Cook Children’s Health Care System in Fort Worth, Texas, is a nonprofit organization comprising eight integrated pediatric companies that focus on the singular goal of improving the health of every child in our region through the prevention and treatment of illness, disease, and injury. As part of the Cook Children’s network, Child Study Center (CSC) operates three day programs that serve families with children with disabilities: Jane Justin School (JJS), Autism Services, and Behavior Disorders Clinic (BDC). Combined, CSC invites close to 100 children through its doors every day. When COVID-19 hit, we shuttered our educational and therapeutic programs, consistent with Cox, Plavnick, and Brodhead’s (2020) call for risk mitigation. Abruptly finding ourselves without patients to serve, our three departments collectively mobilized to provide a different kind of community service. To give context to the story, here is a brief description of our programs.

JJS is an accredited private school that provides evidence-based, individualized instruction to students aged 3–21 with complex developmental and intellectual disabilities and related behavior disorders. The vision of the school is to impart the skills necessary for children, adolescents, and young adults to return to a more traditional setting. The educational practices at JJS are guided by the principles of behavior analysis and supervised by two Board Certified Behavior Analysts (BCBAs).

Autism Services is an early intensive behavioral intervention program that provides comprehensive services to children with autism. Comprehensive services include assessment, an individualized treatment plan delivered via discrete-trial training and incidental teaching, and weekly parent training. The aim of treatment is to bring about an improvement in all important areas of functioning. These include, but are not limited to, language, social skills, academic skills, leisure skills, and self-help skills (e.g., using the toilet, eating). Reduction of stereotypy and other problem behavior (e.g., tantrums) are also targeted. Services are provided 7 hr per day, 5 days per week, and have an overall duration of 2–3 years. Services are delivered in a tiered format with a staff-to-patient ratio of 1:1. Each “team” of 7–10 children is overseen by a BCBA.

Our third day program, BDC, provides assessment, treatment, and parent training to address severe problem behavior in children, adolescents, and young adults aged 2 to 21. Behaviors commonly addressed include aggression, noncompliance, self-injury, property destruction, elopement, food refusal, and toileting refusal. The program comprises 2 weeks of intensive treatment and parent training, and all aspects of the program are overseen by BCBAs. Thanks to a generous grant from Masonic Children & Family Services of Texas, services are provided at no cost to families.

Combined, these programs staff 7 BCBAs, 7 certified lead teachers, 9 assistant teachers, 3 lead behavior technicians (either a BCBA or an advanced graduate student in behavior analysis), 39 behavior technicians, and 4 administrative assistants. These 69 individuals, normally tasked with providing therapy and education to children with disabilities, were all redeployed to provide a different kind of service to the local community.

The whispers floating through the hallways of CSC about COVID-19 began toward the end of February and grew louder by the first week in March. At that time, all day programs were gearing up to enjoy spring break. When we walked out of the building that Friday, March 6, we did not realize it was the last time we would see our students and patients for an undetermined amount of time (6 weeks and counting at the time of this writing). On Friday, March 13, in conjunction with senior leadership and after consulting with state and local health authorities, CSC closed the day programs for 2 weeks. And then on Thursday, March 26, in a heartbreaking announcement, we let our families know that this closure would last “until further notice.”

Between March 13 and March 18, Cook Children’s leadership, CSC administration, and department heads began working diligently to prepare for an unknown period of program closure. It was an interesting time because two plans were being developed in a parallel fashion: one to address the needs of children in our day programs and one to address the needs of essential employees at Cook Children’s Medical Center.

Regarding the former, the staff at our day programs began discussing ways to support parents of our students and patients who are sheltering in place at home. Although it was an easier endeavor for JJS than for Autism Services or BDC, JJS was suddenly charged with providing ad hoc distance learning to students. Because of our unique population, we felt it was unreasonable, if not unethical, to ask parents to become their children’s teachers and require online learning. Further, many of our parents were themselves considered essential employees and were not home with their children. These considerations led us to develop classroom distance-learning websites that contain customized links where parents and students can access worksheets and online educational programs. Teachers also communicate with students via Zoom and are able to check work and provide feedback. At the time of this writing, about 90% of our students are reliably engaging with the content on the websites.

