Connecting Behavioral Health Specialists With Schools: Adapting a Telementoring Series During COVID-19

Abstract

To address the daunting behavioral and mental health needs of Kansas’ rural and underserved communities, Telehealth ROCKS (Rural Outreach for the Children of Kansas) Schools project partnered with school-based health centers, school districts, and special education cooperatives to provide a range of telebehavioral health intervention services and teletraining. This project used the Project Extension for Community Healthcare Outcomes (ECHO) telementoring framework to connect specialty providers with school/community providers for web-based continuing education and case consultation to support students with special education needs. Our team created the Function Friday for Better Behavior ECHO series to address challenging behaviors in schools, based on the concept of functional behavior assessment and function-based treatment. Part of the ECHO series came into being after the onset of the COVID-19 pandemic. This article describes how our ECHO series provided an effective mechanism for supporting school and community providers during the pandemic, and participating educators utilized skills as they transitioned from onsite education to the virtual learning environment with students.

Mental and behavioral health challenges among school-age children are an area of concern. Behavioral health disorders are one of the top five chronic pediatric conditions leading to functional impairment (i.e., learning, speech, and developmental difficulties, Slomski, 2012). Of children ages two through eight years, approximately one in seven children have a diagnosed behavioral, mental, or developmental disorder (Centers for Disease Control and Prevention, 2021b). In addition, approximately one in five children in the United States have a special health care need, requiring additional behavioral, physical, developmental, and mental health support compared with peers (Centers for Disease Control and Prevention, 2021a).

The American Academy of Pediatrics (AAP) emphasized the importance of advocating for children with disabilities during the COVID-19 public health emergency, as 80% of children with mental and behavioral health needs relied on school-based services, many of which were not available after the pandemic school closures (Masonbrink & Hurley, 2020). The AAP pointed out the need for engagement with special educators in structured learning environments, as many parents of children with high needs were not equipped with resources to effectively provide and maintain the necessary level of remote learning and services (American Academy of Pediatrics, 2021a; United States Department of Commerce, 2020).

Since teachers are a crucial part of these children’s learning and development, it is critical to ensure that school personnel are trained to manage challenging behaviors associated with mental/behavioral health diagnoses using evidence-based strategies (Beyer et al., 2012; Powell et al., 2006). Reinke et al. (2011) reported that only 17% of surveyed educators reported receiving “substantial education and/or training” related to behavioral interventions and noted that 44% of surveyed educators were “unaware or unsure” of what the term “evidence-based practices” was in relation to behavioral and mental health needs (Reinke et al., 2011). Owens et al. (2018) examined teachers’ use of evidence-based practices in responding appropriately to students’ rule violation behaviors (e.g., off task, interrupting) and observed that teachers’ appropriate responses (i.e., labeled praise, appropriate commands, appropriate response to rule violations) ranged from 11% to 47%. In addition, studies report that educators do not feel equipped to address students’ increasing behavioral and mental health needs (Flower et al., 2017; Landau, 2001; Oliver & Reschly, 2010; Reinke et al., 2011). Even before the pandemic, school personnel did not consistently receive this training either during teacher preparation programs (Corona et al., 2017; Lauderdale-Littin & Brennan, 2018) or through consistent professional development opportunities (Barnhill et al., 2014).

Access to teacher education related to evidence-based practices in managing challenging behavior is even more limited in rural communities as compared with urban communities (Rural Health Information Hub, 2019). Despite a higher need for it, rural children from small communities exhibit a higher prevalence of mental, behavioral, and developmental disorders than children living in cities and suburbs (Robinson et al., 2017) but have fewer resources for support (Centers for Disease Control and Prevention, 2021c). Barriers to access, paired with stigma and a lack of anonymity of behavioral health treatment in rural communities, may result in a lack of treatment or delays in seeking care (Gamm et al., 2010; Smalley et al., 2010). Moreover, rural areas are more likely to have shortages to mental and behavioral health care; thus, access to behavioral health specialists (e.g., psychologists, behavior analysts), remains limited (Rural Health Information Hub, 2019), impeding the ability of communities to locally seek specialized support for behavioral health care.

