Virtual Training of Medical Students to Promote the Comfort and Cooperation of Patients with Neurodevelopmental Disabilities

Research indicates that individuals with neurodevelopmental disabilities (NDD) generally have poorer health than those without disabilities. Individuals with NDD present with greater levels of obesity, inpatient hospitalizations, emergency room visits, and medical appointments (Boulet et al., 2009; Havercamp & Scott, 2015; Havercamp et al., 2004; Lauer et al., 2019; Weiss et al., 2018) and are less likely to receive needed medical care than those without disabilities (Center for Disease Control, 2019). Physicians also report that they order fewer preventive care services (i.e., blood pressure checks, cholesterol monitoring, mammograms) and provide less counseling on high-risk behaviors (i.e., smoking, inactivity) for patients with NDD (Rehabilitation Research & Training Center [RRTC], 2003). In fact, it has been estimated that more than a third of deaths of patients with NDD were potentially preventable by healthcare interventions (Hosking et al., 2016).

Uncooperative behavior of patients with NDD during medical appointments is one barrier to receiving adequate medical care. Patients with NDD may display uncooperative behaviors due to unfamiliarity with people in the medical environment or due to past exposure to aversive medical procedures (e.g., physical exams, blood draws) that led to a learned fear of medical stimuli (Kopecky et al., 2013). Uncooperative behaviors can take a variety of forms, including crying, protesting, refusing to follow directions, running away, and hitting others. In some cases, noncooperation may be due to poor receptive language skills (i.e., difficulty understanding instructions to open the mouth or to breathe when checking lung functioning; Cuvo et al., 2010). Uncooperative behavior may lead to the use of risky, potentially unnecessary procedures, such as restraints, sedation, or anesthesia (Boynes et al., 2010; Dougherty, 2009; Kouo et al., 2021). Such procedures may deter caregivers from seeking services for their children (e.g., Kannikeswaran et al., 2009).

Research suggests that most medical professionals do not have the knowledge and training to promote the comfort and cooperation of patients with NDD (Austriaco et al., 2019; Bruder et al., 2012; Jensen et al., 2020; Zerbo et al., 2015). As a result, medical professionals may be unwilling to implement accommodations for patients with NDD, may draw incorrect assumptions about the patients’ skills or needs, and may exclude patients with NDD from their practice due to behavioral difficulties during health care exams and procedures (Kupzyk & Allen, 2019; Nicolaidis et al., 2015; Raymaker et al., 2017; Wilson & Peterson, 2018). Medical professionals have cited lack of time, unfamiliarity with or lack of access to community resources, difficulties with communication, and lack of training or experience with this population as barriers to providing care (Carbone et al., 2010; Morris et al., 2019).

One way to reduce health inequities for patients with NDD is to provide more specialized training to medical students and practicing medical professionals (Johnson & Rodriguez, 2013). Current medical school education to work with patients with NDD typically is limited to just a few hours of didactic classroom instruction (Albino et al., 2012). Research suggests that this type of training is ineffective for preparing caregivers and professionals to work with this population (e.g., Hudson, 1982; Ward-Horner & Sturmey, 2012). A recent review of studies on autism-specific training for physicians and physician trainees also noted a lack of evidence that existing programs produce changes in physician behavior when interacting with this patient population (Clarke & Fung, 2022). Furthermore, surveys of health care providers indicate that they prefer hands-on training (e.g., Smith et al., 2021). An important consideration is how best to disseminate more specialized training to the students and professionals who would benefit. An effective training that is time- and cost-efficient would be more likely to be incorporated into existing medical school curricula or to be used by practicing professionals.

Numerous studies have demonstrated the effectiveness of behavior skills training (BST) for teaching professionals to implement behavior management strategies. BST is a competency-based training that utilizes instruction, modelling, and role-play with feedback (Parsons et al., 2012). BST has been effective to teach new skills when delivered in individual and group-training formats (e.g., Erath et al., 2020; Gormley et al., 2019; Hinkle & Lerman, 2021; Sarokoff & Sturmey, 2004). More recently, research suggests that BST also might be successful when delivered in a completely virtual format. In Matteucci et al. (2022), dental students and professionals met with an experimenter via video conferencing technology to learn how to increase the cooperation of patients with NDD during routine dental exams. After the experimenter provided initial instructions and modeling, the participants engaged in virtual role-play with the experimenter, who pretended to be a patient with NDD. The participants performed mock dental exams while practicing behavior management strategies until they mastered the strategies. Results indicated that the virtual BST was highly effective in teaching the targeted skills and took no more than 90 min for participants to complete. Most important, the participants’ skills transferred to in-person mock dental exams immediately after the training for six of the seven participants, demonstrating the generality of the fully remote training format. Virtual formats may enhance the cost-efficacy and accessibility of training, particularly if the trainer does not have to observe the trainee working with actual patients. However, further research is needed because the experimenters only assessed the skills during exams with actual patients for one of the seven participants.

