Educ. Treat. Child.

(2023) 46:5–22
https://doi.org/10.1007/s43494-023-00089-7

ORIGINAL ARTICLE

Evaluation of a Telehealth Training Program to Teach

Educators to Implement Behavioral Assessment
and Treatment
Patrick W. Romani · Kelsey Young ·
Andrea L. Boorse · Brooke Carson

Accepted: 14 February 2023 / Published online: 14 March 2023

© Association for Behavior Analysis International 2023

Abstract In the current study we used telehealth to procedures by coaching the educators to implement
train six educators from three rural schools to con- a functional communication training (FCT) program
duct multiple stimulus without replacement (MSWO) with their student. With FCT in place, the educa-
preference assessments. Three of the educators were tors reduced their student’s problem behaviors by an
subsequently trained to implement functional analysis average of 90.6%. Each educator rated the telehealth
(FA) of problem behavior. Behavioral skills training procedures for learning the MSWO, FA, and FCT as
(BST) was used to teach each educator to conduct highly acceptable. These data provide guidance for
the assessment procedures with an adult confederate. practitioners and researchers using telehealth to train
After mastering the procedures in the training con- others to implement behavior-analytic assessment
text, each participant implemented the MSWO and and treatment procedures for students diagnosed with
FA with a student diagnosed with autism spectrum ASD in rural settings.
disorder (ASD) in their school who was referred for
the assessment and treatment of problem behavior. Keywords telehealth · behavioral skills training ·
Results indicated that BST delivered via telehealth preference assessments · functional analysis ·
was an effective way to train educators to implement functional communication training
these two behavior-analytic assessment procedures.
Each student’s MSWO identified preferred items and
each FA indicated a social function of the problem Individuals diagnosed with intellectual or developmental
behavior. We validated the results of these assessment disabilities engage in problem behavior at a higher
rate than their typically developing peers (Emerson
& Einfeld, 2011; Matson et al., 1997; Williams et al.,
The authors thank the participants and their families for
participating in this project.
2018). Although much is known about the needs of
these individuals, caretakers in rural areas often do
P. W. Romani (*) not have appropriate access to specialized providers
Children’s Hospital Colorado, University of Colorado, (Gupta et al., 2022). As a result, many rural community
Anschutz Medical Campus, 13123 East 16th Avenue,
members rely on school personnel to function as subject
Aurora, CO 80045, USA
matter experts on a broad range of topics (Habeger
K. Young · B. Carson et al., 2018). Although it is certainly a privilege to be an
Colorado Department of Education, Denver, CO, USA essential member of a community, rural educators report
feeling unprepared to manage the unique educational
A. L. Boorse
University of Denver, Denver, CO, USA needs of individuals with disabilities, particularly those

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 6 Educ. Treat. Child. (2023) 46:5–22

who also engage in problem behavior within the school plans, but variability in the quality of the FBAs. Lack
environment (Chaparro et al., 2022). of access to training, in the form of supervised expe-
Several evidence-based approaches for addressing rience with feedback, is sometimes cited as a reason
behavior concerns among individuals with disabili- for this variability (Berry et al., 2011). In fact, Hott
ties are grounded in the principles of applied behavior et al. (2018) found that some rural educators rely on
analysis (Roane et al., 2016). One approach to behav- non-peer-reviewed sources, such as internet blogs or
ioral assessment and treatment to address these prob- social media, to obtain information to support their
lem behaviors begins with a functional analysis (FA) students. A clear need exists to develop capacity
of problem behavior, which leads to the develop- within rural school districts to offer evidence-based
ment of a functional communication training (FCT) training services from reputable experts to address
program (Lindgren et al., 2016). Functional analysis quality of IEPs.
procedures evaluate the extent to which sources of Behavior analysts have successfully provided
positive (i.e., attention and access to tangible items) school-based trainings utilizing behavioral skills
and negative reinforcement (e.g., escape from task training (BST; Parsons et al., 2012). BST consists of
instructions) maintain problem behavior (Iwata six general steps: (1) describing the target skill; (2)
et al., 1982/1994). Identifying the function of prob- providing written descriptions of skills; (3) mod-
lem behavior informs a function-based treatment that eling target skills; (4) arranging opportunities for
delivers the reinforcer shown to maintain problem trainees to practice the skill; (5) provide feedback
behavior contingent on an alternative response, such during practice; and (6) repeating the last two steps
as communication. In many cases, a stimulus prefer- until mastery. Overall, past studies have shown that
ence assessment is employed to ensure a high-quality delivering BST in-person is an effective and accept-
reinforcer follows the appropriate behavior (DeLeon able approach to teach stimulus preference assess-
& Iwata, 1996). Research has consistently demon- ments (Leaf et al., 2020; Roscoe & Fisher, 2008), FA
strated the function-based treatments lead to greater (Iwata et al., 2000; Ward-Horner & Sturmey, 2012),
reductions in problem behavior than non-function- and FCT (Suess et al., 2014). Unfortunately, these in-
based treatments (Ingram et al., 2005). Indeed, the vivo training services can be challenging for school-
Individuals with Disabilities Education Act mandates based providers located in rural areas to access due
the use of functional behavior assessment prior to to distance and ease of accessibility (Frieder et al.,
developing a behavior intervention plan for students 2009; Glover et al., 2016). Thus, identifying effec-
in need of special education support for their problem tive and accessible professional development oppor-
behavior. Thus, school teams must use this evidence- tunities presents a significant barrier in these settings
based behavioral assessment and treatment pro- (Barrett et al., 2015).
gram to address problem behavior within the school To address these barriers to accessibility of train-
environment. ing services, researchers have investigated the use
Given the effectiveness of this approach, it is cru- of telehealth to deliver health-care services over the
cial for these modes of behavioral assessment and internet (Collins et al., 2017; Lindgren et al., 2016;
treatment to be accessible to providers working with Lloveras et al., 2022). In two recent studies, Higgins
children engaging in problem behavior in classrooms et al. (2017) and Rios et al. (2020) delivered BST via
(Neely et al., 2017; Tomlinson et al., 2018). Unfor- telehealth to teach direct-care staff and educators,
tunately, there is variability in the behavioral assess- respectively, how to conduct multiple stimulus with-
ment procedures used in school settings, particularly out replacement (MSWO) preference assessments
schools located in rural settings (Bassingthwaite and FA, respectively. The procedures for both stud-
et al., 2018). A recent study evaluated 126 individu- ies were similar. During a protocol-only baseline,
alized education plans (IEP) developed by rural edu- participants received access to a protocol describing
cators for students experiencing social, emotional, or procedures for implementing the relevant assessment.
behavioral needs (Hott et al., 2021). These research- All participants demonstrated low implementation
ers demonstrated general compliance with core accuracy following this condition. Following BST
components of IEP development, such as functional delivered via telehealth, each staff person’s proce-
behavior assessment (FBA) and behavior intervention dural integrity improved with the relevant assessment