Oftentimes, school personnel, including special education teachers and school-based providers, are the only professionals available to support children/students with behavior concerns and face challenges regarding access to training and resources (Hemmeter et al., 2008; Kurth & Keegan, 2014). There is a growing evidence base supporting the idea that school-based telehealth approaches can successfully bridge the gap between behavioral health services and the training needs of rural communities with limited access to such care (Love et al., 2019; Pradhan et al., 2019; Young & Ireson, 2003). For example, school-based telepsychiatry services have been used in rural West Virginia to improve access in under-resourced areas (Pradhan et al., 2019). Similar school-based behavioral telehealth in Maryland found it was effective in improving access to mental health services and removed barriers (e.g., transportation, scheduling) that prevented families from accessing other mental health supports in their community (Stephan et al., 2016). However, while telehealth, particularly behavioral telehealth or telepsychology, has expanded substantially during the COVID-19 pandemic, there remains a critical shortage of pediatric mental health providers to respond to what the AAP has called a “national emergency in child and adolescent mental health” during the COVID-19 public health emergency (American Academy of Pediatrics, 2021b).

Another method of expanding the reach of behavioral health specialists is the use of teleconsultation. Rather than a traditional method of service delivery involving one behavioral health specialist, meeting with one child or family, teleconsultation links school educators and behavioral health specialists (e.g., psychologists, behavior analysts). Such collaboration helps facilitate the development of effective behavioral interventions for students in resource-limited regions and expand access to behavioral health interventions (Al-Khalaf et al., 2014; Ferguson et al., 2019; Frieder et al., 2009). Teleconsultation and teletraining have been used successfully to train special education teachers to conduct behavioral assessments and interventions, including functional analysis (Alnemary et al., 2015). Since the COVID-19 pandemic, teleconsulation and teletraining have become more common (Ros-DeMarize et al., 2021; Trikoilis & Papanastasiou, 2020), which has the potential to improve access to behavioral interventions broadly to students and teachers in schools.

The Project ECHO Model

Project ECHO (Extension for Community Healthcare Outcomes) is an innovative and flexible web-based method for providing teletraining and teleconsultation that has been used extensively in health care to expand specialty care reach in rural areas (Archbald-Pannone et al., 2020; Faherty et al., 2020). Developed in 2003 at the University of New Mexico, the Project ECHO model was originally designed as a collaborative model of medical education and care management to improve health care providers’ competence in providing expert-level care to their patients with hepatitis C in rural or underserved communities (Arora et al., 2007). The ECHO model connects panelists from an interprofessional “expert hub” (typically an academic medical center) with community providers/educators in recurring videoconferencing meetings to share best practices through brief didactics and engage in group discussion of specific de-identified real cases presented by the community participants (Arora et al., 2007, 2011; Faherty et al., 2020). The ECHO model is different from a traditional training workshop due to its ongoing nature (participants meet with the expert hub on a recurring basis), its relatively brief didactics (approximately 15 min), and its primary focus on discussion of cases brought forth by the community participants (University of New Mexico [UNM] Project ECHO, 2021). The goal of this “all teach, all learn” model is to share best practices in specialty care and to reduce disparity in underserved communities through ongoing telementoring and education. This telementoring model has a small but increasingly strong evidence base supporting positive outcomes for both patients and providers (McBain et al., 2019; Zhou et al., 2016).

Project ECHO has been replicated and expanded across the globe and on various topics (Archbald-Pannone et al., 2020; Faherty et al., 2020). To date, there have been 960 ECHO programs in 48 states and 45 countries. The areas of focus are broad, including autism, behavioral/mental health, cancer prevention, diagnosis, and treatment (UNM Project ECHO, 2021). Project ECHO programs have played a critical role in providing quality education and mentoring, promoting community health and well-being, and reducing inequalities in access to health care for underserved populations and areas (Zhou et al., 2016). Several programs have used Project ECHO to support educators (e.g., UNM Project ECHO, 2021; University of Wyoming [UW] Project ECHO, 2021), including the University of Wyoming ECHO. Specific to special education, Oklahoma State University (OSU) has used its TeleSPED ECHO to support special educators throughout the state (OSU TeleSPED Project ECHO, 2021). As COVID-19 and its impact continue to spread globally, the Project ECHO community has rapidly responded to this crisis to help their partners navigate resources and connect experts and frontline health care professionals together (Archbald-Pannone et al., 2020). At the time of this study in 2020, over 162 COVID-19 response ECHOs were completed, with only five focused on children, and to our knowledge, only one ECHO focused solely on supporting educators during this crisis (UNM Project ECHO, 2021).