Another important consideration is what to teach medical professionals as part of large-scale training programs. Ideally, the strategies should be practical and effective for increasing the comfort and cooperation of patients with NDD. The most common behavior management strategy described in pediatric and dental communities is a procedure called “tell-show-do” (Allen et al., 1990). For this strategy, the professional describes the procedure to the patient (e.g., “I am going to place this cuff around your upper arm”), shows the patient the procedure (e.g., puts the blood pressure cuff on their own arm), and then implements the procedure with the patient. Despite its popularity, tell-show-do alone is unlikely to promote cooperation in patients with NDD (e.g., Mah & Tsang, 2016).

Researchers have also identified several evidence-based behavioral interventions that are effective for increasing cooperation or decreasing fear-correlated measures (e.g., crying or screaming) during health care procedures (for reviews, see Kupzyk & Allen, 2019; St. Joseph & Machalicek, 2022). These interventions include gradually exposing the patient to elements of the procedure (e.g., Cavalari et al., 2013; Grider et al., 2012; Kupzyk & Allen, 2019; Szalwinski et al., 2019), pairing preferred items or activities with putative aversive procedures (Gorski et al., 2004; Jensen et al., 2020; Nordahl et al., 2016), providing frequent breaks from the procedures (O’Callaghan et al., 2006), preventing escape from the procedure contingent on disruptive behavior (i.e., escape extinction; Szalwinski et al., 2019), and providing reinforcement for cooperation (Cavalari et al., 2013; Grider et al., 2012; Stuesser & Roscoe, 2020).

For example, Stuesser and Roscoe (2020) examined the efficacy of differential reinforcement with and without graduated exposure for increasing cooperation during simulated medical procedures (e.g., taking temperature, drawing blood). Participants were one child and three teenagers with autism spectrum disorder. Initially, the experimenter provided praise and a food reinforcer each time a participant cooperated with a procedure without engaging in disruptive behavior. If differential reinforcement alone was ineffective, the experimenters broke down the procedures associated with noncooperation into smaller sub-steps and gradually exposed the patient to an increasing number of sub-steps. It should be noted that the experimenter always provided a brief break from the procedure when the participant engaged in disruptive behavior to ensure that the treatment would be safe and practical for medical personnel to implement (i.e., the procedure did not include escape extinction). Treatment was efficacious for all participants, with three of the four requiring gradual exposure for certain procedures. Results maintained from 2 weeks to 1 year after the final treatment session.

Although research findings indicate these behavioral interventions are effective for increasing patient cooperation, experimenters rather than health care providers implemented the interventions in most studies. Furthermore, some of these interventions may not be practical or possible for health care providers to implement. For example, for graduated exposure, the experimenter implemented the intervention over multiple sessions before the participant could complete all of the medical procedures, a strategy that might be time- and cost-prohibitive for health care providers or patients (Stuesser & Roscoe, 2020; Szalwinski et al., 2019). The experimenters implemented the interventions outside the context of health care appointments (i.e., during mock exams). This is a limitation because the gains obtained in the therapy environment may not generalize to the health care setting. In addition, experimenters have implemented escape extinction (i.e., prevented escape from the medical procedure when the patient engaged in uncooperative behavior) (Cuvo et al., 2010; Iwata et al., 1990; Slifer et al., 2011). Health care providers may be unable or unwilling to implement escape extinction (Stuesser & Roscoe, 2020).

An alternative approach is to train medical professionals to apply a set of practical and potentially effective procedures that are appropriate for the medical context. For example, professionals could pair preferred items with the exam, provide reinforcement for cooperation, and break down some of the more challenging exam steps into smaller steps within the context and duration of typical medical appointments. Research suggests that an intervention combining these components would be effective for at least a portion of patients who are uncooperative with medical exams and procedures (Kupzyk & Allen, 2019). As such, it seems appropriate to include these procedures as part of large-scale training programs.

The purpose of this study was to evaluate the effectiveness of virtual training of medical professionals in how to implement evidence-based procedures that can increase cooperation and decrease disruptive behavior during routine medical exams and that can be implemented within the context of a single appointment.