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Educ. Treat. Child. (2023) 46:5–22 7

and their skills transferred to work with a child. At 2–4 and 6). All six of the educators identified as female
the conclusion of these studies, participants were also and white. Each educator participated in an autism
asked to rate social acceptability of the telehealth spectrum disorder (ASD) mentorship program to learn
procedures. In one example, Lindgren et al. surveyed FBA and function-based treatment skills supervised by
parents living in mostly rural communities about the a Board certified behavior analyst. Educators reported
social acceptability of receiving behavioral services having no prior experience with preference assess-
via telehealth using the Treatment Acceptability Rat- ments, FA, and FCT. Each educator provided written
ing Form-Revised (TARF-R; Reimers & Wacker, consent to participate in this study.
1988) and found that parents reported high accept-
ability ratings. Thus, parents and hospital staff receiv- Students
ing services in rural areas seem to benefit from tel-
ehealth-related services and find them to be socially Three students, one from each school building, par-
acceptable (Butzner & Cuffee, 2021). There is little ticipated in this study. The research team asked edu-
research, however, showing the effectiveness and cators to select students who were (1) diagnosed with
acceptability of these procedures for rural educators. ASD; (2) within the ages of 3–13 years old; and (3)
In rural communities, schools offer a multitude of reported to exhibit problem behavior in the class-
services (e.g., parent support), in addition to provid- room. Student 1 (Educators 1 and 2) was a 4-year-
ing educational services to students (Starrett et al., old white female who was nonverbal (i.e., no vocal
2021). Although most schools located in rural areas speech) and diagnosed with ASD and global devel-
have access to quality technology services, access opmental delays. School staff served this student in
to equipment to conduct telehealth visits and over- a self-contained classroom. Student 2 (Educators 3
all social acceptability of telehealth-based services and 4) was a 13-year-old white male who spoke in
varies (Fox et al., 2022). Furthermore, Neely et al. full sentences and held a diagnosis of ASD. Student
(2017) and Tomlinson et al. (2018) have encour- 3 (Educators 5 and 6) was a 13-year-old white male
aged continued investigation of strategies to teach who was nonverbal (i.e., no vocal speech) and diag-
others these assessment/treatment procedures via nosed with ASD and moderate intellectual disability.
telehealth. The purpose of the current study was to Student 2 participated in general education instruc-
(1) evaluate the effectiveness of BST implemented tion and Student 3 participated in a self-contained
via telehealth on rural educators accurate imple- classroom. Problem behaviors exhibited by Students
mentation of a MSWO preference assessment and 1 and 3 were aggression (e.g., hitting, biting), prop-
FA; (2) examine the effect of FCT provide by rural erty destruction (e.g., throwing work materials), and
educators trained via telehealth; and (3) examine the tantrums (e.g., crying, yelling). Problem behaviors
social acceptability of training rural educations to exhibited by Student 2 were negative statements
implement behavioral assessment and treatment pro- (e.g., “I hate you” or “I’m not doing this”). Students’
cedures via telehealth. caregivers provided written consent for them to par-
ticipate in this study. The student that spoke in sen-
tences provided assent to participate in this study.
Method The other two students walked into the classroom
independently and stayed in the classroom through-
Participants out the entirety of their involvement in the study,
which was considered assent.
Educators
Setting and Materials
Six educators from three different public schools (two
educators at each school) participated in this study. All Telehealth Center
six completed the MSWO training procedures and three
completed the FA training procedures. Two of the edu- The experimenter provided all coaching from
cators were occupational therapists (Educators 1 and an office at a university-based hospital. The tel-
5) and four were special education teachers (Educators ehealth center was modeled off the technological

