Friday, January 24, 2014

Top 10 Reasons Why Kids With Autism Deserve ABA







I recently did a post with my own Letterman-esque “Top 10 List” of essential strategies that should be in every home that has a child with Autism. So when a friend sent me this article: Top 10 Reasons Why kids with Autism deserve ABA by Mary Beth Walsh, I immediately loved it!

I love the practical advice and humor in the article, as well as the basis of the argument for ABA: these kiddos deserve quality, effective treatment. These kiddos deserve the opportunity to improve and to learn.
 As an ABA enthusiast, I don’t  try to sell people on ABA like I’m some used car salesman in a bad suit. I know what ABA can do. I know that even with environmental barriers, weak staff, and resistant parents, kiddos can still make progress. I know that there are still  kiddos with Autism out there receiving ineffective "fad" treatments, or no treatment at all...their lives could change with the implementation of quality ABA.

Instead of feeling like I need to push ABA on people, I help families understand that ABA strategies are really just effective parenting. That’s it. 
Much of what I explain to families consists of techniques and strategies the families have already tried, or at a minimum have heard of.  The problem usually lies in the implementation, the consistency, or the intensity, which is where I come in to help.

Below is the Top 10 List from Mary Beth Walsh, with my own comments added:

Children with Autism deserve ABA because……..

  1. There is more scientific evidence demonstrating ABA works than there is for any other intervention or treatment – Still don’t believe ABA therapy is effective? Read this. Or this. Or this. Or this.
  2. Because they are human -  I agree with the author that the pendulum of public perception toward Autism used to be firmly set in the area of mentally retarded, incapable of learning, hopeless, etc. Now that pendulum has swung towards viewing  Autism as no big deal, just a little “unique”, or socially awkward. Neither assumptions are respectful of the vast and varied ways that Autism can present in children, and how Autism impacts the life of not just the child, but the whole family.
  3. Because it will help their parents be the best parents they can be for them – Lots of the strategies I recommend to parents can sound counter-intuitive. It may sound illogical, or downright odd to not pick up and comfort a crying child. I get that. But here's whats important to understand: normal parenting strategies may NOT be effective with children with Autism. What your parents did with you, or what you do with your other children, may be ineffective or potentially worsen the behavior of your child with Autism.
  4. It will help teach them how to sleep through the night and use the bathroom – The skills that parents learn from active involvement in their child's ABA therapy can generalize to countless other important skills. You learn how to shape behavior. You learn how to create interventions. You learn how to assess if a treatment method is working or not. Or to put it simply, you learn the best methods to help your child use the toilet or sleep through the night :-)
  5. It is the best defense against the tyranny of low expectations – Low expectations can come from the school, the family, or other professionals. Unfortunately I have had several experiences of interacting with people in my clients’ life who basically told me the child would never talk…never improve…..never stop engaging in aggression. Low expectations for kiddos with Autism steals them of a future they could achieve, and does a disservice to the child.
  6. Because it can teach them the skills necessary to make friends – Yes, teaching communication is important. Yes, teaching toileting skills is important. And so is helping kiddos with Autism smile at peers, play with toys, date, have sleepovers, and enjoy being a child. Everyone deserves to have companionship and friendship.
  7. Because it enables their parents and teachers to capitalize on their strengths and preferences – We all have our carrot tied to the stick that keeps us doing the things that we do. There is a reason why you answer your phone, kiss your spouse, lecture your children, etc. ABA helps parents understand that for every skill they want to teach their child, step #1 is to ask yourself: “What motivation does he/she have to do what  I want him/her to do?”
  8. Because it can teach parents how to respond in the moment – There is no way that I can spend every minute of the day working with my clients. They see me a few hours each week, and when I am not there I need the parents to generalize skills, implement strategies, and be consistent. Quality ABA programs teach parents what to do when the ABA therapists and supervisors wave goodbye and drive off after each session.
  9. Because some day their parents are going to die – It’s what no parent wants to think about, and especially the parent of a child with Autism. Parents  learn over time how to modify the environment to make things easier for their child. It’s a natural process of parenting that gets heightened when the child has special needs. But eventually the child will grow up and become an adult who must interact with society. As part of any quality ABA program, the long term benefit of behavior change must be discussed and planned for…..as unpleasant as that conversation may be.
  10. Because it can prepare them to be their own best advocates – You may wonder how to teach self-advocacy skills to a child with Autism. It isn’t that difficult. Self advocacy is really just about teaching someone how to stand up for what they want, and decline what they don’t want. Self advocacy gives power to kiddos with Autism, and how often do you think individuals with disabilities get to feel powerful?
Friday, January 17, 2014