Results for all participants are shown in Fig. 1. Poppy’s correct responding during baseline (simulated patient) averaged 42.3% of opportunities. During post-training (simulated patient), Poppy’s correct responding increased to a mean of 98.6% of opportunities with a slight decrease to 90.3% during maintenance (simulated patient). Leona’s correct responding during baseline (simulated patient) averaged 32% of opportunities. Leona’s correct responding was high during post-training (simulated patient), averaging 90.3% of opportunities. Like Poppy, correct responding slightly decreased during maintenance (simulated patient) to a mean of 85.7% of opportunities. Fiora’s correct responding during baseline (simulated patient) averaged 36.7%. Fiora was not able to participate in the post-training phase due to COVID-19 restrictions. However, during maintenance (simulated patient), Fiora responded correctly on a mean of 97% of opportunities. Darius’s correct responding during baseline (simulated patient) averaged 45.7%. During post-training (simulated patient), Darius’s correct responding averaged 91.4%. His performance remained high during maintenance (simulated patient; M = 94.2%).

Irelia’s correct responding averaged 46.7% of opportunities during baseline (simulated patient) and increased to a mean of 96.7% of opportunities during the post-training phase (simulated patient). During maintenance, Irelia responded correctly on 80.6% of opportunities with an actual patient. Her most frequent error was failing to provide praise following the patient’s cooperation with a medical procedure. Due to scheduling issues, Irelia could not participate in any further sessions with actual patients. However, she responded correctly to a mean of 97.6% of opportunities during subsequent sessions with simulated patients.

Lulu’s correct responding during baseline (simulated patient) averaged 57.1%. She responded correctly on 40.3% of opportunities during a baseline exam with an actual patient. Lulu’s correct responding during post-training (simulated patient) increased to a mean of 94.5% of opportunities. During her first post-training (patient) exam, Lulu responded correctly on 50% of opportunities. During this first patient exam, Lulu saw a patient who had been diagnosed with cerebral palsy and was minimally responsive. During the post-session debrief with the experimenter, Lulu stated that during the appointment she did not provide praise or vocally state the instruction or tool being used due to the patient’s lack of responses. However, during the meeting, Lulu corrected herself and stated that she should not have assumed the patient’s level of understanding and she should still implement those two steps of the procedure; these responses indicated self-correction without any feedback from the experimenter. She then implemented the procedures with high fidelity following this self-correction. During the next two post-training (patient) exams, Lulu’s correct responding exceeded the mastery criterion of 90%. During maintenance (simulated patient), Lulu correctly responded on 100% of opportunities.

Zeri’s correct responding during baseline (simulated patient) averaged 36.6% of the opportunities. She responded correctly on 26.9% of opportunities during a baseline exam with an actual patient. Zeri’s correct responding during post-training (simulated patient) increased to a mean of 93.87% of opportunities. Her performance decreased somewhat during post-training exams with actual patients. She responded correctly on a mean of 82.3% of opportunities because she often failed to provide praise or a 15-s break following the patients’ cooperation with the medical procedure. Because Zeri’s performance did not meet the mastery criterion of 90% or above for two consecutive sessions, the experimenter provided feedback to Zeri about her performance with the second patient. Following feedback, Zeri responded correctly on 90% of the opportunities during an exam with a third patient. During maintenance (simulated patient), Zeri responded correctly on 94.1% of opportunities.

All participants met the mastery criterion during a remote training that lasted no more than 3 h, with each participant requiring no more than four practice trials with each set of procedures (e.g., noncontingent reinforcement) and, on average, about 30 min of practice to meet the criterion. Finally, because the participants’ opportunities to implement different components of the behavioral procedures with actual patients (as opposed to simulated patients) depended on the patients’ behavior, the data were further analyzed to identify the procedures that participants implemented during these exams. This information is displayed in Table 5.

Overall, results from the social validity survey completed post training and at maintenance indicated that the medical students found the behavioral procedures to be acceptable, that they believed that the procedures would be effective with patients, and that they would be willing to implement the procedures with patients (see Table 6 for social validity ratings). On the survey completed at maintenance, participants estimated that they had used the procedures with a range of 2 to 30 patients (M = 10.5) during their rotation at the clinic. Furthermore, the participants provided similar ratings on the survey immediately following the training and after implementing the procedures with patients (see Table 7 for social validity ratings of individual participants). Anecdotally, many of the participants stated that they wished this training was a part of their standard curriculum, and one participant expressed an interest in providing the training to her other classmates.

Results suggest that virtual BST may be an efficient, practical approach for training health care professionals to implement a set of general behavior management strategies to increase the comfort and cooperation of patients with NDD during exams and procedures. For all participants, performance in the virtual environment generalized to an in-person format and maintained across 2 weeks. Further, results for a subset of participants suggested that the training was sufficient to prepare them to implement the strategies with actual patients in the absence of further training. This latter conclusion must remain tentative, however, because only three of the seven participants had the opportunity to apply the trained skills to actual patients during the study; furthermore, their performance with patients was somewhat variable, and none had an opportunity to implement graduated exposure or respond to problem behavior during the exams.

