Development of Interdisciplinary and Tele-Health Clinical
Training Opportunities in North Dakota & Wyoming
James Carpenter – MSW
Dakota Dye – SLP
Leisa Harmon – SLP
Katie Snyder – ABA-SpEd
Project Description
The purpose of this project was to explore the use of distance technology to conduct
interdisciplinary child behavior and developmental screenings and assessments in Wyoming.
Currently, North Dakota uses an interdisciplinary telehealth model to conduct some assessments
of children who live in remote areas. This project will explore the feasibility of replicating the
North Dakota program in Wyoming. To that end, we conducted a literature review, interviews
with key stakeholders, and an evaluation of the North Dakota program to determine the
possibility of developing a similar program in Wyoming.
Introduction
All members of the team were interested in this project because they currently live in a
state with a significant rural population, which poses unique challenges to providing services for
individuals with disabilities. North Dakota, Wyoming, Idaho, and Utah are among some of the
least populated states in the nation, and much of that small population is very rural. With such
similar populations, it is likely a program that works well in one state could be implemented
successfully in others with little difficulty. For this project, we evaluated a program in North
Dakota that utilizes distance technology to conduct autism assessments. We are also evaluated
the technology infrastructure in Wyoming, the utility of distance technology assessments, and the
capability to readily adapt a program like North Dakota’s into that state.
Autism spectrum disorders (ASD) have been increasing in prevalence throughout the
country in recent years. While this is a national issue, in most cases, the states are left to decide
how to deal with addressing assessment and intervention issues. Given the rural nature of
Wyoming, it is hypothesized that some families may have to travel cumbersome distances to
access evaluative services for their children. The cost, in terms of both time and money, can be
burdensome for families. Distance technology may be a more efficient way to allow families to
access diagnostic services without the undue hardships associated with long-distance travel. The
goal of this project was to obtain sufficient information about the current program in North
Dakota and the current state of assessment and evaluation in Wyoming to determine the
necessity and feasibility of implementing an assessment program utilizing distance technology in
Wyoming.
Research Hypothesis
The current program utilized in North Dakota to assess individuals with suspected ASD via
distance technology can be effectively replicated in Wyoming.
Methodology
The participants in this project are the members of the Leadership Project Team from
URLEND. They have also had to rely heavily upon liaisons from both North Dakota and
Wyoming who were chosen due to their relationship with URLEND and because of their
knowledge of their respective state and current and past programs therein. Stakeholders
identified by the liaisons were also key participants due to their ability to answer specific
questions about program logistics and implementation within the scope of their own
backgrounds. Additionally, the team assessed the burdens, in terms of cost, time, and stress,
experienced by families in Wyoming in getting their children assessed and evaluated by a
qualified professional. The input of families who have had direct interaction with programs like
the one being evaluated in North Dakota was also considered.
Evaluation Tools
The evaluation tools used to gather information include a literature review and interviews.
The literature review covers both the implementation of the program currently being used in
North Dakota and others like it, and programs that have been previously attempted in Wyoming.
The literature review also addresses best practices in assessment, detailed information about
arena assessments, and the barriers to using distance technology for assessment purposes both in
general and specifically to particular disciplines. In addition to the literature review, interviews
were conducted with key stakeholders in Wyoming who have had previous experience with
trying to run other clinics using distance technology. Some of these stakeholders included
psychologists who conduct autism evaluations, special education professors, and administrators
at Developmental Preschools in Wyoming. Interview questions were designed to gather
information about the state of assessment and evaluation of children in Wyoming suspected of
having an autism spectrum disorder, the current referral process across different age groups, and
the current state of the technology infrastructure in Wyoming. Professionals currently involved
with the ongoing program in North Dakota were also interviewed.
A literature review was deemed an appropriate evaluation tool for this project because the
team needed to explore a) the empirical evidence for interdisciplinary, arena assessments and b)
the experiences of other professionals who have attempted to use distance technology to conduct
evaluations and interventions. The interview was a suitable tool to evaluate the current needs in
Wyoming in terms of autism assessment and the technology available for the project. Interviews
allowed the team to gather specific information from a variety of stakeholders.
Procedures
As with most formative type analysis, this project began with the definition of the research
question followed by information gathering. The information gathering on this project was very
important due to the differing backgrounds of all members of the team. With any multidisciplinary work, it was important for all team members to have proficient knowledge of the
subject matter so they could fully participate in the decision making process. The next section of
the process is the analysis of the information gathered. This analysis consists of the team
identifying key infrastructure and logistics that allow the current program running in North
Dakota to work and then analyzing all gathered information about Wyoming to see if the same
program could be carried out successfully. Another part of this project is the dissemination of
the information gathered from the analysis to the stakeholders who have vested interest in the
program. This would include all persons and organizations that played a part in progress of the
project, and other entities that may be able to use the information gathered to either improve their
current system or implement a new one, such as other western states like Idaho or Montana.