Common ABA Work Settings




This post will generalize greatly because there is so much job  variability in this field even in the same state, and especially from work setting to work setting. 

Although many people just think of ABA therapy as being home based, there are multiple work settings ABA professionals can work in. Each work setting has its own pros and cons, and unique work cultures, that will be better suited to certain individuals than others. 

Do you want to wear jeans to work, or your nice slacks with a pair of boots? Are you able to handle a work environment where telephones ring, the family is cooking dinner a few feet away, and baby siblings chew on your car keys? Do you prefer working with a team of professionals, rather than solo? Do you need office space, or are you fine having a “mobile office”?-- (that’s a really PC term for having a car that looks like an aisle at Office Depot) Do you need a salaried position with benefits? Or would you prefer a high hourly rate that may require you pay your own taxes, and deduct expenses?  Would you be uncomfortable working in a setting that may be hostile towards ABA, or where you're the only one who understands ABA? Do you need a set schedule (8-4), or are you ok working random hours that change from day to day? Do you want to supervise only, or would you prefer a mix of direct clients and supervision clients? 
All of these are important issues to consider when deciding what work setting is best for you as an ABA professional, and what work setting will bring you the greatest job satisfaction.

Many BCBAs expect to get certified and immediately become “The Boss”, complete with a FT salaried position and a nice cushy office. That may, or may not, be realistic depending upon your work setting.

Often times salaried positions come with billable hour requirements that do not take into consideration circumstances outside the ABA professionals control (clients who habitually cancel sessions, client suddenly goes out of town for 2 weeks, etc.). For this field FT is closer to 30 hrs vs the standard 40 hour work week. Kids are only available certain hours of the day, and younger clients may still nap which deducts from possible therapy hours.
 Also,  drive time must be considered to commute back and forth between clients. So working 8 hours a day in this field is unlikely........ However, the admin side of this job WILL take you into FT territory although usually you cannot get paid for admin time. That means report writing, case conceptualization, making materials/flashcards, researching treatment methods, or meeting with staff outside of the work setting may not be paid time, but you have to do it anyway. :-)
 
 As you come into your own as an ABA professional you will develop your own preferences of work setting, and will learn the pros and cons of applying ABA treatment across settings. I personally have the most experience with home based treatment, but my preference would be clinic settings. 

I recommend researching actual job postings across settings, to get an idea of how pay, responsibilities, and job requirements can vary as the work setting varies.


 Here is a very general snapshot of what to expect when working in various ABA settings:

Home Based – Can work directly for families or for a company, work in the clients home, involves lots of driving around to specific clients which can be very taxing, less instructional control in this environment, low to moderate pay range, few to no benefits offered, varying hours and a jam packed schedule that will be more evening heavy, may have empty gaps in your schedule where you need to “kill time” in between clients, easiest environment for generalizing skills, parents can easily be incorporated into treatment, kind of a “lone wolf” and isolated from colleagues, can include direct therapy or supervision model, may be difficult to implement behavior plans due to parent dissatisfaction with strategies (parents may not allow interventions where the child cries for extended periods of time), admin/paperwork time is usually unpaid and done outside of working hours, may be difficult or not possible to target social interaction goals or group instruction goals, supplies/materials may be provided by the company or you have to purchase/make them, program goals are often more adaptive in nature (skills important to the family like self help, feeding, bathing, etc), your car is your office!