Although there is increased adoption of using the Project ECHO model to support educators and school-based providers in meeting students’ educational and behavioral needs, the literature is limited in describing the application of Project ECHO in school settings. To the authors’ knowledge, this is among the first papers to describe an established, ongoing ECHO programming for general and special educators working with students with challenging behaviors. In addition, this article describes how this ECHO series was modified due to the onset of the COVID-19 pandemic to adapt to the needs of rural educators and students. Additional references related to the implementation of the ECHO model are provided (please see the appendix).

Method

Function Friday for Better Behavior ECHO

Our regional Midwestern U.S. academic medical center has a decade-long partnership with rural schools and communities through the Telehealth ROCKS (Rural Outreach for the Children of Kansas) project and its longstanding pediatric Project ECHO series with schools. This project provides videoconferencing, telementoring, continuing education, and telehealth services (behavioral and physical health care) in Southeast and Southcentral Kansas schools, community health centers, and special education cooperatives. Due to the national need for continuing education in evidence-based behavioral interventions (Barnhill et al., 2014), as well as requests from these local rural partners, an ECHO series titled Function Friday for Better Behavior was initiated in January 2020 (referred to as Function Friday ECHO hereafter). This ECHO series focused on improving the understanding and use of functional behavior assessment (FBA) and function-based behavior intervention plan (BIP) development, which are key evidence-based practices for managing challenging behaviors, and interventions commonly used by psychologists and behavioral specialists (Wong et al., 2015). During the series, we invited a small group of school and community “champions” who were interested in diving deeper into the topic of behavior in an ongoing, intensive, and interactive format to participate.

Recruitment

The Function Friday ECHO series was designed to facilitate the understanding and application of assessing functions of behavior and developing function-based behavioral support plans for educators and school and community-based behavioral health providers (e.g., general and special education teachers, school psychologists, counselors, behavior specialists, and behavior health clinicians from community mental health centers). Participants were eligible to enroll in the series if they primarily worked with preschool and elementary-age children (ages birth–12 years). In addition, participants agreed to attend all sessions and identify one student or child to practice and apply skills learned throughout the series. An initial cohort of 20 participants was recruited via a listserv of over 400 prior Kansas ECHO participants and other interested community members, including school and mental health agencies.

The facilitators of the ECHO series were a school psychologist, a child clinical psychologist, and postdoctoral fellows (applied behavior analysis and school psychology) in the Department of Pediatrics at the University of Kansas Medical Center (academic medical center “hub”). An ECHO Participant Guidebook was provided to participants with information regarding the structure and content of this ECHO series, the technology required, and guidelines for participation.

ECHO Curriculum and Setting

During the ECHO series, eight sessions designed to feature topics relevant to using FBA and function-based behavioral intervention plan development when working with children with challenging behaviors (Bruni et al., 2017) were delivered to school personnel. Table 1 displays a complete list of session topics including changes made due to the COVID-19 pandemic that occurred in the middle of the ECHO series. The series took place twice a month over a 4-month period between January and April 2020. Before COVID-19, the ECHO series facilitators and support staff members initiated the sessions from a room with audio and video equipment at the University of Kansas Medical Center (academic medical center “hub”) while participants joined from their respective worksites across the Midwest during lunch hours.

Table 1.

Function Friday ECHO Series Didactic Session Topics.

Session	Topic
Pre-COVID-19
1	Introduction, data collection
2	Overview of functions of behavior
3	Functional behavior assessment (FBA): antecedents
4	Functional behavior assessment: consequences
5	Prevention
Post-state-wide stay-at-home order
6	• Planned content Pre-COVID-19: Interventions: based on the function of access attention/tangibles in the onsite school setting • Post-COVID-19 modification: Intervention based on function in a virtual school setting
7	• Planned content Pre-COVID-19: Interventions: based on the function of escape/sensory needs in the onsite school setting • Post COVID-19 modification: Engaging with children and interventions in a virtual school setting
8	• Planned content Pre-COVID-19: crisis planning • Post-COVID-19 modification: Risk assessment for virtual school; creating safety plans for virtual school and supporting families during COVID-19

Note. FBA = functional behavior assessment.