Findings
Literature Review
From 1997-2001, personnel at the University of Wyoming along with 24 families and
other professionals from early intervention programs embarked on a project entitled Teaming
with Technology (Thompson et al, 2005). This project utilized distance technology to conduct
arena-style assessments of children with disabilities. Overall, team members deemed this a
successful project, particularly in making observations of children in their natural environments
and in conducting appropriate teaming practices. This project was discontinued, however, due to
lack of funding and technology limitations encountered at the time (personal contact, William
Maclean, September 30, 2010). Currently, assessments of children with suspected ASD are
being conducted through the North Dakota Center for Persons with Disabilities using telehealth
technology and arena assessment. The purpose of the present study is to explore the use of
modern distance technology to conduct interdisciplinary autism screenings and assessments in
Wyoming, similar to the previous Wyoming and the current North Dakota projects.
The Individuals with Disabilities Education Act, the federal law governing special
education services, requires an assessment approach that is family-centered and encompasses the
perspectives of many disciplines (IDEA, 1997). In an arena-style approach, team members from
a variety of disciplines are present at the same time, producing an evaluation that addresses the
overall needs of the child. This form of assessment is considered to result in the most accurate
evaluation of the needs of the whole child, and is cost- and time-efficient for both the family and
providers (King et al., 2009). In addition, families have reported higher satisfaction with arena
assessments as compared to traditional multidisciplinary assessments (Wolery & Dyk, 1984).
Distance or telehealth assessments have been used in various disciplines to perform
hearing screenings, language assessments, literacy evaluations, motor speech disorder
screenings, and various mental health evaluations. Studies focused on these assessments suggest
telehealth is a promising alternative to in vivo assessments that results in high inter-rater
reliability and high levels of agreement with direct assessment. However, one common concern
regarding telehealth as an assessment delivery tool involves bandwidth size, which increases the
lag time between the client and the test administrator. Telehealth has also proved to be a concern
for children under the age of six who have difficulties maintaining focus, require furniture
modifications, and have difficulty interacting with professionals via videoconference (Waite,
Theodoros, and Russell, 2010). However, studies have generally shown that telehealth
assessment results in high satisfaction rates for both test takers and administrators.
Stakeholder Interviews
According to Dr. Rex Gantenbein, director of the Center for Rural Health Research and
Education (CRHRE) at the University of Wyoming, the current infrastructure for telehealth
varies significantly. While larger communities have an abundant amount of bandwidth available,
most facilities in smaller communities have cable or DSL connections with bandwidth that is
barely sufficient to carry out telehealth.
Gantenbein also noted the best technology available at the endpoints for carrying out
clinical applications is videoconferencing systems (e.g., Polycom, Tandberg/Cisco, LifeSize) that
have the built in quality, reliability, and privacy. However, these systems are somewhat
expensive –ranging from $5000 to $20000 – making them unaffordable for many facilities.
Smaller facilities find telecommunications to be especially costly, as a T1 line, a minimum
requirement for telehealth, can range from $500 to $1000 a month.
Fortunately, there are a number of programs that help support providers and facilities in
adopting telehealth and paying for these costs. Wyoming received just under $1,000,000 in 2008
from the Federal Communications Commission through its Rural Health Care program to install
telecommunications at 40 small hospitals, clinics, and mental health centers throughout the state.
This project, headed up by the CRHRE, is currently under way. Additional federal grant
programs that support development of telehealth can be found through the Health Resources and
Services Administration (HRSA) and the US Department of Agriculture. Despite the existing
programs available to help facilities afford telehealth, cost is still believed to be the primary
reason healthcare providers would be against its implementation.
Another obstacle includes the learning curve that accompanies the use of new
technology. Gantenbein noted most small facilities do not have technical support available on a
regular basis to manage the systems, and many of the employees at the network sites are still
unaware of what they can do (or are expected to do) with the new capacity. To solve this
problem, CRHRE is offering outreach and education to help professionals see how they can use
the lines to expand their reach, bring in specialists that are not locally available, etc. A final
obstacle includes those professionals who are concerned using telehealth will somehow distance
them from their patients and prevent them from giving the best care. However, Gantenbein is
hopeful that as younger providers get out into the community, their familiarity with technology
will overcome this fear.