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features described by Lee et al. (2015). The office Property Destruction Property destruction was
was approximately 3.0 m x 3.0 m (9.8 ft x 9.8 ft) and defined as a child taking a pencil and drawing on a
contained a desk, lap-top computer, and an exter- piece of paper or surface not intended for writing
nal web-camera. The lap-top computer had Vidyo or in a counterindicated manner or throwing a work
software installed to transmit and receive audio and item approximately 0.3 m (1 ft). Frequency of property
visual input from the educator’s school. Vidyo is a destruction was counted and divided by the total ses‑
secure third-part telehealth platform often used in sion time to produce responses per minute.
health-care settings to transmit protected health
information (www.​vidyo.​com). Debut Video Cap- Negative Vocalizations Negative vocalizations
ture (NCH Software, 2023) was installed on the lap- were defined as a child raising their voice above a
top computer and was used to record the computer conversational tone, using profanity, or vocally pro-
screen. A second observer used these videos to code testing an adult request (e.g., “I’m not going to do
data. Video recordings were stored on a password- that.”). Frequency of negative vocalizations was
protected external hard drive. counted and divided by the total session time to pro-
duce responses per minute.
Schools
Communication Communication was defined
The educator groups were located at three different as the student requesting a break from the instruc-
schools in a Mountain West state. The average dis- tion to play with toys. For Student 1 and Student 3,
tance from the university-based clinic was 166 miles communication was touching a picture card. For
(range: 124–189 miles) or 267 km (range: 199–304 Student 2, communication was vocally saying, “Can
km). Groups were instructed to select private office I play, please?” Frequency of communication was
spaces that had access to a computer with an internal counted and divided by total session time to produce
web-camera to conduct the telehealth sessions. Stu- responses per minute.
dents also participated from these private offices.
Interobserver Agreement

Response Definitions and Observation System A second, independent observer collected data on
an average of 35% (range: 33%–50%) of all educator
Educator Response Definitions training sessions and sessions involving the student.
The second observer recorded data from the video
See Tables 1, 2, 3, 4 and 5 for a complete list of recordings of sessions. When observing educator-
behaviors evaluated during the MSWO and FA pro- only sessions, the second observer used the recording
cedures. Data were collected on percentage of proto- sheet to track correct or incorrect educator response
col steps accurately completed. Accurate steps were during the assessment. When observing FA and FCT
divided by the total number of steps on the protocol sessions that involved the student, the observer scored
and multiplied by 100 to form a percentage. Observ- the sessions twice—once for the educator integrity
ers coded accurate protocol steps as a “1” and inaccu- with session procedures and a second time to track
rate protocol steps as “0” on paper data sheets created student behavior. Observers always coded student
specifically for this study. behavior using Countee (described below). Observa-
tions of the MSWO with the student were only con-
Student Response Definitions ducted once. Data collectors recorded integrity and
student choice making simultaneously.
Aggression Aggression was defined as when a stu-
dent’s hand or foot contacted the body of an adult IOA for Educator‑Only Sessions
from a distance of approximately 0.3 m (1 ft) and
with force. Frequency of aggression was counted IOA coefficients were calculated using an item-
and divided by the total session time to produce by-item comparison of the data. Agreements were
responses per minute. defined as protocol steps in which the primary and

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Table 1  MSWO Steps Evaluated During Training

Dependent Measures Operational Definition

Preliminary Procedures
1. Select five items in the office (Not scored) Participant randomly selected five items (e.g., pen, calculator) in
their office to use during the assessment.
2. Interview Participant asked what stimuli might serve as high, medium, and
low preferred.
3. Presession Exposure Participant presented each item to the participant for 10 s (+/- 5 s).
Trial-by-Trial Procedures
4. Item Arrangement and Prompt Participant placed each stimulus 2 ft apart and in a straight line in
front of the confederate. Confederate directed to “pick one.”
1. Record Selection and Exposure Time Stimulus selected recorded on the data sheet. Stimulus was
available for 30 s (+/- 5 s).
2. Item Restriction Selected stimulus placed behind therapist.
3. Rotate Items Participant moved the item on the confederate’s left side to the far
right and then moved each item one place to the left.
End of Session Procedures
1. Graph Therapist entered the stimuli selected in the correct order within
the Excel spreadsheet.
2. Interpret Graph Therapist moved text boxes embedded within the graph to label
high-, medium-, and low-preferred stimuli.
Correct Response to Confederate “Challenges”
1. Two stimuli selected at the same time on the first trial. Therapist blocks confederate access to both toys and places them
back into the array.
Confederate directed to select one item.
2. Two stimuli selected at the same time on the second presenta- Therapist blocks confederate access to both toys. Ends
tion. assessment.
3. No response to therapist prompt to “pick one.” After 5 s, therapist again directs confederate to “pick one.”

Table 2  Steps to Accurately Conduct the Free Play Condition of the FA

Dependent Measures Operational Definition

Preliminary Procedures
1. Present high-preferred items Educator provides access to previously identified high-preferred items
Trial-by-Trial Procedures
2. Provide attention at least once every 30 s Educator vocally interacts with student once every 30 s.
3. Minimize attention to problem behavior Educator does not vocally attend to student problem behavior.
End of Session Procedures
4. Graph Therapist entered the stimuli selected in the correct order within the
Excel spreadsheet.
Correct Response to Confederate “Challenges”
1. Student does not play with toy for 20 s Continue to provide attention and encourage toy play.
2. Student engages in nontargeted problem behavior Minimize attention and encourage toy play.
3. Student engages in targeted problem behavior Minimize attention and encourage toy play.