Clinic Based – May be self-employed (open your own clinic) or work for a clinic/center, much less driving as you go to the same place daily, more typical work hours (e.g. 8-4), in between clients can do admin tasks/paperwork, moderate to high pay range, some benefits may be offered, best instructional control, generalization is harder, team environment so its easier to collaborate with other BCBA’s and ABA staff,  more difficult to include parents into training/teaching, more likely to include direct therapy as well as supervision duties, supplies/materials provided by the clinic owner, program goals may lack adaptive skills, best environment for implementing behavior plans,  advantage of multiple peers for social, play, and group instruction opportunities, often have opportunities for cross collaboration with non ABA providers (SLP’s, OT’s,etc.) typically provided with a shared “office space” that all employees use.

School Setting –  These types of positions may be harder to find depending on where you live, moderate pay range, benefits are very likely, may be self-employed (private consultant) or a school employee, may work for 1 school (minimal driving) or several schools (tons of driving), schools often hire “Behavior Specialists” which is a position that may not require a BCBA, typical work hours (e.g. 8-4) unless you travel between multiple schools,  opportunities for cross collaboration with non ABA providers (SLP’s, teachers, OT’s, etc.), program goals are typically heavily academic, more of a consultation model and less of a direct or supervision model, may be difficult to involve parents in training/teaching, generalization is harder, interventions are more classwide than individual, minimal to moderate instructional control, can be difficult to implement behavior plans in a classroom environment, admin/paperwork time is usually unpaid and done outside of working hours, supplies/materials might be provided by the school,  advantage of multiple peers for social, play, and group instruction opportunities, usually do not have an on-site office.


Tuesday, January 7, 2014

Conducting Client Intakes







Related posts: VB MAPP and ABLLS-R



“Intake” is an information gathering process that ABA professionals (usually someone in a supervisory role) use with new clients to determine a few things:

  • What specific needs, strengths, and deficits does the client present with?
  • Determine the parent training and/or education that will be needed about the purpose of ABA, and the precise implementation of treatment
  • Get an idea of current functioning level, as well as past levels of functioning (has the child recently regressed? Are they currently experiencing a surge in language?)
  • Determine the best individualized treatment plan for the client



Intakes can be small, or quite large. Many companies have the supervisor who will be working with the client conduct the intake, or if it’s a smaller company, one person may handle all new client intakes (company owner). The intake process should be consistent across individuals, and needs to be lengthy enough to gather important information. Some companies only allow 1-2 hours for intake, which is not enough time at all. It isn’t uncommon that intake may stretch over a few days, especially if other care providers are interviewed or observed, such as the Speech Therapist.

I don’t recommend accepting a new client into your private practice or ABA program without conducting a proper intake assessment. The reason why is it will be difficult to properly create the treatment plan if you only have minimal information about the client. This can lead to poor quality “cookie cutter” programs where all clients who look like "this" get treatment 1, and all clients who look like "that" get treatment 2, etc. Even if important information can be obtained through a brief phone interview, these interviews are usually conducted by office staff. Office staff may have little to no knowledge of ABA treatment planning and often do not know how to gather the kind of information an ABA professional would need.

Most of my intakes take anywhere from 3-4 hours to a few days, and include lots of paperwork. I usually send much of the paperwork to the family in advance, to save time during our actual meeting. This way I can get more into interviewing and direct skill probing, since the background information questions have already been answered via a questionnaire, or form. This is also a great way to begin record review, by having the family or caregivers send you relevant information such as recent psychological reports, the initial evaluation (the report done by whoever diagnosed the child), recent IEP, etc., before you actually meet the client.

