standardize the delivery of research-based services

Provide training, collaboration & supervision across multiple staff, families and geographic locations

Multi-media & interactive formats

Supplements existing resources

Cost-effectively manage the increased demand

Proprietary CompaniesRethink Autism (www.rethinkautism.com)Center for Autism & Related Disorders (www.centerforautism.com)

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Technology to Train Professionals

CARD eLearning™ is a 40-hour online training course designed to facilitate effective intervention for children with autism. Completely web based.

• Tool for training therapy staff• Teaches ABA procedures for treating autism• Narrated presentations provide video demonstrations• Self-guided and go at your own pace• Online note taking• Quizzes track progress of each module• Passing final exam results in a certificate of completion• Continuing education units available for this training

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Technology to Assess & Treat ASD

Skills™ is a treatment management program for comprehensive assessment, curriculum, and progress-tracking.

• Assessment with age milestones• 4,000 lesson activities and tens of thousands of targets• Covers all areas of child development• Assessment links directly to customizable lesson plans• Includes printable materials, worksheets, and data sheets• Tracks/Graphs assessment results and treatment progress• Multidisciplinary approach allows the entire treatment team

to evaluate the effects of other treatments, life events, and challenging behaviors on child progress

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Synchronization between multiple systems of care

Authoring SystemChild Data

HomeClinic or School

There is an “App” for that

Application software, also known as an application or an "app", is computer software designed to help the user to perform specific tasks

App manipulates text, numbers, or graphicsClassification of apps:

Information worker (accounting programs) Content access (web browser; media player) Entertainment (video games) Educational (references; learning software) Enterprise infrastructure (database; business workflow) Simulation (flight; driving; emergency) Media development (editing; animation; simulation; 3-D) Product engineering (design; program testing; editing)

Over 140,000 apps for iPad (“work, play, & everything in between”)

Google search “autism app”: >10,700,000 results

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General classification of autism “apps”

Speech; language; communication

Basic Education

Specific learning tasks

Visual learning

Augmented communication devices

Data collection; behavioral therapy supports

Social skills

Improve eye contact & physical skills

Schedules & transitions

Games and fun

Caregiving

Miscellaneous

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Autism “Apps” Websites:

www.autismspeaks.org/family-services

www.autismepicenter.com

www.modelmekids.com

www.squidalicious.com

www.itunes.apple.com/us/app/autism

www.snapps4kids.com

www.hackingautism.org

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Hacking Autism Website: “Idea Gallery”www.hackingautism.org

Examples of >300 concepts submittedHealth / Wellness: Job chart or progress chart. Check list of chores and tasks. Basic tutorials on brushing teeth, potty training, buckling seat belts, crossing the street, etc.

Behavioral: an app that teaches my autistic son to use his napkin and not his shirt - his fork and not his fingers. Also, one that teaches him to try a new food... can say ' no thank you' in a nice calm voice instead of saying 'NO EGGS!' in a loud, scary voice

Basic Education: Handwriting app that allows them to trace letters and write whole sentences - not just a flashcards app. Speech / Communication: An app that helps reinforce spoken and sign vocabulary and share by particular sign variants, gestures and behaviors with caregivers.

Fun: i would like to see an app that would not only be fun but would teach a child with autism basic everyday skills like dressing or potty training or how to deal with crowds and situations that they may face day to day  

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Program Flowchart

TPSID Grant: Jeff Ross

Ipad 2 Lead: Joe’ll Chaidez

Educational Use:Accommodation Specialists

Social Use: Accommodation Specialist/ Field Supervisors

Vocational Use: Career Coaches/ Field Supervisors

Assessment/ Outcomes: Joell Chaidez

TPSID Grant: Jeff Ross

Applications

Academic Applications

Class SchedulerAudio BooksEBooks My Math Flash CardsMath RacerCampus LifeStudy AidStudy BuddyHome Work Tracker Writing TipsComplete Class Organizer

Vocational Applications

Resume GeneratorSkypeInterview ProCareer BuilderJob CoachMonsterjobsClassifieds 2 goCareer JetStyle TipsIpad MirrorDress to ImpressEtiquette ProTwitterBizzBites

Social Applications

FacebookFandangoSkypeTouch TrainerFubarTwitterooVoo Video chatGrocery PalBill ReminderHours TrackerAce BudgetDating DNADating IdeasMeal PlannerGot Questions

Integration & Implementation

Innovations for ASD & Behavioral Sciences

Behavior Capture ™

Behavior Connect ™

Telemetric monitoring

EEG & other brain monitoring systems

Automated facial expression detection

systems

Real-time data & pattern recognition

algorithms

Autonomic nervous system monitoring

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physiologic monitoring & data feedbackphysiologic monitoring & data feedback

Applying Futuristic Applications to the Diagnosis & Treatment of ASD

This will be the wave of the future

Change is going to come

EMR Video Capture MultimediaMedical Record

Autism, Technology, & Public Policy

SB 946 (Steinberg): Autism Behavioral Treatment Health Insurance Mandate

AB 415 (Logue): Telehealth Advancement Act•Updates terminology•Includes asynchronous (store & forward)•Includes email & telephone services•Provides for telehealth coverage of services•Eliminates “barrier” requirement•Eliminates “informed consent” requirement

SB 764 (Steinberg): Autism Telehealth Program

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Adapting Innovations in the ‘Digital Age’ to Improve the Lives of

Individuals with ASD & Other Learning Differences

The EndThe End

“The only constant in life is change”

“Never doubt that a small group of committed people

can change the world.

Indeed, it is the only thing that ever has.”

Margaret Mead