Table 6.

Decision Areas and Rationale

Decision areas	Decision	Considerations	Decisions taken
Initial decisions on enrollment and service delivery	Participant profile for a successful transition	Right to effective treatment Does the student have any challenging behaviors? What was the student’s attendance span in in-clinic sessions? How does the student score on parameters of cooperation?	All students whose parents applied, except students with high-rate challenging behaviors, would be accepted. For students with a low attendance span, tasks would be started with a reduced duration and the duration of attendance to tasks would be shaped.
	Which therapists can be involved in the transition	Is the therapist recently recruited and under training? Can the therapist commit to a certain number of hours daily to work from home without distractions?	Only therapists who have worked with BMI for at least 6 months and have trained in most of the protocols could conduct telehealth sessions. Therapists who had constraints at home with too many family responsibilities would be exempt. Only therapists who could commit to being available daily for assigned hours would be selected.
Ethical considerations	Technology for communications with parents	Almost all messaging platforms carry a risk of hacking and risks to privacy. Are there any adverse government advisories in India against specific platforms? With what platforms did parents feel at ease?	WhatsApp messenger would be used, as most parents and therapists were comfortable with its use, and there were no adverse advisories from the government.
	Informed consent	Are the existing informed consent agreements adequate?	Additional informed consent agreements with parents were to be secured by email: the first for telehealth use for instructional sessions and the second for recording meetings for internal training purposes.
	Technology for video meetings	There were no regulatory requirements in India like HIPAA and FERPA in the United States. Is there any advisory against the use of any specific video meeting platforms? With what platforms were parents most comfortable?	There was an advisory note against the use of the Zoom app. Skype “meet now” would be used and technologies and the decisions would be reviewed after a year.
	Recording sessions	Is there a higher risk of inadvertent video sharing outside the organization?	Therapists would be trained to record sessions only on email instruction from a behavior supervisor or clinical director.BMI  further would further ensure that they uploaded the recordings to a secure site and deleted them from their equipment by 5:30 p.m. the same evening. Existing agreements with therapists would address adherence to client confidentiality requirements.
Operational decisions	Mode of instruction delivery	Can the students attend a telehealth session independently and self-administer reinforcers? Will parents be required for prompting and reinforcer delivery? Can one parent commit to being available throughout every telehealth session?	TSD: A therapist would run telehealth sessions directly with verbally interactive students who had a record of task-attendance span of 20 min or more. TSPM: A therapist would conduct instructional sessions, seeking parent assistance for prompts. PBST: Behavior supervisors would train parents in implementing ABA-based procedures using telehealth and BST.
	Assigning therapists to students	Was the therapist implementing programs with the student in clinic? Does their availability match with the parents’ requirements?	As far as possible, the same therapist–student dyads as in the in-clinic sessions would be continued. If such therapist was not available, another therapist who has implemented similar programs as required by the student’s IEP would be assigned.
	Initial targets	The priority is to ensure that the student sits and attends to the camera for the specified initial duration.	All the students would be started with maintaining mastered skills to ensure cooperation. Targets would be added gradually to their IBI plan. Where required, parents would assist in prompting the student to attend to the camera.
	Skills to be taught	The limitations imposed by mode used	TSD students: Therapists would derive targets from the students’ IBI plan, leaving out manding for tangibles. There was no such restriction for TSPM students. BST student targets would be based on their IBI plan but limited based on the protocols that the behavior supervisor trained their parent in.
	Data collection	Cloud-based data collection and collation	Therapists would be trained to use Google Sheets on their phones. In some instances, they would send photographs of the data noted on paper, and the administrator would enter the data into Google Sheets.

Note. HIPAA = Health Insurance Portability and Accountability Act; FERPA = Family Educational Rights and Privacy Act; TSD = therapist-student direct; TSPM = therapist-student parent mediated; PBST = parent behavioral skills training; ABA = applied behavior analysis; IEP = individualized education program; IBI = intensive behavioral intervention.