It won’t always be possible, but I recommend scheduling the intake visit at a time when the client will be present. Observation, interaction, and direct skill probing  are critical to accurate intake, and you will need the client present in order to complete these steps. You also want to keep in mind that parent report can sometimes over or under exaggerate. If the child is actually present, you can test statements the parent has made, or probe for yourself. For example, the parents may state that the child always has a tantrum if they hear the word “no”. You could then set up a scenario where you tell the child “no” to something they want, and see if a tantrum occurs. If a tantrum does not occur, that would tell you there is a history of reinforcement tied to the behavior that is causing the problem behavior to be exhibited in one setting (toward the parents) and not in another (towards you).

A thorough intake assessment will give me much of the information I need to create a behavior plan, initial acquisition programs, and parent training documents. Of course I will need to keep getting to know the child and family dynamics, but much of what I need to know is revealed during intake: Is the house chaotic and disorganized? A routine and visual schedule will likely be necessary. Is the child incredibly aggressive towards their siblings, OR ignores their siblings completely? Social interaction programs, including involving their sibling and other peers, will need to be taught.. Do the parents reinforce problem behaviors in front of you? Parent training will be key. And so on……


The following is intended to be a guide to conducting intake assessments, and there is a link to a sample intake form below.

Conducting an Intake Assessment

Eligibility - This will vary greatly depending on the funding source, if you work independently, or if you work for an agency. Eligibility basically is determining if the client is eligible for services. Some funding sources require a diagnosis of Autism. Companies may require that families complete parent training before they can begin services. If you work independently, you may create your own eligibility criteria that families must meet in order to work with you. Things to discuss during this portion of the intake process include: How will the family pay for treatment? What is the client’s diagnosis (and are there secondary diagnoses)? How many hours per week of treatment is being requested? Do your experiences and expertise qualify you to work with this client (e.g., you have only worked with adult clients and this client is 3)?

Observation – This can include observation of parent/child interactions, as well as just observing the child. Observation should occur across environments, to gain more information about the child’s strengths and deficits. It may be necessary to explain to the family when your observation will begin, and what it will entail. I have met with families who tried to contrive scenarios during my observation or tell their child how to behave. To be most helpful, you should be a "fly on the wall" during your observation process. Sit in an unobtrusive place and refrain from speaking to the child or family. Take clear and detailed observation notes that reflect only what you saw (be objective). If you will be observing at the child’s school, this post  may be helpful to read.

Interview – The interview portion of intake is where you want to find out as much relevant information as possible about the clients history, previous treatments, current treatments, functioning level, problem behaviors, skill deficits, etc. I have found that approaching the interview as a conversation, versus a stiff and formal Q&A session yields better responding. I typically give the parents forms to complete the interview portion before we meet, and then we can discuss them in detail during our face to face meeting. Be sure to interview all relevant caregivers. If there is a regular babysitter who spends 5 hours each day with the client, that person is a valuable source of information.  Ask about all the people who spend significant amounts of time with the child, and see if you can interview these people as well. If appropriate, siblings can also be interviewed.

Assessment – The assessment process typically includes an assessment tool such as the Vineland, ABLLS-R, or VB-MAPP. These assessment tools will give a detailed snapshot of the clients skill functioning. Parents and caregivers often appreciate beginning ABA therapy with a  detailed summary of their child’s performance across skill domains. Just like with observation, it may be necessary to explain to the parents the point of assessment, and what their role should be while you are assessing their child. Parents may try to prompt or help their child, such as telling the child “Say blue…c’mon, say blue. I know you can say blue”. It is difficult for parents to watch their child miss assessment responses or fail to respond, so be patient and help the parents understand why they cannot prompt responding.

Goals – Program goals can be created during the intake process. I approach goal setting with a team approach: I need to know from the parents what is important for them, and then I tell them what deficits I see. This is also a great opportunity to help the parents create goals for themselves, for example being able to implement a DRA procedure independently with their child. It isn’t unusual that the family may have goals in mind that are currently unrealistic. It may be necessary to help explain the pre-requisite skills necessary for a specific goal, as well as the required consistency across environments in order to see progress.