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Table 3  Steps to Accurately Conduct the Attention Condition of the FA

Dependent Measures Operational Definition

Preliminary Procedures
1. Present low-preferred items Educator provides access to previously identified low-preferred items
2. Engage in 1-min of attention Educator interacts with student for 1 min.
Trial-By-Trial Procedures
3. Restrict attention after 1 min presession period ends Educator directs student to play alone after 1 min.
4. Educator reads a magazine Educator looks at a magazine and not at student
5. Educator delivers 30 s attention when targeted prob- Educator puts magazine down and attends to student for 30 s.
lem behavior occur
6. Data collection Educator writes a tally each time a targeted problem behavior occurs.
End of Session Procedures
1. Graph Educator entered data collected into the correct cell within the Excel
spreadsheet.
Correct Response to Confederate “Challenges”
1. Student asks nicely for attention Educator minimizes attention to student
2. Student yells at educator Educator minimizes attention to student
3. Student engages in hand biting Educator talks to student for 30 s before returning to their magazine.

Table 4  Steps to Accurately Conduct the Tangible Condition of the FA

Dependent Measures Operational Definition

Preliminary Procedures
1. Present high-preferred items Educator provides access to previously identified high-preferred items
2. Allow student to access items for 1 min Educator allows student to interact with item for 1 min.
Trial-By-Trial Procedures
3. Educator restricts toy after 1-min exposure period Educator takes student toy away from them.
4. Educator restricts student access to toy Educator maintains control over student’s toy.
5. Educator delivers 30 s access to the toy when tar- Educator returns toy to child following targeted problem behavior
geted problem behavior occur
6. Data collection Educator writes a tally each time a targeted problem behavior occurs.
End of Session Procedures
7. Graph Educator entered data collected into the correct cell within the Excel
spreadsheet.
Correct Response to Confederate “Challenges”
8. Student asks nicely for toy Educator minimizes attention to student
9. Student yells at educator Educator minimizes attention to student
10. Student pushes educator Educator returns toy to child for 30 s

secondary data collectors recorded the same rating 100 to obtain the percentage of IOA for the specific
(e.g., 1 or 0). Disagreements were defined as protocol session.
steps in which the primary and secondary data col- For Group 1 during the MSWO, IOA was collected
lectors recorded different ratings for the same step. on an average of 40% (range: 30%–50%) of sessions
In each implementation of the MSWO or FA, the in each of the baseline, remote-BST, and in-situ
number of agreements was divided by the number probe conditions. IOA was 100% for Educator 1 and
of agreements plus disagreements and multiplied by the average IOA for Educator 2 was 98.2% (range:

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Table 5  Steps to Accurately Conduct the Escape Condition of the FA

Dependent Measures Operational Definition

Preliminary Procedures
1. Educator gets pencil and work materials prepared Educator places work materials and a pencil on desk
Trial-by-Trial Procedures
2. Educator presents instruction to student Educator vocally directs student to complete work
3. Educator gives a 30-s break from instruction when targeted problem Educator removes task from table
behavior occurs
4. Data collection Educator writes a tally each time a targeted problem
behavior occurs.
End of Session Procedures
5. Graph Educator entered data collected into the correct cell
within the Excel spreadsheet.
Correct Response to Confederate “Challenges”
6. Student asks nicely for break Educator minimizes attention to student
7. Student yells at educator Educator minimizes attention to student
8. Student tears pencil or throws task Educator removes task for 30 s

95.1%–100%). For Group 2, IOA was collected on an “Countee.” Countee is an iPad application that
average of 33% (range: 28%–42%) of sessions across permits recording of both frequency and duration-
sessions in each of the baseline, remote-BST, and in- based behavior. We calculated IOA coefficients
situ probe conditions. The average IOA for Educator using a block-by-block method. In particular, data
3 was 92.3% (range, 90.8%–100%) and IOA for Edu- from the two independent observers were placed in
cator 4 was 100%. For Group 3, IOA was collected 10-s bins to be compared. Agreement percentages of
on an average of 38% (range: 33%–48%) of sessions each target behavior (i.e., those behaviors recorded
across all sessions in each of the baseline, remote- by both observers during the same 10-s interval)
BST, and in-situ probe conditions. The average IOA and the nonoccurrence of the target behaviors (i.e.,
for Educator 5 was 94% (range: 91.4%–100%) and target behaviors not scored by either observer dur-
the average IOA for Educator 6 was 91.7%. (range: ing the same 10-s interval) were collected based on
90.8%–100%). an interval-by-interval comparison of each observ-
For the FA, IOA for Educator 1 was collected er’s records. The IOA score was calculated based on
on an average of 33% (range: 25%–40%) of all ses- mean occurrence per interval (Cooper et al., 2019).
sions in each of the baseline, remote-BST, and in- Within each interval, the number of agreements was
situ probe conditions. The average IOA for Educa- divided by the number of agreements plus disagree-
tor 1 was 95.5% (range: 89.2%–100%). For Educator ments and multiplied by 100 to obtain the percent-
3, IOA was collected on an average of 33% (range: age of IOA for the specific interval. Interobserver
29%–36%) of sessions across all sessions in each of agreement for each interval was then averaged to
the baseline, remote-BST, and in-situ probe condi- obtain the percentage of IOA for each session.
tions. IOA was 100% for Educator 3. For Educator For Student 1, IOA was collected on an aver-
5, IOA was collected on an average of 40% (range: age of 38% (range: 33%–45%) of sessions for all
36%–50%) of sessions across all sessions in each of experimental conditions and averaged 99.4% (range:
the baseline, remote-BST, and in-situ probe condi- 97.3%–100%). For Student 2, IOA was collected on
tions and averaged 92.9% (range: 87.4%–100%). an average of 40% (range: 34%–45%) of sessions
across all experimental conditions and averaged
IOA for Student Involvement 93.3% (range: 85.7%–100%). For Student 3, IOA was
collected on an average of 40% (range: 36%–43%) of
To obtain IOA data during FA and FCT ses- sessions across all experimental conditions and aver-
sions with the student, data were collected using aged 97.8% (range: 96.6%–100%).

