Caregiver Training Methods

3. Rehearsal

• The caregiver practices the skill with the client (in vivo) or with the BCBA (role play).
• Practice in the actual environment where the caregiver will implement the strategy.
• Start with simple scenarios and progress to more complex or challenging ones.
• Multiple practice opportunities are essential—one rehearsal is rarely sufficient.

4. Feedback

• Deliver feedback immediately after the rehearsal.
• Positive feedback first: Identify specific things the caregiver did correctly ("You waited the full 3 seconds before prompting—that gave him a chance to respond independently").
• Corrective feedback: Specific, actionable, and paired with a rationale ("Next time, try to deliver the reinforcer within 2 seconds of the correct response so he connects the two").
• Positive-to-corrective ratio: Aim for 3:1 or higher.
• Repeat rehearsal-feedback cycles until the caregiver meets the mastery criterion.

Written Materials

Design Principles

• One-page maximum for quick reference guides.
• Use visuals: photos, icons, simple flowcharts.
• Large font, high contrast, minimal text.
• Include: what to do, what to say, and what to do if it does not go as planned.
• Translate materials into the caregiver's primary language when needed.
• Consider literacy level—use Flesch-Kincaid readability assessment (target grade 6–8).

Types

• Step-by-step cards: Laminated cards placed in the environment (e.g., on the fridge) with the procedure steps.
• Visual guides: Photos of each step in a procedure.
• Video models: Short (1–3 minute) videos showing the correct procedure.
• FAQ sheets: Answers to common "what if" questions.

Competency-Based Assessment

Defining Mastery Criteria

For each caregiver skill, specify what "competent" looks like:

• Accuracy threshold (e.g., 90% of steps implemented correctly on the fidelity checklist).
• Number of consecutive observations meeting criterion (e.g., 2–3 consecutive observations).
• Performance in the natural context (not just during training sessions).

Assessment Process

1. Baseline: Observe the caregiver implementing the skill without training (pre-BST).
2. Training: Deliver BST.
3. Post-training: Observe the caregiver implementing the skill.
4. Follow-up: Observe 1–2 weeks later to assess maintenance.
5. If mastery is not met, provide additional training cycles.

Caregiver Fidelity Checklist

Create a checklist mirroring the treatment integrity checklist but adapted for the caregiver's implementation.

• List each step the caregiver should perform.
• Score each step as correct, incorrect, or not applicable.
• Calculate the percentage of correctly implemented steps.
• Use the same checklist across observations for consistent measurement.

Pyramidal Training

Train one caregiver (or staff member) to train others.

When to Use

• Large teams where the BCBA cannot train everyone individually.
• Parent-to-parent training within support groups.
• School settings where one teacher trains paraprofessionals.

Procedure

1. Train the primary caregiver to mastery using BST.
2. Train the primary caregiver to deliver BST to others (instruction, modeling, rehearsal, feedback).
3. Observe the primary caregiver training a secondary caregiver.
4. Provide feedback on their training delivery.
5. Assess the secondary caregiver's performance to confirm training was effective.

Telehealth Caregiver Training

Considerations

• Ensure stable internet connection and appropriate device (tablet or computer with camera).
• Position the camera so the BCBA can see both the caregiver and the client.
• Use screen sharing for instruction and written materials.
• Modeling may require pre-recorded videos rather than live demonstration.
• Rehearsal occurs with the caregiver and client at home—the BCBA coaches in real time via audio.
• Bug-in-ear technology can enhance real-time coaching.

Evidence Base

• Research supports telehealth BST as effective for teaching caregivers ABA strategies (e.g., Lindgren et al., 2016; Wacker et al., 2013).
• Some payers require specific telehealth documentation and modifiers.

Addressing Barriers to Caregiver Training

Cultural Sensitivity

• Ask about family values, communication preferences, and daily routines before designing training.
• Respect cultural practices that do not conflict with the client's safety or treatment.
• Use interpreters for families with limited English proficiency—do not rely on the child to interpret.
• Be aware of power dynamics: the BCBA is a guest in the family's home.

Competing Demands

• Caregivers have jobs, other children, household responsibilities. Be flexible with scheduling.
• Prioritize the most critical skills first—do not overwhelm with a long training list.
• Embed training into natural routines rather than requiring additional dedicated time.

Low Literacy or Limited English

• Rely on video models, visual supports, and live demonstration rather than written materials.
• Simplify written materials if used.
• Confirm understanding through demonstration, not verbal report.

Motivation

• Connect each training target to the caregiver's stated priorities ("This will help Maya tell you what she needs instead of screaming").
• Celebrate caregiver successes explicitly and genuinely.
• Provide data showing the impact of the caregiver's implementation on the client's progress.

Documentation for CPT 97156/97157

Required Elements for 97156 (Individual Caregiver Training)

• Date, start/end time, duration in minutes.
• Who was trained (relationship to client).
• Specific skill or procedure trained.
• BST components delivered (instruction, modeling, rehearsal, feedback).
• Caregiver's performance: what they did well, areas for improvement.
• Competency data: fidelity percentage if assessed.
• Plan for next session.

Required Elements for 97157 (Group Caregiver Training)

• Same as above, plus: list of all caregivers present, group size.
• Note: bill only one unit per group session regardless of number of families.

Key References

• Parsons, M. B., Rollyson, J. H., & Reid, D. H. (2012). Evidence-based staff training: A guide for practitioners. Behavior Analysis in Practice, 5, 2–11.
• Lerman, D. C., et al. (2020). Remote coaching of caregivers via telehealth: A review. JABA, 53, 1630–1649.
• Lindgren, S., et al. (2016). Telehealth and autism: Treating challenging behavior at lower cost. Pediatrics, 137(S2), S167–S175.
• Wacker, D. P., et al. (2013). Conducting functional communication training via telehealth to reduce the problem behavior of young children with autism. JABA, 46, 31–40.