The study extends the current literature by evaluating the effectiveness of brief virtual BST when teaching health care students to apply a set of practical behavior management strategies that should be effective for at least a portion of patients with NDD. The majority of prior studies on autism-specific training for health care professionals evaluated lecture-based, educational programs, a format that is unlikely to produce changes in practices, and none evaluated changes in actual trainee behavior (for reviews, see Clarke & Fung, 2022; Walsh et al., 2021). Furthermore, few prior studies on BST have examined its efficacy when conducted solely in a virtual environment (see Lloveras et al., 2022, for a notable exception). The abbreviated, virtual nature of the training may increase its accessibility to health care students and professionals. All of the participants completed the training in less than 3 h, which included 90 min of didactic instruction, 18 min of video modeling, and practice in role play (approximately 30 min per participant). Furthermore, the two formats embedded within the training (hands on and web based) were consistent with the reported preferences of medical professionals (Bruder et al., 2012; Smith et al., 2021).

Typically, medical students receive no more than brief didactic classroom instruction on treating patients with NDD (Austriaco et al., 2019). Nonetheless, voluminous amounts of research indicate that BST is far more likely to change actual practices. If widely available, this training might increase the number of providers who are willing and able to work with this population, directly addressing one barrier to equitable health care for individuals with NDD (Carbone et al., 2010; Morris et al., 2019). Moreover, training health care providers how to increase the comfort and cooperation of patients with NDD may decrease the number of patients who experience restraint or sedation during health care exams and procedures, as well as those who require more intensive services from behavior specialists.

The social validity questionnaire focused on the content of the training rather than on the training modality. However, results indicated that the participants generally found the behavior management strategies to be acceptable and effective with patients. On the questionnaire completed 2 weeks after the training, all of the participants reported that they had applied the strategies to multiple patients during their clinical rotation. Most importantly, many of the participants rated the procedures more favorably after implementing the procedures with patients.

Nonetheless, further research is needed to address various limitations of this study. First, due to the COVID-19 pandemic and scheduling difficulties, the experimenter observed just three of the seven participants implementing the procedures with actual patients. Baseline data with an actual patient could not be collected for one of those participants (Irelia), and only one patient was available for a post-training exam with this participant. Second, the participants only had opportunities to implement a subset of the procedures with actual patients because none of the patients displayed disruptive or noncompliant behaviors during the exams; in addition, the caregivers could not report a specific part of the exam that had evoked anxiety or physical resistance in past exams. Thus, the experimenter could not observe the participants’ responses to problem behavior or their implementation of graduated exposure. Third, maintenance of the skills was limited to a 2-week period and all but one of those maintenance checks were conducted with simulated patients.

Another limitation was that the experimenter conducted training with just one or two participants simultaneously during meetings that lasted up to 3 h, a format that may not be practical for preparing large groups of medical students and professionals. Further research is needed on the efficacy of more efficient training formats. For example, instructors could provide the didactic and modeling portion of BST via a training video to large groups of trainees and then arrange short, small-group role-plays for the practice and feedback portion. Pyramidal training, or train-the-trainer arrangements, also might increase the accessibility of the training and make it more practical to embed within existing medical school curriculum or large health organizations (e.g., Mery et al., 2022). Continuing education for practicing professionals likely will need to incorporate asynchronous training modalities (i.e., on-line instructional modules and videos) to permit more flexible scheduling. These asynchronous opportunities could be combined with periodic virtual meetings to provide opportunities for discussion, role plays, and case presentations, similar to that utilized in the Extension for Community Healthcare Outcomes (ECHO) model (e.g., Mazurek et al., 2020).

A final limitation is that the procedures were not developed with the input of caregivers and patients with NDD. Obtaining more information about potential factors that might increase patient comfort during health care appointments could help improve the efficacy and acceptability of the procedures. Further research should assess the acceptability of selected behavior management strategies by soliciting input from caregivers and patients before and after they receive direct exposure to the procedures.

It also should be emphasized that this training focused on just one important component of a comprehensive curriculum for preparing health care providers to serve patients with NDD (see Clarke, 2022). It was not envisioned as a stand-alone program but as a model for disseminating knowledge and evidence-based practices when providing services to this population. Further research is needed on best practices for embedding a complete curriculum into existing training programs. In addition to the content of this training, health care providers would benefit from information that dispels misconceptions about patients with NDD, increases knowledge of their health care needs, and improves health care providers’ communication with their patients, among other topics (Havercamp et al., 2016, 2021).

In addition to changes in health care practices, further research should measure other important outcomes of specialized training programs, such as changes in the number of patients with NDD included in the trainees’ practice and the satisfaction of these patients with the services provided. Long term, it would be important to evaluate the impact of training on the health of patients with NDD and other measures of health inequities experienced by this population. With the continued rise in the estimated prevalence of NDD, particularly ASD, it is imperative that all health care providers receive the training and experience needed to serve this population effectively.