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For problem behavior and communication during example, during the MSWO, the researcher may have
FCT for Student 1, IOA was collected on an aver- told the confederate to select two items rather than just
age of 34% (range: 30%–38%) of sessions and aver- one, or to not make a choice at all. In another example,
aged 94.3% (range: 92.2%–100%). Educator 3 and the confederate may have been asked to make a nega-
4 had IOA collected on an average of 42% (range: tive statement after 1 min of completing instructions
38%–45%) of sessions conducted during Student 2’s during the escape condition of the FA. The researcher
FCT evaluation. Their IOA averaged 97.5% (range: changed the order in which “challenges” occurred
95.7%–100%). Finally, Student 3 had IOA collected between sessions so the educator playing the role as
on 50% of FCT sessions conducted. IOA averaged therapist could not predict confederate responding. The
92.5% (range: 88.9%–100%). confederate was instructed to comply with “therapist”
instructions in between periods in which challenges
Experimental Design were expected to occur. After the educator serving the
role of “therapist” reviewed their protocol, they put it
Training educators on MSWO and FA procedures out of sight and began conducting the procedures. If
occurred within a concurrent multiple-baseline the procedures called for the “therapist” to interview a
across educators design to evaluate the effect of caregiver, they were told to interview the research team
BST delivered via telehealth on accuracy of each member on the video call for this information. The
protocol implementation. That is, all baselines “therapist” then completed the steps of the protocol in
began on the same day and data were collected at the order they are presented in Tables 1, 2, 3, 4 and 5.
the same points in time across educators. The stu- The research team did not provide feedback on perfor-
dent FAs were conducted within a multielement mance unless the confederate did not implement a step
design to evaluate behavioral function. FCT was on their protocol or attempted to give guidance to their
conducted within a concurrent multiple-baseline partner. The research team immediately interrupted
across students design to evaluate the effect of FCT the interaction and either prompted the confederate to
on student problem behavior. review their protocol or directed the “therapist” to con-
tinue working. After the session ended, the “therapist”
graphed their data and then emailed it to the first author
Procedures for analysis. No feedback on performance was deliv-
ered after the graph was sent. These procedures were
For all participants, experimental appointments then repeated with the confederate educator assuming
occurred once per week for 1 hr. The first author sent the role of therapist and vice versa until each educator
a link to a Vidyo chat room 15-min prior to the begin- was able to function as the “therapist” and “confeder-
ning of the appointment. Once the research team and ate” at least two times.
both participants were present, the research team con-
ducted a check to ensure sound and video quality. Remote BST During BST for the MSWO, each
educator was seated next to each other in front of the
Protocol‑Only Baseline (for MSWO and FA) Dur- computer screen so the experimenter could deliver
ing the Baseline, one educator was provided with a training to both at the same time. Thus, both edu-
“therapist” protocol describing the relevant assessment cators received BST during the MSWO evaluation.
and the other educator was given a “confederate” pro- During BST for the FA, one educator sat in front of
tocol describing how they should respond during the the computer for training while the second educator
assessment. Information about the therapist and con- left the room until BST was completed. Only one
federate responses during the MSWO and FA training educator received BST during the FA evaluation to
periods are provided in Tables 1, 2, 3, 4 and 5. The ensure the remote BST influenced improvements in
educator assigned to the role of therapist had 5 min to integrity and not observing their partner implement
review a protocol of the specific condition procedures. the assessment.
The researcher provided the confederate with a list of During BST, the experimenter reviewed the tar-
“challenges” and instructions for when to engage in geted protocol, modeled correct implementation of
those challenges via the chat function in Vidyo. For the assessment, and arranged opportunities for each

