The COVID-19 pandemic impacted everyone in the world in some way. Essentially, the world was homebound at one point in time, and this was exceedingly difficult for some populations. To those with autism, the effects of the pandemic were extremely isolating and often resulted in a complete lack of access to therapies and services. 

During the pandemic, applied behavior analysis (ABA) clinicians and therapists learned how to navigate telehealth quickly to try to provide services to their clients with autism. Some families and children benefited greatly from this type of therapy, which helped them bridge the gap until quarantine periods were over. However, for others, telehealth didn’t work as well, and it was difficult to get some children to attend to video services in a therapeutic manner. 

Post-pandemic, telehealth use remained a mainstay for ABA treatment, particularly when sessions had to be canceled due to illness or for families that were too remotely located to access services. However, as of 2023, telehealth may begin to faze out with some insurance companies.

Read on to learn more about how ABA has changed and how life has changed for those with autism after the wake of COVID-19.

What Is ABA? What Did ABA Look Like Prior to COVID-19?

According to the American Psychological Association (APA), ABA is an evidence-based practice. ABA methodology has undergone a thorough research and review process, supporting that ABA can be a very successful treatment for those with autism. ABA is based on the science of behavior and learning. Using ABA therapy, trained professionals can better understand how learning occurs, how the environment affects behavior, and how behavior “works” overall. When considering a therapy to reduce the symptoms of autism, ensure the therapy is evidence-based.

ABA is commonly associated with autism but can be used for other reasons, such as substance abuse disorders or dementia. Before the pandemic, ABA clinicians would deliver therapy either in the clinic, at home, in school, or in the community, such as during an event. The design of ABA includes an assessment, subsequent treatment plan, and therapy delivered by an ABA clinical team; this often includes one or more board-certified behavior analysts (BCBAs), registered behavior technicians (RBTs), and behavioral technicians (BTs). 

BCBAs have a master’s or doctoral degree, and oversee the RBTs that work individually with each client. During supervision, the BCBA delivers therapy as well and interacts with the child. BTs are present to support other clinical staff. There is a lot of close contact in ABA therapy, whether a child shares a screen, plays a game, or completes a task. 

While lockdowns and quarantines were mostly mandated at the state level, in many cases, applied behavior analysis was not determined as a “medical need” and had to change the method of service delivery. Not only did this impact access to clinics, but it also completely eliminated in-home therapy, where most of the work was accomplished. No one knew when lockdown would be over, and quickly, children and other clients with autism lost access to their much-needed services. ABA and other services were drastically affected, such as occupational therapy (OT), physical therapy (PT), speech therapy, and mental health and psychiatry services. 

Clinicians, educators, parents, and those with autism were at a loss as to what to do. Telehealth was used infrequently before the pandemic, but it seemed the best option moving forward, with no real knowledge of when life would return to “normal.”

Autism and Regression During COVID-19

Any ABA clinician or educator familiar with autism or ABA will tell you that routine and consistency are key—these are two strong tenets of ABA. However, the world was completely unprepared for the isolation that the pandemic would cause. In February 2020, children were going to school as usual and attending their services. By mid-March 2020, schools were nearly completely shut down across the country, as well as supportive services. What was a child with autism and their family to do?

According to a CNN article, “During the early months of the COVID-19 pandemic, many families canceled in-home services, fearing infection. Virtual therapy often didn’t seem to work, especially for nonverbal and younger children. With fewer clients, some providers laid off staff or shut down entirely.”

Another setback during the pandemic was the lack of autism diagnoses. Because so many practices were shut down or barely running during the height of the pandemic, children suspected to have autism had to wait longer for diagnoses, as pediatricians couldn’t complete initial assessments and clinical psychologists weren’t able to diagnose. 

Prior to the pandemic, many families struggled to get autism diagnoses covered and authorizations for ABA therapy under their insurance, and it was even more difficult during the pandemic. 

Post-pandemic, it was clear many children had regressed. Regression included a loss of skill sets and increases in maladaptive behaviors, such as self-injury and aggression. A 2022 study looked at boys with moderate-to-severe autism after their return to school and found strong increases in hyperactivity, aggression, self-injurious behavior, repetitive behaviors, and anxiety. While this is but one study, others have been conducted with similar findings. 

The pandemic was also difficult for ABA clinicians who worked in the field as well. A study found severe burnout in ABA clinicians during the pandemic, because of issues such as work and family conflict, loss of work or underemployment, increased stressors with virtual therapy, and other concerns.

ABA During the Pandemic: Telehealth

With everyone concerned about close contact and the spread of germs, telehealth emerged as a viable ABA treatment option during the pandemic (and after). 

Telehealth ABA sessions may look different than traditional ABA sessions. However, it can be just as effective, particularly if parents are strongly involved and prepare well for individual sessions. Telehealth varies for every client, depending upon their individual needs. The ABA clinician will usually meet with the client virtually using an app or program. These can include FaceTime, Zoom, Microsoft Teams, and other HIPAA-compliant methods. Clinicians and clients can also talk by phone in lieu of a video session; however, video sessions are most effective. The child can use a variety of devices to connect with telehealth, such as a desktop or laptop computer, tablet, or smartphone. The therapist can be in person with the supervising clinician joining virtually, or both can be virtual. 