Teaming with Technology (TWT) was a project conducted over ten years ago in
Wyoming utilizing distance technology to assess children with developmental disorders. The
project was located in Laramie, Cheyenne, some on the Wind River Indian Reservation, and in
the Guernsey/Torrington area. Dr. Laura Westlake, participant in TWT, indicated that project
was worthwhile yet ahead of its time due to limitations in technology at the time. She stated, “I
think the technology is probably much better now and the quality of what a team could view via
distance would be extremely helpful. One of the issues in a state such as Wyoming is
accessibility to expertise across disciplines. This approach would allow for that.”
Westlake reported disciplines represented in TWT were speech-language pathology,
occupational therapy, early childhood special education, nursing, social worker, and psychology.
In addition, the lead assessment administrator primarily conducted the entire assessment by
administering a variety of standardized protocols while other team members observed and scored
their discipline specific protocol. Assessments were play-based and utilized parent interviews
such as the Vineland for social and emotional development. The Peabody Motor Scales and
Peabody Language Scales, Mullins, PEP-R, were also used; the LEITER was administered once.
Inter-rater reliability was judged to be “very good” as the team continued to work together. Dr.
Westlake indicated it was beneficial to have real time communication between the administrator
of the assessments and the team members so if additional information was needed, the team
members could request that. Westlake also noted videotaping a home section to be viewed was
useful in allowing team members to view interactions between child and parent.
Westlake encouraged exploration of a similar project in Wyoming utilizing improved
current technology. She noted that many individuals assessed in TWT were those who were
difficult to assess due to the presence of autism spectrum disorder characteristics. She
encouraged any future distance assessment projects to have a process in place for parent
involvement and to ensure resources are allocated so that a “collaborative approach can be used
not just for assessment, but for program development and implementation follow-up/evaluation.”
Dr. Douglas Scambler, a clinical psychologist and former member of the Wyoming
Autism Task Force, described the process of autism evaluations in the state of Wyoming.
Across the state, there are two individuals who are consulted to conduct autism evaluations: Dr.
Scambler and Dr. Diane Edwards, a developmental pediatrician based in Casper. Dr. Scambler
stated that he uses the Autism Diagnostic Observation Schedule (ADOS) and an adapted Autism
Diagnostic Interview- Revised (ADI-R) when conducting autism evaluations, but could not speak
to the use of the ADOS by other diagnosticians.
Prior to the age of five, referrals are made by the developmental preschools, which serve
children with developmental delays from birth to five years old. Once children are school-aged,
school districts may contract with JFK partners at the University of Colorado to conduct
evaluations. Interdisciplinary teams, consisting of a psychologist, occupational therapist, speechlanguage pathologist, and a social worker travel from Colorado to conduct evaluations; however,
significant behavioral difficulties typically necessitate this type of evaluation due to its cost. To
gather more information on the referral rate and process in the developmental preschools, Dr.
Scambler referred us to Michael Massie, the director of Child Development Services.
In turn, Michael Massie suggested we contact Ken Fischer, who is a special education
administrator at Stride Learning Center, a developmental preschool in Cheyenne. Mr. Fischer
stated the goal of the developmental preschool is to have children diagnosed as early as possible,
but that no preschool has a clinical psychologist on staff, so this can be difficult. In addition to
taking advantage of the benefits of early intervention, the developmental preschools encourage
families to seek a medical diagnosis before the age of three when possible for funding reasons;
prior to the age of three, medical insurance covers an evaluation, whereas after three, the
evaluation is the responsibility of the Department of Education. If a child is three or older, his or
her eligibility for special education services would be categorized as a speech/language delay. It
is sometimes difficult to get a full evaluation funded by the Department of Education for a child
suspected of having an ASD after the age of three. Therefore, when children fall through the
cracks of the evaluation system in Wyoming, it is often because they have not been evaluated
prior to this age.
Dr. Trevor Hall from Northwest Neurobehavioral Health, the director of the Autism
Clinic in Boise, Idaho, was also interviewed to gather information about funding. Dr. Hall was
very clear in stating that each state has different rules in reimbursement for diagnostic services
and, in fact, many of those policies have changed this year with the current state of the economy.
Overall, Dr. Hall stated that the majority of money his clinic brings in is through the psychologist
as he administers the majority of the tests and writes comprehensive reports, both of which are
billable. The other professionals are able to bill for standard assessments for each child seen, but
actually bill a relatively small total amount. Dr. Hall stated that the speech pathologist and
occupational therapist involved in the clinic make more money in the long run because they
provide services to families who come for subsequent clinical intervention services. Dr. Hall
expressed concern that a purely diagnostic program would have trouble supporting itself without
the assistance of an outside financial source such as a grant.