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participant to practice aspects of the protocol they did FCT (Carr & Durand, 1985). The training for FCT
not complete accurately during baseline. For example, was different than for the MSWO and FA procedures
if within-session analysis of the MSWO demonstrated due to time constraints at the end of the school year.
that an educator did not offer a 10-s introduction to Prior to beginning the FCT sessions, the research team
each item at the beginning of the assessment, the met with each educator and described the FCT proce-
researcher coached the educator and provided feed- dures which were similar to those described by Suess
back about how to engage in this response. During et al. (2014). Educators did not receive opportunities to
these practice opportunities, immediate feedback was practice FCT with feedback, though. In total, this train-
delivered to shape participant performance. Training ing lasted approximately 20–30 min. After educators
occurred until the educators implemented the proto- expressed understanding of the procedures, the stu-
col with greater than 80% integrity and without assis- dents were invited into the room to begin procedures.
tance on one occasion. After BST was completed, FCT sessions lasted 5 min. FCT sessions began with
the educators transitioned back to the Protocol-Only one educator presenting a visual schedule to the stu-
Baseline condition to evaluate improvement in proce- dent and saying, “First work and then play.” The stu-
dural integrity without the feedback programmed to dent was subsequently directed to a desk in the room
occur during BST. to complete a small instruction. The educators placed
a picture card representing play on the desk and posi-
In‑Situ Probes During In-Situ Probes, each edu- tioned themselves next to the student to deliver instruc-
cator that had received training conducted the rel- tions. Educators acknowledged but denied requests for
evant assessment with a student diagnosed with play that occurred before the assigned work had been
ASD. In-Situ Probes occurred an average of 3 weeks completed. Educators used the same requests utilized
(range: 1–4 weeks) after educators completed the during the FA. If the student engaged in problem
Remote BST condition. Prior to sessions, the edu- behavior (the targeted behaviors or nontargeted behav-
cators gathered all items necessary for both assess- iors, such as crying), educators directed their atten-
ments. For the MSWO, the educators used five items tion to the student’s preferred activities and vocally
they had observed the student engage with in the prompted task completion every 30 s. For example,
past. For Student 1 (Educators 1 and 2), the educa- if a student engaged in problem behavior, the educa-
tors selected an iPad, card games, coloring materi- tor walked away from the student and engaged with
als, Legos, and books. Educators 3 and 4 selected one of the preferred activities in the room. They deliv-
iPad, Legos, magic tricks, coloring materials, and ered reminders every 30 s for the student to complete
board games for Student 2. Finally, Educators 5 and work to earn toys. Following task completion, regard-
6 selected iPad, Legos, coloring, board games, and less of the occurrence of problem behavior, the stu-
stacking blocks as items for Student 3’s MSWO. We dent received praise and the instruction was removed.
used a brief FA for this study and conducted the FA At this time, the first communicative request from the
on property destruction for Students 1 and 3 and student produced 2 min of access to preferred items,
negative statements for Student 2 (Northup et al., similar to the procedures described in Golonka et al.
1991). Escape, tangible, and attention test condi- (2000). If the student did not communicate, the edu-
tions were conducted to probe responding under cator vocally prompted the student to communicate
each condition. Sessions of each FA condition lasted after 30 s. The educator’s partner engaged with the stu-
5 min. The educators were directed to conduct ses- dent during play and then delivered the next instruc-
sions, collect data, and graph data similar to how tion according to the described routine. The educators
they did in the Protocol-Only Baseline condition, set initial and terminal treatment goals for the student
again without feedback on their performance. Edu- prior to beginning FCT. For example, the educator may
cators did not give each other feedback during or have wanted the student to complete one discrete task
after their work with the student. at the beginning of FCT and increase to five discrete
tasks in order to access reinforcement by the end of
Functional Communication Training After receiv- FCT. Once this goal was achieved, and problem behav-
ing training on, and implementing, the MSWO and iors remained at low rates with a steady rate of com-
FA with their student, the educators transitioned to munication, the treatment evaluation ended.

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 14 Educ. Treat. Child. (2023) 46:5–22

Social Validity After In-Situ Probes sessions were During baseline, Educator 1 conducted one session of
completed, each educator completed a modified ver- each FA condition. All were conducted with low-to-
sion of the TARF-R (Reimers & Wacker, 1988) to moderate integrity. Educator 1 conducted the escape
assess acceptability of the experimental procedures condition with 27.3% accuracy, attention with 27.3%
for the MSWO, FA, and FCT. The TARF-R provides accuracy, free play with 33.3% accuracy, and tangible
educators with a Likert-type scale (i.e., 1 = not accept- with 45.5% accuracy. Likewise, Educator 3 conducted
able and 7 = highly acceptable) to rate the procedures. the FA conditions with low integrity. Educator 3 aver-
The only exception was the item describing costliness aged 50% accuracy when implementing the escape
of the intervention. For this item, a score of 1 meant condition, 33.3% accuracy with the attention condi-
“low cost” and 7 meant “high cost.” We analyzed the tion, 66.7% accuracy with the free play condition, and
educator rating to evaluate the acceptability of all pro- 45.8% accuracy with the tangible condition. Educator
cedures. Educator responses to the TARF-R remained 5 implemented procedures with low integrity across
confidential. Educators completed the TARF-R using a all FA conditions during baseline. Attention was con-
Qualtrics survey to maintain anonymity. ducted with an average of 23.7% accuracy, free play
with an average of 29.6% accuracy, escape with an
average of 27.3% accuracy, and tangible with an aver-
Results age of 22.2% accuracy.
Following BST, Educator 1’s performance imme-
Educator MSWO Performance Figure 1 displays diately improved. This educator was able to conduct
data for Educators 1 and 2 (top panel), Educators 3 the free play, escape, and tangible conditions with
and 4 (middle panel), and Educators 5 and 6 (bottom 100% accuracy. The attention condition was con-
panel). During baseline, all three groups performed ducted with 95.5% accuracy. Educator 3’s perfor-
the MSWO preference assessment with low-to-mod- mance also increased following BST. Accuracy with
erate integrity when administering it with a confeder- the attention condition averaged 87.5%, free play
ate (M = 46.3%). Educators 1 and 2 averaged 60.3%; averaged 94.4%, escape averaged 95.5%, and tangi-
Educators 3 and 4 averaged 49.4%; and Educators 5 ble averaged 100%. Educator 5’s data showed a simi-
and 6 averaged 37.1%. lar pattern. During free play, average integrity was
Following implementation of BST via telehealth, 94%, during attention was 95.5%, during escape was
each educator’s performance with the MSWO prefer- 90.9%, and during tangible was 91.7%.
ence assessment improved (M = 87.9%). In particular, During In-Situ Probes, Educator 1 maintained high
Educators 1 and 2 averaged 97.3%, Educators 3 and accuracy with the free play and attention conditions.
4 averaged 84.5%, and Educators 5 and 6 averaged Accuracy with implementing the escape (50%) and
85.1%. Five of the six educators maintained their per- tangible (75%) conditions decreased when compared
formance during maintenance when administering the to sessions conducted following BST. A similar pat-
MSWO with a student diagnosed with ASD. Educator tern was observed for Educator 2 in which the atten-
1’s performance decreased from an average of 98.1% tion and free play conditions were conducted with
when implemented with a confederate to 77.8% when 100% accuracy and the escape (33.3%) and tangible
implemented with the student. The results from Stu- (57.1%) conditions were implemented with lower
dent 1’s MSWO showed iPad, Legos, coloring, card accuracy. Their student’s FA (Fig. 3) showed a tan-
games, and books; Student 2’s MSWO results showed gible (M = 0.5 rpm) and escape function (M = 0.8
iPad, Legos, coloring, board games, and magic tricks; rpm). No problem behavior occurred during the atten-
and Student 3’s MSWO results showed Legos, color- tion or free play conditions.
ing, iPad, board games, and stacking blocks. Results Educator 3 implemented three of the four FA condi-
from the TARF-R showed high acceptability of the tions with 100% accuracy during the In-Situ Probes. The
telehealth training procedures (Table 6). educator restricted or denied access to preferred items led
to this student’s problem behavior. Thus, a tangible condi-
Educator FA Performance and Identified Func‑ tion was not indicated for this student. Educator 4 imple-
tions Figure 2 displays data for the three educators mented the free play and escape conditions with 100%
who administered the FA (Educators 1, 3, and 5). accuracy and implemented the attention condition with