These 1-hr ECHO videoconferencing sessions were hosted on a secure Zoom platform. Unlike traditional distance-based training or webinars that focus on didactic presentations from the experts, the Project ECHO series followed a consistent structure with an emphasis on case-based learning. The sessions included a 5- to 10-min introduction and check-in; a short 15-min didactic presentation related to prevention, assessment, and treatment of challenging behaviors presented by the academic medical center “hub” facilitators; and a final 35- to 40-min case presentation (presented by a school team) and participant discussion. Presenters developed didactics guided by the latest research, compiled into short PowerPoints. De-identified cases were submitted through an online case presentation form and presented by the participants of the ECHO series. For the de-identified case presentations, participants volunteered to describe student characteristics, problem behaviors observed, possible functions of these observed behaviors, and behavioral strategies tried. Through the ECHO format, behavioral strategies were developed through team-to-participant and participant-to-participant interaction (Table 2). Consistent with other ECHO programs (UNM Project ECHO, 2021), all sessions began with introductions, and participants and presenters kept their video cameras “on.” Participants were encouraged to unmute or use the chat feature during questions and case discussions. These strategies were selected to encourage active participation and a community learning approach, rather than passive webinar participation.

Table 2.

De-Identified Cases Presented During Function Friday ECHO.

Case	Student characteristics	Behaviors observed	Possible functions	Strategies tried	Strategies developed during ECHO
1	5 y/o male (kindergarten) • IEP for developmental delay; • Significant trauma history	• Physical aggression (choking, hitting, kicking, self-injury, property destruction) • Work refusal	• Escape from work • Adult attention	1. Praise 2. Teaching missing skills 3. Sticker chart 4. Visual schedule 5. Offering choices	1. Positive attention and relationship building 2. Family trauma support 3. Behavioral momentum 4. Break request cards 5. Replacement behaviors (request breaks)
2	5th-grade female • IEP for learning disability • History of work refusal • Trauma history (foster care as toddler)	• Noncompliance • Aggression • Disrespect, elopement	• Escape • Attention/control	1. Girls’ group 2. Lunch buddy 3. Individual counseling 4. Therapy dog 5. Separate quiet work space/classroom	1. Evaluate academic mastery level 2. Reduce academic demands 3. Behavioral momentum 4. Visual schedule 5. Rewards and breaks 6. Social skills instruction 7. Consistent staff response to behavior 8. Adjust ratio of positive to negative interactions 9. Break cards
3	6th-grade male • Diagnoses of ADHD, anxiety, & oppositional behavior • Parents discontinued ADHD medication • Family stressors (e.g., divorce)	ADHD symptoms: blurting out; making noises; explosive reactions	Attention	1. Special day school 2. Small classes/high adult ratio 3. BIP with goals to increase compliance and use of coping skills for self-regulation.	1. Frequent positive feedback 2. Providing unconditional attention preventatively 3. Praise positive opposites related to ADHD symptoms 4. Family psychoeducation about ADHD and treatment recommendations
4	5 y/o male (kindergarten) • Diagnosed w/ DMDD and receiving outside mental health support. • No history of preschool or childcare outside of home	• Difficulty w/transitions • Work refusal • Crawling under desks • Inappropriate reactions to peers/teachers	• Attention • Escape from difficult tasks (e.g., math)	1. Behavior chart 2. Small-group math instruction 3. Rewards focused on 1:1 attention w/adults 4. During pandemic, continued behavior chart w/parent collaboration during virtual learning 5. Provided opportunities for socially distanced interaction w/staff as rewards (porch picnic)	1. Discussed creating a plan for re-entry into school setting when appropriate 2. ECHO discussion focused on success of implemented strategies, including school–home collaboration

Note. IEP = Individualized Education Program; BIP = behavior intervention plan; ADHD = attention-deficit/hyperactivity disorder; DMDD = disruptive mood dysregulation disorder.