Through interviewing families who have participated in the diagnostic clinic in North
Dakota, several strengths of the program were identified. Families all stated that they really
enjoyed the opportunity to meet with so many professionals all at once and to receive feedback
the same day. They stated that most of the professionals were able to be there in person and only
one had to participate via distance technology. The families did not have to interact directly with
the distance technology since many professionals were able to be present in person and handled
all of those interactions. All families interviewed stated they were very impressed with the clinic
as a whole and felt like it should be used in other states.
Discussion
The purpose of this study was to investigate the feasibility of utilizing a distance
technology approach to assess individuals with suspected autism in Wyoming, similar to the
current model being utilized in North Dakota. Results of this study indicated that such a project
is feasible although obstacles do exist. At the beginning of the project, it was the team’s
assumption that the technology of Wyoming would be the most limiting factor in introducing a
distance diagnostic clinic. Based on the information gathered, it became clear that the
technology in Wyoming has improved over the years. With some training and minimal
adaptation to make the technology functional for a diagnostic clinic, this service could be
available at a few rural sites.
Results of this project indicate there is great potential for an interdisciplinary telehealth
clinic in Wyoming to assess individuals with suspected ASD. Based on conversations with
people throughout Wyoming, it appears personnel are available to create an effective team of
professionals needed to facilitate a clinic of this kind. It is unknown if this team would have the
capability of the one in North Dakota to travel to many of the sites in person while having only a
small number of professionals participate via distance. Families who have utilized similar clinics
in North Dakota were very pleased with the services provided and stated that they received the
best possible assessment.
The primary limitation facing this project is the lack of funding needed to support the onset
of such a project and to maintain it. The programs in place in other states have received funding
from outside sources to maintain their programs, and the investigation into a purely diagnostic
program supporting itself was not promising.
In conclusion, the TWT project has proven a diagnostic clinic via distance is feasible when
properly funded, even with the technology limitations faced ten years ago. The technological
infrastructure has improved, and the necessary human resources appear available to start a
program that has proven successful in North Dakota. Wyoming simply lacks the monetary
support to put such a plan into action at this time. Finally, if such a project comes to fruition in
Wyoming, ongoing evaluation of the validity and reliability of telehealth assessment would be
critical in documenting its effectiveness.
Work Cited
Bagnato, S.J., & Neisworth, J.T. (1991). Assessment for early intervention: Best practices for
professionals. New York: Guilford Press.
Division for Early Childhood Task Force on Recommended Practices (Eds.). (1993).
Recommended practices in early intervention. Reston, VA: CEC
Filipek, P., Accardo, P., Baranek, G., Cook, E., Dawson, G., Gordon, B., Gravel, J., Johnson, C.,
Kallen, R., Levy, S., Minshew, N., Prizant, B., Rapin, I., Rogers, S., Stone, W., Teplin, S.,
Tuchman, R., and Volkmar, F., (1999). The Screening and Diagnosis of Autistic Spectrum
Disorders. Journal of Autism and Developmental Disorders Vol. 29, No. 6.
Hall, T. (2011, January 26). Autism Clinic Director, Northwest Neruodevelopmental Health.
Interview.
Individuals with Disabilities Education Act Amendments of 1997, Pub. L. No. 105-17, §1400, 37
Stat. 111 (1997).
King, G., Strachan, D., Tucker, M., Duwyn, B., Desserud, S., & Shillington, M. (2009). The
application of a transdisciplinary model for early intervention services. Infants & Young
Children, 22, 211-223.
Nesbitt, T., Cole, S., Pellegrino, L., and Keast, P. (2006). Rural outreach in home telehealth:
Assessing
challenges and reviewing successes. Telemedicine and e-Health, 12(2), 107-113.
Thompson, C., Buchanan, M., Westlake, L. and Heinlein, K. (2005). Utilizing interactive
technology to
conduct team assessments: Teaming With Technology research project. NHSA Dialog, 8
(1), 121-134.
Waite, M., Theodoros, D., and Russell, T. (2010). Internet-based telehealth assessment of
language using
the CELF-4. Manuscript submitted for publication.
Wolery, M., & Dyk, L. (1984). Arena assessment: Description and preliminary social validity
data. Journal of the Association for Persons with Severe Handicaps, 9(3), 231-235.
The team involved in this project would like to extend our gratitude to Jolynn Webster, Bill
MacLean, and Doug Petersen for their guidance and support in this project. Your wisdom and
suggestions helped to bridge the distance between us in completing this endeavor.