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Spectrum: Autism Research News

New autism clinicians reflect on skill gaps, gains after remote training

by  /  15 March 2022
New normal: The pandemic has left many clinical trainees feeling isolated from their instructors and classmates.

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Jiedi Lei kicked off her training in clinical psychology at King’s College London in the United Kingdom in October 2020, seven months into the COVID-19 pandemic. For her entire first year, she assessed patients and provided therapies over the internet. Although many sessions were productive, Lei says, the virtual environment made it difficult to engage with some of the adolescents she saw, who would sometimes just switch off their cameras.

That year of remote training has left Lei wondering how ready she is to enter the clinical world, now that face-to-face sessions are resuming, she says. “In some ways, I’m really acutely aware of things that I haven’t done or haven’t had experience with, and that concerns me a little bit.”

Lei’s worries are common among the crop of clinicians who trained during the pandemic. Online learning formats diminished their opportunities for mentorship and peer support, some say. Pandemic travel restrictions made it difficult or impossible for them to interview for fellowships or residencies in person; many have already changed jobs multiple times, in some cases without meeting their new colleagues in person or touring the campus ahead of time. And virtual clinic visits and training opportunities made it difficult for them to get comfortable with providing assessments and therapy — especially for autistic adults and children, who already have social-communication problems.

“It’s been really challenging,” says Marika Coffman, clinical associate in psychiatry and behavioral sciences at Duke University in Durham, North Carolina, who was in the middle of her postdoctoral training at Cincinnati Children’s Hospital in Ohio when the pandemic began. She says she struggled to adapt a group autism intervention she was working on to a virtual format, and to preserve its key elements and the same high level of interaction — all while learning how to do clinical work in the first place.

Some of the less tangible skills that should accompany clinical psychology and psychiatry are particularly difficult to learn and develop virtually, says Catherine Lord, distinguished professor of psychiatry and education at the University of California, Los Angeles. “It cuts into the warmth that you can provide people, the reassurance that ‘here I am, I am a person, I value you, I care about you, and then we’re going to talk.’ As opposed to just talk, talk, talk.”

In an editorial published in Autism Research in December, Lei, Coffman and other trainees offered recommendations on how faculty can support trainees in the remote learning environment and how trainees can advocate for themselves, should future lockdowns arise and some remote instruction stay the norm. Among their suggestions: Trainees should create systems of accountability with their peers, such as groups that meet regularly to share writing goals, whether they’ve met them and if not, why not. And faculty members should seek new ways to provide mentorship and networking opportunities, including making virtual introductions between trainees and potential collaborators.

“Clinical experiences have looked different, but we have been able to create new, interesting opportunities in the midst of that,” says Rebecca Shaffer, associate professor of pediatrics at Cincinnati Children’s Hospital, who was Coffman’s mentor for the first five months of the pandemic. “Mentors have had to take a more active role in checking on trainees to see how they are doing emotionally and managing life outside of work.”

“I always cared about these things,” she says, “but it has taken more of a central role in mentorship over the last two years.”

Some telehealth is bound to stay. Growing evidence indicates that it can work. The U.S. Congress plans to extend public health emergency telehealth allowances for people with public insurance. And, despite the challenges, remote training offers some advantages — to trainees and their clients alike, some new clinicians say.

Before the pandemic, pediatrics resident Jennae Reken saw many children in the clinic. She saw many of her fellow residents at the University of Missouri in Columbia in person, too — at work, weekly lectures and other activities: a plant-potting night, pumpkin-carving at Halloween, even dog park trips with Reken’s Bernedoodle, Olive, in tow.

“It was very isolating” when all that stopped, Reken says, and it presented a bit of a setback in her training. But it also enabled her to evaluate children in the context of their home environment — something she might not have been able to do before the pandemic.

Children may be less reserved when they attend therapy sessions from home, where they are more comfortable, Reken says. So trainees can observe behaviors, such as meltdowns, that children may not display during in-person clinic visits. Virtual visits can also help to foster moments of intimacy, such as when a child shows a trainee her favorite toy.

“Their ability to have a little more freedom in the way that they were interacting painted a little more to the picture than what we are able to see in the office,” Reken says.

Telehealth sessions also gave trainees a bit of a safety net, Lei says. She appreciated being able to pull up notes on her screen to reference or to share with clients or their parents during a session. That was particularly helpful as she was learning various therapeutic models, she says, “but obviously you can’t have that when you’re meeting people in person.”

Lei says that her year on screen gave her a firm understanding of how subtle movements such as sitting back in a chair can communicate something different from what she intends — a lack of interest, for instance. “Face to face, you never see what you look like,” she says.

And Lei probably did more proactive planning, too, than she may have when she was “just seeing clients face to face, back to back,” she says — a habit that helped her structure in-person sessions when she started working with autistic children and adolescents in person this past October.

At first, Lei did not trust her own abilities, she says, having missed out on the opportunities normally afforded clinical trainees, such as shadowing more experienced clinicians and getting hands-on experience conducting assessments. Her supervisors were surprised that a second-year clinical trainee had never been in the room with a patient before. But they helped her get acclimated by building in plenty of of check-ins and observing her while she worked without any notes in front of her on a screen.

“It took a bit more confidence-building to let go of the somewhat unhelpful safety things you develop for yourself when you’re working online,” she says. “It’s still a bit of a struggle now.”

Over the past five months, though, Lei says she has been honing the clinical skills that mattered less online. She is learning how to navigate social customs, how to read body language, how to catch parents informally after a visit with their child, just to chat.

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