The facilitators guided the telementoring discussion of the case by asking questions, soliciting feedback from other participants, and providing specific content expertise (e.g., explaining the diagnostic criteria of disruptive mood dysregulation disorder) when needed. The facilitators then summarized suggestions and recommendations generated from the discussion at the end of each session. Written summaries were also sent to the correspondent case presenters after each session. Participants were encouraged to practice using the strategies presented between sessions with children they work with who have behavioral health needs.

Adaptations During the COVID-19 Pandemic

The fifth ECHO session was conducted on March 13, before COVID-19 changed the school landscape. On Tuesday, March 17, 2020, Kansas Gov. Laura Kelly announced that school buildings across the state must be closed for the duration of this school year. However, state and district leaders emphasized that learning would continue for Kansas students. This decision and the public health emergency greatly impacted the ECHO participants, particularly the school-based staff and special educators. Participants and facilitators also faced the transition to working at home. The ECHO planning team quickly convened to discuss next steps (e.g., Should we continue conducting the ECHO series with the originally planned topics? Should we pause or discontinue the ECHO series? Should we change our focus from addressing challenging behavior at school to assisting our participants with responding to the COVID-19 impact?) Driven by school participant input, the discussions led to two decisions: (a) continuing the ECHO series with adaptation to respond to changes such as virtual learning and intervention and (b) expanding the rest of the ECHO series to school providers who were not initially able to attend due to the restriction of the number of participants. The ECHO series resumed, with facilitators, support staff, and participants all joining from their homes. The rest of the ECHO sessions included topics such as function-based interventions in a virtual setting and how to create a family support plan and crisis safety plan for students with challenging behaviors or needing support, following the standard ECHO structure. The check-in portion of each section was used for participants to share how they were adapting to virtual teaching and telehealth, successful stories, lessons learned, and self-care. One de-identified case study was presented with an emphasis on finding creative ways to continue providing behavioral support to the child in the home setting.

Evaluation

A researcher-developed demographic survey was administered before the start of the series to collect information regarding participants’ personal and professional backgrounds, including their roles related to working with children and their employment affiliation. In addition, a researcher-developed post-ECHO evaluation survey was administered upon completion of the Function Friday ECHO series. The survey focused on the following areas: Knowledge and Skill Development (six items); Access to Specialist Team (two items); Satisfaction with ECHO Format (three items); Future Attendance and Recommendation (two items); Application of Content (three items); and COVID-19 and Self-Care (three items). Participants were asked to rate their level of agreement with each statement on a 5-point Likert-type scale, with 1 indicating strongly disagree and 5 indicating strongly agree. Participants who attended at least one ECHO session, including those who were part of the “expanded” access to the ECHO program, were invited to complete the survey.

Results

Participants

Of the 18 participants who enrolled before COVID-19 expansion and attended at least the first session, 17 were female, and one was male. Fourteen participants were from rural (9) and urban and suburban (5) school districts in Kansas, and four were from rural community mental health centers. Thirteen participants were licensed service providers, including social workers, school psychologists, board certified behavior analysts, occupational therapists, and clinical marriage and family therapists. Five non-licensed service providers attended, including four case managers and one psychology intern. Most of the participants were school-based providers who work with children receiving special education services. Given our small response pool within a small community of rural educators, available demographics are limited to be sure participants could not be identified. With so few school personnel participating, there was concern that breaking down responses could potentially make comments identifiable.

When schools were closed due to COVID-19, our team chose to continue the ECHO series and expand participation beyond our original criteria to include all school personnel interested in this type of virtual support. Another recruitment flyer was emailed out to invite others to participate in our transforming COVID-19 support ECHO. An additional 17 participants signed up during the post-COVID-19 recruitment period. To reduce the burden of participation during such a challenging time, the demographics of the participants who signed up after the COVID-19 expansion were not captured. However, we were able to collect contact information for a total of 35 participants who participated before and after the COVID-19 adaptations. Surveys were sent to all 35 participants, regardless of whether they enrolled before or after the COVID-19 expansion.

Participants’ Experience With the ECHO Series

Eight participants out of 35 who were sent the survey responded, and seven of them attended at least one session during the pandemic. The survey response rate (23%) is consistent with typical emailed survey response rates (Sheehan, 2001). A summary of survey item responses is presented in Table 3.

Table 3.

Participants’ Experience With Function Friday ECHO Series.