During the week that Autism Services’ patients were originally scheduled to return from spring break, the department’s clinical staff reached out to families to check on how they were faring during the closure. Responses could generally be divided into two categories: “We’re doing fine, but she misses her therapists and peers” and “Being stuck inside with her routine disrupted has brought about problem behavior like we’ve never seen before!” Knowing that we had to do something for the latter group, we frantically began exploring options for the provision of telehealth services. Although we had never previously considered telehealth, we are fortunate to be part of a health care system with physicians who practice telemedicine, so the infrastructure had already been developed. Still, significant thought and effort were required to understand payor rules, evaluate delivery methods, and ensure that the services we provide would genuinely make a positive impact on our patients. As most who work in clinical settings would predict, responses from insurers were often inadequate or contradictory. Thanks to the work of staff in our Client Services Department, we began providing telehealth services on Thursday, April 9.

During the period in early to mid-March—as we saw local, state, and federal disaster declarations coming out—administrators and department heads had the first of many conversations about how CSC could pitch in to help hospital staff. We would soon know, as Cook Children’s Emergency Task Force asked if we could operate a childcare facility for the children of essential employees. Cook Children’s operates a day care on site, but with every school district and most early childhood centers closed, ensuring all employees had childcare was difficult. Thus, CSC transitioned into “Camp Cook,” a free-of-charge childcare facility operating Monday through Friday from 6:00 a.m. to 8:00 p.m. and staffed by CSC day program staff.

Camp Cook is not your typical childcare center. First, our guests are much older than you would normally find in day care. They range in age from 3 to 13 years. Second, because of social distancing guidelines, we limit the number of guests in each room, resulting in much smaller classrooms (≤10) and ratios (1:5). Third, the hours are extended to accommodate employees who work a 12-hr shift at the hospital. And finally, many of our guests have been assigned online schoolwork to complete during the day. This has worked in our favor, as who is better equipped to monitor virtual schoolwork than a staff of teachers and behavior technicians? When our guests complete their virtual school requirements, Camp Cook staff schedule periods of time that vary in structure. Guests participate in classroom games and activities, use two outdoor playgrounds and our indoor gym, and go to art class three times per week. Children, especially the ones in camp for 12 hr, also have time to just hang out with staff and each other, play on their personal devices, or play a video game on one of our gaming systems. It is not a bad way to spend a day.

It is not just us teaching the children at Camp Cook; the children are teaching us as well. They are typically developing individuals with no major barriers to learning. Most of them are completing work at or above grade level. They have amazing social skills, flow effortlessly through conversations, and follow directions with a smile and a “yes, ma’am” (and maybe an occasional eye roll from our preteen set). They eat their lunches, use the restroom, wash their hands, and generally take care of their business independently. Not surprisingly, we have observed that these children are sensitive to the same contingencies of reinforcement as the students and patients we traditionally serve in each of our respective programs. Having a well-prepared staff who are accustomed to providing high rates of positive reinforcement helped ease the transition. Moreover, this is an opportunity for our staff to see what typical development looks like. It is a reference point and a good reminder of the outcomes for which we are working every day.

Although it has been nice to hear children laughing in the classrooms again, we are cautiously optimistic that we may soon return them to their home districts and welcome back the students and patients for whom our staff were specially trained.

FormalPara Author Note

Tracie Mann, Child Study Center, Cook Children’s, Fort Worth, Texas; Jesse Anderson, Child Study Center, Cook Children’s, Fort Worth, Texas; Lee Mason, Child Study Center, Cook Children’s, Fort Worth, Texas; Duy Le, Child Study Center, Cook Children’s, Fort Worth, Texas.

The authors would like to thank Melinda Robison for her contribution to this manuscript and Kimberly James-Kelly for her contribution to Camp Cook.