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*Recommended Post: Programming Sequence

I decided to do another audio post, about an important topic: ABA intervention goals and how they vary as the client ages. It doesn't matter whether you are an ABA professional, a parent, or an educator/paraprofessional, if you are responsible for selecting treatment plan goals this post should help you.
This post will answer questions such as:

  1. What exactly does "learning how to learn" mean?
  2. For young children/adolescents/adults, what are some common areas of concern that intervention needs to address?
  3. How can these areas of concern be addressed, specifically?
  4. Why is it so important to target these specific areas at different client ages or stages? How do these specific intervention strategies help teach critical life skills?
  5.  If my client is approaching a new age or stage, how can I prepare them for the upcoming stage of intervention?  

You can download the presentation here, then just start the slideshow and click on the little speaker icons to hear the audio narration.
 I hope its helpful!

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*Note: ABA can effectively be applied in so many diverse ways, with any population, across the lifespan, that for this post I am specifically talking about an intensive ABA therapy program.  

 ABA therapy isn’t for everyone.

Did I just say that??
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For all of the joys, successes, and breakthroughs that quality ABA therapy can bring about, it is an unfortunate reality that ABA therapy isn't accessible to all. Especially if the individual needing services lives in a rural or international location, or is an adult.
Oh how I wish this were all so simple that an individual could demonstrate a need for therapeutic services, a local provider is contacted, funding is provided, and services begin. Some states are lucky enough that this really is how services are initiated. Unfortunately for countless others, it is nowhere near this simple.
One of the worst parts of my job is seeing children who very much need help either go without services, or start and then quickly have to stop services. You always wonder about those clients or potential clients and how they are doing now. Did they learn to speak? Are they toilet trained now? Are they still harming themselves?

There are so many reasons why quality ABA intervention is not accessible to all, such as: the supply of knowledgeable and available providers does not meet the demand, the school systems are overburdened with a growing special needs population as their funding to help these students gets slashed, and although Autism does not discriminate there are clear racial disparities amongst who receives access to treatment. There are far more reasons than I can list here, so I will just name a few:

  •         ABA Haters /Against behavioral intervention – So clearly, if a parent/caregiver is against behavioral intervention then they won’t seek out ABA Therapy. Some parents/guardians feel that ABA is too harsh, too demanding, too data driven, or robs a young child of a childhood (since therapy is intentionally intensive). Sometimes parents look into other treatment options that appear more fun or less intimidating than ABA, give ABA a “try” and then abandon it, or for some families they may choose not to pursue treatment at all.
  •  Unable to fit therapy in to your schedule – I once worked for a company where I had sibling clients receiving ABA services. The parents both worked from about 7am-8pm, every day. The only person in the home besides the children was a nanny who did not speak English. The company I worked for had a policy that mandated parent participation, and I was stuck in the unpleasant position of trying to come up with exciting and creative ways to involve the parents and the nanny, despite the time and language barriers. Ultimately, the company discharged the family for lack of participation. ABA Therapy requires active involvement of stakeholders. Even if services occur at home, we may need to involve the teachers, and vice versa. I have also been in situations where the family was so involved in extra -curricular activities (karate, band, boy scouts) that they were canceling therapy sessions left and right, or always arriving late to therapy sessions. At that point you have to ask, “Do you really want this therapy??".
  •    $$$$/The True Cost – A full time ABA program with a couple of direct staff and a supervisor can cost thousands of dollars a month. If your insurance won’t cover it, Medicaid won’t cover it, the school doesn’t offer anything remotely close to ABA, and you don’t own a personal money tree, then what are your options? For some families, the only remaining option is to just go without therapy. Beyond the financial expense, the “cost” of scheduling your life around ABA sessions can be far too high for some. I have worked with some families where it wasn’t the financial cost that led them to terminate therapy, it was the strain on their marriage, the issues with their other children, or the loss of spontaneity to their life.
  •  No providers – Maybe you have funding for services, and the time to commit to therapy, but there are no providers anywhere near you. You can try expanding your search because many ABA professionals will travel to you (goodness knows I do plenty of traveling!), but keep in mind you may be responsible for the cost of their travel. Or, maybe the providers in your area all have year long waiting lists. Often the most prestigious/well known providers have super long waiting lists, precisely because their services are so great!
  •  D.I.Y. without oversight – I once worked with a family who had difficulty locating providers (or affording them) so they started working with their daughter themselves. They researched ABA, they read books, they pored over research articles, and they made lots and lots of flashcards. Unfortunately, once I started working with their daughter it became clear there were teaching errors the parents were unaware of. Such as overprompting, issues with scrolling (a type of guessing) when responding, and a chain of problem behaviors had been shaped up by the parents giving in to tantrums. My point is that a program can seem to be working, the child can learn new things and make progress, but without professional oversight errors or issues can be invisible to the untrained eye. If you have decided to serve as your child’s therapist, then please contact a BCBA to oversee the program and to properly train you. To put it another way, if I read some medical literature and attend some webinars online, that doesn’t qualify me to perform surgery on my own child. If ABA therapy looks easy to implement, that’s because you are watching a skilled and well trained person make a highly complex intervention appear simple.

*Quick Tip: all ABA is not equal.
If you DO want ABA services and for whatever reason cannot access them, please carefully consider setting up your own program (which includes professional oversight). Here is a handy resource that should help clear up the differences between quality ABA and “trying to appear like” ABA.

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This post is pretty unique. Instead of writing the information out, I decided to put it into a brief Power Point presentation. Why you ask? Well, why not? :-)

This post is a general outline of the sequence of teaching a target in skill acquisition and moving the skill from unknown to the learner, to known/absorbed by the learner.
There are many important steps to take along the way, particularly when teaching individuals on the Spectrum: maintaining a learned skill can be difficult, as can demonstrating the skill if the learning environment changes (if a teacher asks at school vs if Dad asks at home). All of this must be taken into consideration when teaching.