Area and items	Strongly disagree (%)	Disagree (%)	Neither (%)	Agree (%)	Strongly agree (%)
Knowledge and skill development
Improved understanding of function of behavior	0.00	12.50	12.50	75.00	0.00
Improved my understanding of FBAs	0.00	12.50	25.00	37.50	25.00
Improved my understanding of function-based treatment or support	0.00	0.00	12.50	87.50	0.00
Developed my ability to collect data and conduct FBAs	0.00	12.50	0.00	75.00	12.50
Developed my ability to create function-based treatment plans	0.00	12.50	12.50	62.50	12.50
Developed my ability to conduct safety planning	0.00	12.50	25.00	50.00	12.50
Access to specialist team
Access to specialist expertise and consultation is an important area of need for me and my team	0.00	0.00	0.00	75.00	25.00
Access to specialist expertise has benefited my clinical/educational knowledge and practice	0.00	12.50	12.50	62.50	12.50
Satisfaction with ECHO format
Case-based learning is an effective way for me to develop my clinical/educational knowledge and skills	0.00	0.00	0.00	50.00	50.00
My participation has increased my connection to other professionals	0.00	12.50	25.00	62.50	0.00
I gained new insight on how to support children and improve behavior in a virtual learning setting	0.00	0.00	37.50	50.00	12.50
Future attendance and recommendation
I would recommend ECHO to my colleagues	0.00	12.50	0.00	37.50	50.00
Application of content
I will apply knowledge learned to other children with challenging behavior	0.00	12.50	0.00	37.50	50.00
COVID-19 and self-care
Content related to self-care were helpful in this time	0.00	0.00	37.5	50.00	12.50
Content was appropriately modified to be relevant	0.00	0.00	25.00	50.00	25.00

Note. FBA = functional behavior assessment.

In the area of Knowledge, Skill Development, and Functional Behavior Assessment Content, 75% (n = 6) of respondents reported improved knowledge or skills related to FBA and function-based treatment planning (rated “agree” or “strongly agree”). Respondents found the Access to Specialist Team helpful (75%; n = 6; “agree” or “strongly agree”), and 75% (n = 6; “agree” or “strongly agree”) found the virtual, case-based, and community-participation ECHO Format beneficial. Most respondents indicated they would recommend ECHO to a colleague and attend a future ECHO session (78%; n = 6;“agree” or “strongly agree”). Respondents also indicated intent to apply their content knowledge in their work (79%; n = 6; “agree” or “strongly agree”), consistent with the recommendation to practice the strategies discussed between sessions. Though 75% (n = 6; “agree” or “strongly agree”) of the respondents indicated that the content of ECHO sessions after the onset of the pandemic was appropriately modified, respondents reported less satisfaction with content related to self-care (63%; n = 5; “agree” or “strongly agree”). Only 38% (n = 3; “agree” or “strongly agree”) of respondents indicated that participation in the ECHO improved their ability to support children and families remotely during the pandemic.

Discussion

Educators and providers in schools often face challenges when supporting children receiving special education services who also exhibit challenging behaviors. The authors shared how the Project ECHO model can be used to support educators and providers in meeting the needs of rural children with behavioral challenges. Using this community of learning model, our Telehealth ROCKS Schools team trained school-based providers in the basics of functional behavior analysis and function-based BIPs before and during the COVID-19 pandemic. Four cases of actual student examples were presented to ECHO participants to support learning and application the trained skills. Overall, participants reported that access to a specialist team and the virtual case-based participation ECHO format were the most beneficial aspects of teletraining. In addition, participants felt this series led to improved knowledge or skills related to FBA and function-based treatment planning. These results suggest that the ECHO format and access to a specialist team could be valuable and effective in serving and training educators in the future.

Rural special education educators and providers need support during the pandemic to better assist children with disabilities and behavioral health needs (American Academy of Pediatrics, 2021b; Ault et al., 2020). The continuation and rapid transformation of this series during the COVID-19 pandemic demonstrates that building on distance-based technology, the ECHO model can be a feasible way to virtually reach and support rural educators during challenging and unprecedented circumstances, such as the COVID-19 pandemic. In fact, the academic hub facilitators found it more convenient and efficient to participate from their own audio- and video-equipped computer devices rather gathering in a centralized location with shared equipment. With the COVID-19 pandemic, ongoing partnerships and community training opportunities faced challenges and choices to make—continue with the planned curriculum, suspend the partnership/training program, or adapt the material to apply to COVID-19. The evolution of this series demonstrates the importance of adapting training materials to respond to the COVID-19 public health emergency and garner feedback from ongoing participants about their priorities and needs.