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Educ. Treat. Child. (2023) 46:5–22 15

Fig. 1  Percentage of Steps

Completed Accurately on
the MSWO Preference
Assessment Protocol

71.4% accuracy. The result of their student’s FA (Fig. 3) function (0.8 rpm). Educator 5 chose not to conduct a
showed problem behavior was reinforced by escape second tangible condition due to concern that the stu-
from instructions (M = 1.0 rpm). No problem behaviors dent would escalate to highly aggressive behaviors.
occurred during the attention or free play conditions. No problem behaviors occurred during the attention
During In-Situ Probes, Educator 5 implemented all or free play conditions Fig. 4.
FA conditions with high accuracy. Free play, escape,
and tangible conditions were implemented with Student Behavior During FCT For Student 1, prob-
100% accuracy and attention was implemented with lem behavior decreased from an average of 0.6 rpm to
an average of 90.9% accuracy. This student (Fig. 3) an average of 0.28 rpm during the initial implemen-
showed a likely escape (M = 0.6 rpm) and tangible tation of FCT under a fixed ratio (FR) 1 schedule of

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 16 Educ. Treat. Child. (2023) 46:5–22

Table 6  Treatment Acceptability Rating Form-Revised Results for All Three Experiments
Item MSWO FA FCT
Average Rating (N = 6) Average Rating (N = 5) Average Rating (N = 5)

How acceptable do you find telehealth training as a way 5.9 6 6.6

to improve care for the student you work with? (range: 5–7) (range: 5–7)
How likely is telehealth training to make improvements 6.4 6 6
to how you conduct [procedure]? (range: 5–7)
How costly will it be to continue participating in train- 2 2 1.4
ing opportunities via telehealth? (range: 1–3) (range: 1–2)
How will are you to carry out the [procedure] you 6.8 6 6.4
learned during telehealth training? (range: 4–7) (range: 5–7)
How confident are you the telehealth training will be 6.2 6 6
helpful as you continue to conduct [procedure]? (range: 6–7)
How willing would you be to change your daily routine 6.2 5 5.4
in order to participate in future telehealth training (range: 5–7) (range: 4–7)
opportunities?
How disruptive will it be for your school for you to par- 3.8 4 4
ticipate in future telehealth training opportunities? (range: 2–4)
How effective is telehealth treatment likely to be to 6.3 6 6
improve your [procedure] skills? (range: 6–7)
How well will participating in telehealth treatment fit 5.5 6 5.8
into your school-day routine? (range: 5–6) (range: 5–6)

reinforcement. Communication increased to an average Discussion

of 0.15 rpm. Following a brief escalation in problem
behavior when transitioning to the FR-5 condition, prob- The current study adds to the growing literature base
lem behavior decreased to an average of 0.28 rpm. Com- showing behavior analysts can effectively deliver
munication maintained at an average of 0.18 rpm. Edu- BST to train others to implement common behavioral
cator 1’s integrity with FCT implementation averaged assessment and treatment procedures via telehealth
97% (range: 95%–100%) and Educator 2’s integrity with (Lloveras et al., 2022; Neely et al., 2017; Neely et al.,
FCT implementation was 100%. For Student 3, prob- 2021; Pollard et al., 2021; Schieltz & Wacker, 2020;
lem behavior also decreased and maintained at zero or Unholz-Bowden et al., 2020). The fact that each edu-
near-zero rates upon implementation of FCT under the cator provided service in a rural school represents a
FR-5 arrangement. Problem behavior specific decreased more novel aspect of this study. We showed that the
from an average of 0.6 rpm to an average of 0.03 rpm MSWO preference assessment and FA of problem
at the end of FCT. Communication also increased to an behavior could be taught to educators via telehealth
average of 0.16 rpm. Educator 5’s integrity with FCT who were working in rural school settings. Five of
implementation averaged 92% (range: 85%–100%). For the six educators demonstrated the ability to imple-
Student 2, problem behavior decreased from an average ment a MSWO preference assessment with high
of 1.0 rpm and maintained at zero rates during the FR-5 accuracy, and all three educators who were trained
condition (problem behavior M = 0.08 rpm). Communi- to conduct FAs using BST were able to implement
cation increased to an average of 0.13 rpm. Educator 3’s at least two conditions with high integrity. Further-
integrity with FCT implementation was 100% and Edu- more, the educator-implemented MSWOs and FAs
cator 4’s integrity with FCT implementation averaged identified clear stimulus preferences and social func-
98% (range: 96%–100%). tions, respectively. The results of the MSWO and FA
were used to successfully individualize an FCT pro-
TARF‑R Results Analysis of the TARF-R results gram for the students. Each educator contributed to
(Table 6), showed the procedures were rated as highly the FCT program, leading to an average of a 90.6%
acceptable by the educators. decrease in problem behavior. Furthermore, each