However, this information is not specific to Autism. At its core, ABA is just good teaching. So feel free to apply this information to teaching strategies for a variety of learners.

The way you have been taught to implement skill acquisition programs at your place of employment may be different from this outline, which is fine. This is a general snapshot of how to break down skill acquisition, to ensure important steps are not skipped over or neglected. Remember, nothing about ABA is one-size-fits-all, or paint by numbers.

This information should be helpful for anyone with the responsibility of creating skill acquisition programming, overseeing the implementation of the programs, and teaching direct staff or caregivers how to properly assess if a skill is "known".

To watch the presentation: download the PP, and play the slideshow. The audio should play by itself, and the slides should change automatically. Enjoy!

Presentation: Programming Sequence Overview

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*Recommended Posts: Are you a great supervisor?
*Recommended Resource: Trainer’s Handbook 

Being in a clinical supervisor role for an ABA program is one crazy job. 

There are so many things you must do on a regular basis that all have to occur near or at the same time. Multitasking and prioritizing must be as effortless for you as breathing, or you will definitely have some challenging days.

Supervisors have reports to write, parent meetings to schedule, data to analyze, treatment plans to create, direct staff to train and critique…. the list goes on and on. I often see staff obtain their certification and move into a supervisory role, and as much as I try to prepare them for what it’s like to oversee a program there's nothing quite like that 1st  jump into the deep end of the pool. It’s simultaneously exhilarating and terrifying, and most brand new clinical supervisors have that somewhat stunned, shellshocked look on their face until they adjust to the demands of the job.
I didn’t always have the best examples of supervisors back in my direct staff days, so in my mind being a clinical supervisor was going to be a cushy office job. Well, I was very, very wrong 

Moving from the role of primarily providing 1:1 instruction to being responsible for overseeing an entire ABA program is a huge transition, and if you aren’t being properly prepared for this transition by your current supervisor then please allow me to pull back the curtain and give you some insight into how this actually works. 
Consider these tips my super-duper informative “cheat sheet” to help anyone in their role as “The Supervisor” (this information will not be applicable to every position or every company).

1.      My biggest tip is: understand that the clinical supervisor role requires honesty, and critical eyes (notice I said critical and not judgmental). You can’t be afraid to say “That was good, but I know you can do better”. Your supervisees/clients are NOT your friends, and your clinical recommendations are not optional suggestions that they can choose to ignore. It is your job to give specific feedback so that parents can learn how to apply ABA and staff can improve their skillset. If your feedback is always vague platitudes (“You guys are great, keep it up”), how exactly do people grow from that?? When I am working, I am either giving corrective feedback on what isn't right, or I am collaborating on what can be better.
2.      Expect huge demands on your time, and let go of the concept of “working hours”. Staff and parents may need to contact you with questions, concerns, or “Uh oh, we have a problem” issues in the middle of the night, on holidays, or on the weekend. Am I saying you have to be on call 24-7? Absolutely not. But, the great BCBA’s that I know are always accessible, and will make the time to stop and answer a question no matter how busy they are.
3.      Your car is going to become an office on wheels, even if you have an actual, real office. For most of us, a typical work day involves driving from client to client or school to school. When I start a work day I have several bags/totes to carry, a clipboard, data sheets, my phone, my water bottle, and my snack or lunchbox (more on that in the next tip). When you arrive to a supervision session you never know what your staff may need, so keep extra data sheets, pens, binders, & toys/fidgets in your trunk so you can quickly grab them and give to your staff.
4.      Speaking of snack/lunch, let go of the idea of a typical 8 hour work day where you get two 15 minute breaks and a 30 minute lunch. As a busy clinical supervisor, I suggest you carry a water bottle and pack snacks that can be eaten on the go. Otherwise, you may find yourself pulling up to drive thru windows pretty frequently. Particularly during the evening hours when you are in the clients’ home late in the evening, and you can smell steaks being cooked in the kitchen……those are the nights where the Burger King down the street starts looking better and better.
5.      I hope organization and time management are strengths for you, because you will need these skills. Most of the time, you make your own schedule. This means it is up to you to put together a schedule where you meet billable hour requirements, give your staff as much of you as they need (including late evening meetings you don’t get paid for), prepare for and write up lengthy reports, conceptualize treatment, and then somewhere in there actually have a life. If you are married, in school, or have kids, organization and managing your time become even more critical or you will quickly find yourself approaching burnout.
6.      Learn the art of assertive confrontation. I had to learn this skill over time, and it was difficult for me at first. When dealing with apathetic parents or disrespectful staff, it’s natural to get annoyed, irritated, or defensive. However none of that is professional. Think assertive not aggressive. What you can do is firmly state your side, explain what you will and won’t do, and attempt to work towards mutual agreement. If the other person insists on continuing to escalate, end the conversation until it can occur in a calm manner. Sometimes the issue is something that can be resolved, and sometimes it is not. You may need to ask to be removed from a case, you may need to fire the staff, or you may need to resign from the company if your employer consistently fails to back you up.
7.      Lastly, a really hard part of being a supervisor that you might not hear about is saying goodbye to some amazing clients. :-(  After you have worked and worked to teach the client important life skills, you suddenly find out the family is moving out of state, or switching to a different agency, or they lost their ABA funding. Change is just part of this job. Allow yourself to be sad, especially if you had a great working relationship with the family, but realize that throughout your career you will work with multiple clients and when you accept a case you never really know how long you will be helping that client.  

*Awesome Download: I recently made this simple handout for a consult client who needed help understanding the role of the clinical supervisor. I hope it’s helpful! Print it, laminate it, and keep it in your car.

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