Moreover, the ECHO format allows for relevant modifications to didactic information and case presentations while still preserving the integrity of telementoring between expert hub teams and community providers. The Function Friday for Better Behavior ECHO provided the participants with didactic information about FBA, data collection, and interventions and offered ideas on how to modify these during the pandemic. In addition, participants anecdotally reported that lessons learned from case examples were shared within their communities and with other Function Friday ECHO participants to help them modify BIPs for current and future cases.

While the adaptation and evolution of this ECHO series is considered a strength, it also led to significant limitations in data collection and data analysis. The original data collection plan included the collection of behavioral data for a student or client that was identified by each of the participating professionals as needing behavioral support. The participating professional would then complete a standardized teacher-report form at pre-and post-ECHO series and provide weekly observational data related to the target behaviors. However, due to COVID-19, participants were unable to continue to collect the data once the state-wide stay-at-home orders were implemented, as they did not observe the child frequently enough to complete the measures. Therefore, behavioral outcome data were not available. Because this ECHO series served a specialized group of participants, limited participant demographic data were included to protect individual identities across rural, suburban, and urban sites. In addition, due to the challenges faced by all educators during the pandemic, our team chose to open the small and targeted participant group to all who were interested in this topic. Therefore, the number and consistency of participants varied greatly throughout the series, and many participants did not attend the entire series. The small sample of educators (n = 35) yielded a smaller number of survey respondents (n = 8), which may impact the generalizability of the findings. It is also possible that the stresses of the early pandemic impacted participant availability to complete emailed surveys.

Several content adaptations were made related to the onset of the COVID-19 pandemic. However, only a smaller percentage of survey respondents (38%) felt that the content improved their ability to support children/families during the pandemic, suggesting that educators need intensive and targeted training in virtual teaching strategies, something that was not widely available through our series or elsewhere at this time. It is important to note the timing of this data collection, in the Spring of 2020, when teachers experienced a high level of stress (Allen et al., 2020) and may have felt powerless to support children and families due to the uncertain nature of the early pandemic. To meet this need for a greater “dose” of training, our team and community partners are exploring options for longer ECHO series and for pairing ECHO with other education strategies (e.g., day-long kick-off series, pre-learning opportunities, and online learning options) as we move forward during and after COVID-19.

The COVID-19 pandemic continues to impact society, and therefore schools and families are faced with the challenging task of educating in a new, non-ideal environment. At this time, it is important to continue to solicit input from teachers and families about their needs and adapt continuing education, consultation, and research programs based on this community feedback. An important lesson that the hub team will foster and evaluate in future ECHOs is the increased hub team-to-participant and participant-to-participant trust over the course of the series. This appeared to support a greater willingness to share very challenging cases impacted by the public health emergency over the course of the series and rich discussions to help one another support children and families.

Our team used the input and feedback from the Function Friday ECHO series that occurred in Spring 2020 and developed another Project ECHO series aimed at supporting educators with all the challenges that continued to arise as the pandemic continued into the Fall of 2020. The Telehealth ROCKS Schools ECHO for Fall 2020, Back to School with Better Behavior, focused on the behavioral and mental health needs of students in virtual or socially distanced schools. In addition, feedback from ECHO participants indicated a need for continued support for educators in their own self-care and resilience, as they face both ongoing and new challenges and opportunities in education during the COVID-19 pandemic. Thus, the Telehealth ROCKS Schools team also developed and led a self-care and resilience ECHO to support educators and providers during this challenging and unprecedented time. The ECHO model described in this article, with its use of an expert hub, emphasis on local participant feedback, expertise in virtual case-based learning, and the flexible nature of topics addressed can provide an excellent mechanism for supporting rural schools and communities during the COVID-19 pandemic and beyond. Moving forward, it will be important to systematically collect and analyze data from these ECHO series to determine participant satisfaction and overall impact.