I had the pleasure of catching up a bit with Gena on the phone yesterday while Emily did some therapy work with Tony. I enjoy our conversations so much I barely registered that we had been talking for nearly 45 minutes before I had to end the call to participate in an OT telehealth session. She asked what those were like, and the truth is that they are often not easy.
Our son has significant problems with motor planning and it takes him a long time to learn how to imitate certain movements, and hands-on support is often required over a period of time for each new learning task we are undertaking. He also recognizes that a therapist who is on the computer is not anywhere near him, and is therefore unable to assist in (or enforce the need for compliance on) any requested attempts themselves. For some of our son’s therapies, my assistance has long been required in addition to the support of a physically present therapist.
Some telehealth sessions have consisted mostly of melt downs and frequent attempts to prematurely close the computer session. I could elaborate more, but I will just wrap this up by tying a neat little bow with the following statement: telehealth sessions usually require much higher levels of parental support, and are often more difficult and less productive than in-person sessions for Tony. I want to make sure I am very clear in saying with this that I am still incredibly lucky, because we are all healthy and together as a family.
Right now, we have more than 113,000 deaths in our country from COVID, and I don’t see a guaranteed end in sight to that any time soon. My heart continues to mourn with those who have lost so much through all of this. Locally, unfortunately, our numbers continue to rise…and in fact, Arizona has been in the national news for this, with the Chief Clinical Officer for the largest hospital network in the valley recently having warned the public that their network is nearing maximum capacity with filled ICU beds. Some telehealth sessions may be necessary for many months (if not longer) because of the ongoing pandemic, so we have introduced a new program during Tony’s ABA hours with Casandra to try and help improve his tolerance and cooperation with these types of sessions.
What we are doing is brief, taking maybe five minutes of each session. Casandra will go and sit on the stairs, just out of sight. Tony and I will sit in the living room logged into a video conferencing app with her. We practice saying hi, and doing three different tasks, such as labeling characters or physical imitation. If Tony doesn’t follow through with the task Casandra has requested, she comes down the stairs and prompts or assists him face-to-face.
Above, Tony is labeling characters on his AAC device. In the second picture, he is using a backup copy of his speech program that is on the iPad mini we purchased for his educational apps (photo taken after his original AAC device died). For communication purposes, it is recommended that Tony have a separate AAC device so that he can talk about what is happening in his educational apps during use, so this isn’t optimal, but it’s allowing him to communicate while we are still waiting on the ordered device. In the above picture, he still insisted on having the dead speech device out with him for a few days because he was so used to having it around.
In these pictures, Casandra is asking him to imitate a physical motion. What we have noticed is that his cooperation is much higher if he knows we’ll be able to go for a walk afterwards. Some nights it’s too hot for us to safely walk, and on those evenings he’s often less inclined to do what is asked of him in these practice sessions. Once we noticed this, we varied when we were doing the telehealth practice sessions so that they didn’t always immediately fall in front of a walk so that we would more naturally simulate typical existing motivations (or lack thereof) during telehealth therapy.
He also will sometimes run up to the stairs to look at her, or start labeling items he sees in her hands as she’s walking up the stairs so that he can try to get part of the tasks over with before the video aspect begins. To prevent this from happening, Casandra has started taking her personal phone with her and pulling up pictures of characters to show him once the practice session has begun.
You will notice that we are all still wearing masks over here. That really isn’t going to change until there is a vaccine or an effective treatment option for COVID. Recent studies and at least one well-publicized case of COVID exposure to 140 individuals within the US have demonstrated that masks work to prevent and reduce transmission. Nobody here loves them, but everyone but Tony will continue to wear one while we are all together in the same space. This is an important part of how we are all able to work together while reducing risks for transmission should someone be asymptomatic and contagious. And, at least in Maricopa County, plans are in the works for a public campaign encouraging mask use.
Even for therapists who feel comfortable working inside our home, there may continue to be periods of time where support will need to be provided via telehealth sessions as we all try to protect one another during periods of possible illness over the course of this pandemic. During yesterday’s OT telehealth session, I still needed to prompt all of the compliance and provide all of the physical support.
But, I can see that Tony is slowly becoming more tolerant of this method of delivery for therapy supports. Perhaps as we go along with Casandra’s practice sessions, we may expand them to add an extra five minutes and more variety to the types of tasks attempted. Her ability to be present and prompt the follow through is key to helping him generalize cooperation to someone other than me during these sessions. And without building the generalization for a need to cooperate under these conditions, telehealth will never be quite as effective as in-person sessions for Tony or any other kiddo who struggles with this method of therapeutic delivery.