Policies & Procedures – If you work for a company, the intake process will often include signing important paperwork, completing contracts, or going through consent forms with the family. Even if you work independently I recommend using the intake process to go over your individual policies or rules, such as: Do you work with ill children? Do you work on holidays? Do you provide therapy materials and supplies? Do you transport clients in your vehicle? I recommend having these policies in writing, discussing them with the family, and then having them sign to indicate acknowledgement of the policies.

Parent Education – If you are conducting an intake assessment for a child who has never received ABA services before, the family may be completely unaware of what exactly ABA is, how it works, what you will do with their child, how intensive treatment will be, etc. I always include in my intake assessments a portion of time for the family to ask questions of me. I encourage them to ask me about my background, my training, my relevant work experiences, ABA, the treatment plan, what to expect from therapy, etc. Especially after a professional has interviewed them for a few hours, some families may be too intimidated to ask the important questions. Gentle nudging may be necessary, such as asking the family if they understand the commitment level required, or asking the family how program information will be shared with the school staff. This can often get a shy or reserved family comfortable enough to start asking questions.  I also use this portion of the intake assessment to explain my expectations for the parents, and review my  Parent Participation Policy.


* Resource: Sample Intake Form
Thursday, January 2, 2014

Quote of The Day




The Truth About Classroom Management

When you’ve been in the classroom for a long time, so much of what you do on a daily basis is ingrained.  It merges and becomes a conglomerate of training, experiences, philosophy and values. It is automatic and effective.  But when you mentor teachers new to the classroom or train interns preparing for a classroom, you have to dissect and analyze your own responses in order to make it an applicable lesson for them.

People new to the classroom worry about discipline and classroom management, but it is more about preparation, pacing and imagining what will intrigue the age level with which you are working.  By being knowledgeable, prepared with appropriate and supportive materials and keeping the pace of the lesson moving along and focused upon the objective(s), the students will be occupied and task oriented.

In terms of preparation, know your subject and have the lesson’s materials organized and available.  Always have more planned than you can possible do in one day. Also, have systems in place that give students additional activities whether centers, computer work, reading, etc.

Pacing may be an intern’s greatest weakness in the beginning.  A lesson that does not move along in sequence will directly affect classroom management, leaving students with time to get off task with their work and their behavior.  Children are experts at lesson diversion. 

Watch the clock!  Time management is critical.    Lessons can drag on until they diffuse from the original objective and are no longer the most effective use of time.  If this becomes a pattern, the class will fall further and further behind day by day and not be prepared for assessments. 

B. Perez, 2012

I love this accurate and insightful description of what excellent classroom management looks like. So much of this directly parallels what an excellent ABA therapist does. Running a therapy session includes thinking 6 steps ahead, managing reinforcers, minimizing problem behaviors, delivering consequences, being creative, maintaining your energy and quick pace, all while being actively engaged with the client.


Sometimes I forget just how many things I do at once when working with children, until I am training a new staff member or a parent. There is so much to learn, and it can be very overwhelming at first. 
Its like learning to drive a car…..at first, just keeping the car in the lane is difficult. Add in watching your speed, looking out for careless drivers, braking quickly when the car in front of you stops…..all of these separate tasks are necessary to learn to drive. 

 If you are new to ABA and feeling overwhelmed, hang in there and be patient with yourself. If you’re anything like me, you didn’t learn to drive in a few days :-)
So you aren’t going to learn to be an excellent ABA therapist in a few days, either. It does get easier, and you develop automaticity, and next thing you know, running a therapy session is as easy as driving your car.



 A great ABA therapist is one who has 10,000 things going on in his/her head, but to a parent it looks like all you are doing is happily engaging with their child.