For some children with autism, telehealth during the pandemic was advantageous. Clients could continue to build rapport and work with their clinicians, albeit through a screen. Telehealth has several overall benefits, including

• Easy to schedule – It’s simple to find a time when both parties are virtual
• Keeps a routine – Telehealth was a way to help keep routines during the pandemic
• Teaches virtual skills – Children could learn virtual and computer skills during sessions, with less chance of regression in these areas
• Less expensive – Overall, telehealth is less expensive than face-to-face therapy; however, parents did struggle with coordinating telehealth with insurance coverage in some cases
• Provides access to therapy – While telehealth was difficult for some, it did provide access to ABA therapy during the pandemic when there were no other channels available 

Telehealth also had, and has, its downsides. It’s not effective for every child, particularly for those comorbid conditions such as attention-deficit hyperactivity disorder (ADHD). It can be tough for children to attend to a screen for long periods of time, particularly if it feels like work. Recent studies do point to telehealth and its effectiveness. However, more studies are needed as results are extremely varied across clients. 

Access to Telehealth Post-pandemic

Telehealth for ABA was fundamentally established during the pandemic as it was not as widely used beforehand. However, post-pandemic, families who experienced the effectiveness of telehealth often continued virtual services. Also, telehealth is a great option when a client or clinician is ill, when a family is traveling on vacation, or if families are in remote areas where they have trouble getting to a clinic or receiving in-home services. Unfortunately, some families may have to pay out-of-pocket for telehealth services beginning in 2024. Why?

The Centers for Medicare and Medicaid Services (CMS) are reviewing the effectiveness of telehealth through the end of 2023, and services will continue to be covered. However, whether services are covered in 2024 remains to be seen. CMS first approved telehealth coverage in January 2020 and has been extending it ever since. However, there is a good chance that coverage for telehealth will be dropped, according to Julie Kornack, chief strategy officer for the Center for Autism and Related Disorders. She reports that telehealth was “never authorized” prior to the start of the pandemic. This could be difficult for families with Medicare and Medicaid who rely on Telehealth services for ABA. 

The “New Normal” and Post-pandemic Autism Treatment

When schools reopened and services resumed, they looked slightly different. Between social distancing measures and masking, delivering services in person came with obstacles to overcome. Slowly, mask mandates and social distancing measures were lifted, and things reasonably resumed to normal. 

For people and children with autism, however, the switch back to normal didn’t always come so easily. Children with autism returned to school with the likelihood of being behind in academics and a loss of social and communication skills. As previously mentioned, some children resumed or intensified self-injurious and aggressive behavior. Working through regression can be a challenge. 

However, a dedicated and caring ABA team can help overcome regression. In addition to ABA and other primary outside services, if your child is still struggling with regression, consider:

• Social skills groups
• Increased ABA hours
• Functional skills training 
• Family training
• Functional communication training 

You may find that your ABA provider already offers some of these programs and training. Your BCBA and ABA clinicians can always offer you more parent training as well, so you can focus on working on regression at home when your providers are not present. 

A summer uptick of COVID-19 cases in Summer 2023 has both clinicians and families affected by autism worried that there will be a return to quarantine, mandates, and social distancing, but we deeply hope that is not the case. 

For more information about ABA therapy or to schedule an assessment for your child, contact the professionals at Acclaim Autism today. 

References

Applied Behavior Analysis. (2017, February). American Psychological Association. Retrieved September 2, 2023, from https://www.apa.org/about/policy/applied-behavior-analysis

Autism and the Pandemic | Autism Therapy Programs TX. (2021, July 1). Camp Worth. Retrieved September 2, 2023, from https://www.discovercampworth.com/autism-treatment-center-fort-worth-texas-blog/easing-a-child-with-autism-back-into-a-post-pandemic-world/

Bosman, J. (2023, August 28). Not Over Yet: Late-Summer Covid Wave Brings Warning of More to Come. The New York Times. Retrieved September 2, 2023, from https://www.nytimes.com/2023/08/28/us/covid-cases-hospitalizations.html

Dattaro, L. (2022, July 15). Access to virtual autism therapy in the U.S. could narrow post-COVID. Spectrum | Autism Research News. Retrieved September 2, 2023, from https://www.spectrumnews.org/news/access-to-virtual-autism-therapy-in-us-could-narrow-post-covid/

Hannawi, A. P., Knight, C., Grelotti, D. J., & Trauner, D. A. (2022, May 06). Impact of COVID-19 Pandemic-Associated Social Changes on Boys with Moderate to Severe Autism. Advances in Neurodevelopmental Disorders, 6, 206-210. https://link.springer.com/article/10.1007/s41252-022-00257-7

Jiminez-Gomez, C., Sawhney, G., & Albert, K. M. (2021, December). Impact of COVID-19 on the Applied Behavior Analysis Workforce: Comparison across Remote and Nonremote Workers. Behavioral Analysis in Practice, 14(4), 873-882. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8320716/

Lindgren, S., Wacker, D., Suess, A., Schieltz, K., Pelzel, K., Kopelman, T., Lee, J., Romani, P., & Waldron, D. (2016, February). Telehealth and Autism: Treating Challenging Behavior at Lower Cost. Pediatrics, 137(Supp2), S167-S175. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4727312/

Miller, A., & Gold, J. (2022, March 28). ‘Heartbreaking’ delays in autism diagnosis and treatment got even worse during the pandemic. CNN. Retrieved September 2, 2023, from https://www.cnn.com/2022/03/28/health/autism-delays-pandemic-khn-partner/index.htmlNicolson, A. C., Lazo-Pearson, J. F., & Shandy, J. (2020, October 16). ABA Finding Its Heart During a Pandemic: An Exploration in Social Validity. Behavioral Analysis in Practice, 13(4), 757-766. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7567003/