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Educ. Treat. Child. (2023) 46:5–22 17

Fig. 2  Percentage of Steps

Completed Accurately for
Each Condition of the FA

educator reported the training procedures during all to successful program implementation. Social
three experiments to be highly acceptable as per the acceptability of services delivered in rural areas is
modified TARF-R (Table 6). highly important. Even though schools in rural areas
As described by Neely et al. (2021), behavior- are often equipped with high-speed internet services,
analytic services delivered via telehealth reliably educators sometimes report feeling underprepared to
produce clinically significant outcomes that are often navigate challenges with using technology (Frieder
consistent with outcomes produced from in-person et al., 2009). In addition, individuals living in rural
services (Lindgren et al., 2016). Thus, the current communities can sometimes be hesitant to accept
study’s data regarding educator acquisition of skills or participate in support from individuals outside of
to implement the MSWO and FA and the clinically their community (Coombs et al., 2022). The current
significant decreases in problem behavior are per- study evaluated social acceptability of the proce-
haps not surprising. However, there are other aspects dures three times over the course of the investigation.

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 18 Educ. Treat. Child. (2023) 46:5–22

Fig. 3  Rate of Problem Behavior during the FA for the Students

Overall, satisfaction ratings were positive (see analyze the dose of training required to achieve results
Table 6) and similar to other published studies using similar to the current study. Finally, educator TARF-
the TARF-R as the measure of social acceptability R responses differed slightly across MSWO, FA, and
(Lindgren et al., 2016). FCT procedures. For example, educators reported the
At least three results from the TARF-R warrant acceptability of telehealth training to learn the MSWO
additional discussion. First, these educators perceived lower than for the FA and FCT. In contrast, educators
participating in telehealth services would be of low expressed the highest willingness to implement the
financial cost to them, as evidenced by their low ratings MSWO compared to the FA or FCT. Future research
to this item. In terms of financial cost, neither the edu- should replicate this study and collect social validity
cators nor the behavior consultant needed to travel or data throughout training of different behavioral assess-
pay to receive or deliver the service. That said, the edu- ment and treatments to examine whether these trends
cators did rate the item asking how disruptive partici- persist. In addition, qualitative measures of social
pating in telehealth services would be for their schools validity could be a useful way to further evaluate the
moderately high. This suggests that there are aspects of acceptability of these procedures.
telehealth service delivery that may be disruptive for Although training programs delivered via telehealth
rural schools. With long-noted staffing challenges in often lead to improved procedural integrity, the main-
rural schools, participating in weekly trainings may be tenance of these findings to in-situ periods varies (e.g.,
challenging for the broader school system (Gagnon & Machalicek et al., 2009). We found this during the in-
Mattingly, 2015). Future research might parametrically situ probes primarily during the FA training. This could

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Educ. Treat. Child. (2023) 46:5–22 19

Fig. 4  Rate of Problem Behavior and Communication during FCT for Each Student

potentially be addressed in two ways. First, for educators conducting the student’s FAs because indirect and
that demonstrate variable integrity, immediate feedback descriptive information collected by the schools did
could be provided and then gradually withdrawn to not suggest maintenance by automatic reinforcement.
help support correct implementation of the procedures. Future research would benefit from including one of
Second, some research suggests that a telehealth-only these conditions. It may be particularly important to
model of service is often less preferred than a hybrid see how adding additional FA conditions affects the
model that consists of both in-person and telehealth ser- acceptability of these procedures. Second, when edu-
vices (Romani et al., 2021). Rural educators might bene- cators’ procedural integrity decreased, they were not
fit from site visits that occur when implementing FAs or always provided with additional training (e.g., for
other nuanced behavioral assessment procedures before Educator 1 when conducting the FA). Future research
transitioning to telehealth-based consultation. Future should closely attend to this and immediately provide
research should continue to evaluate the maintenance of correction to ensure high procedural integrity. Third,
responding and systematically evaluate ways to support brief experimental analyses were employed in the cur-
educator integrity with behavior-analytic assessment and rent studies. School teams preferred brief analyses to
treatments via telehealth. expedite student access to treatment services. However,
Although the current study demonstrated prom- future research should conduct more extended analyses
ising results for a telehealth-training program in to more completely demonstrate experimental control
schools, there are number of limitations that need to over BST and changes in procedural integrity. It will
be addressed with future research. First, for efficiency, be important to see whether and how the acceptability
we did not conduct an alone or ignore condition when of these procedures changes when extended analyses

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 20 Educ. Treat. Child. (2023) 46:5–22

are implemented. Likewise, we did not establish three Consultation, 28(3), 297–318. https://​doi.​org/​10.​1080/​
different lengths of baseline during the FCT evaluation 10474​412.​2018.​14315​48
Behavior Analysis Certification Board. (2014). Professional
because of time constraints. Fourth, after completing and ethical compliance code for behavior analysts.
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Analysis Certification Board, 2014). Ethical bounda- retention, and professional development: Considerations
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