Source: www.PatrickMulick.com


Punishment- A consequence that happens after a behavior that serves to reduce the likelihood of that behavior happening again.  


Teaching - The process of attending to people’s needs, experiences and feelings, and intervening so that they learn particular things.


Got it?

Good.



"Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history:

  1. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day)."

Source-  www.CDC.gov


It is part of the diagnostic criteria for Autism to struggle with Rigidity.

What is Rigidity? It is an inflexibility, an inability to tolerate change or unexpected events, to varying levels of difficulty.

This is something many of my clients struggle with, and it can be quite life impacting in negative ways. Issues around rigidity can affect the school day, relationships/social ties, life at home, transitions, community integration, and vocation/employment success (for older clients).


Some examples can include:

- Difficulty tolerating a change in teacher

-Difficulty staying calm if something breaks, loses power, or the battery dies

-Difficulty staying calm if mom or dad drive past Wal-Mart but we don't go inside 

-Insistence on the same routine every day, Monday-Sunday

-Refusal to change eating habits, clothing choices, etc., from one day to the next

-Difficulty sleeping if traveling, away from home, or the bedtime routine is different


As rigidity is a core characteristic of Autism, treating or intervening on it must be approached carefully. The goal should not be to turn an inflexible person into a flexible person. The goal should be to help the learner adapt to an ever-changing world that will NOT stay constant, and increase the learners coping skills to accept what they cannot control. 


To a degree, most of us are creatures of habit. We buy a certain brand of makeup, we brush our teeth a certain way, we park in the same place when we go to work, we always sit in the 2nd row for our college lectures, etc. It isn't inherently a problem to like sameness and predictability in your life.

But.


This does become a problem when the reaction to the routine being disrupted, is explosion, aggression, self-harming, etc. For example, I have specific restaurants where I order the same thing every time I go. If I went one day and that item wasn't available, I'd be dissapointed, annoyed... I might even leave and go eat somewhere else. But I would not become a danger to myself or others, and I would not perseverate on that annoyance for hours or days.

So how do we help our clients, students, and loved ones calmly accept life's inevitable changes?

ABA provides many, many strategies to teach flexibility and tolerance to change. Let's discuss a few:


  1. What are we teaching instead? This should be priority #1, it is truly that important. We cannot just rip away established patterns and rituals, we have to first identify the replacement behavior(s). This could include teaching the ability to request ("I wanted the red cup"), to wait ("We will go to Wal-Mart, but I'm stopping at Wendy's FIRST"), to self-manage anger and disappointment ("I can see you are angry. Let's do our deep breaths, okay?"), and/or to problem solve ("Oh no, your tablet's battery died. How do we fix that?").
  2. Do we have rule out for underlying issues? It is not uncommon that Autism co-occurs with other diagnoses. Is the learner just "rigid", or are they OCD? Or struggling with an undiagnosed Anxiety disorder? 
  3. Intentionally, and systematically, introduce change. I work with so many families who try to skirt this issue by avoiding changing things in their child's environment, giving in to the rituals, even driving out of the way in the community to avoid passing places that will trigger the child. I know this seems like the easy way to manage this problem, but in reality it will make things worse. It is almost presenting a lie to the learner to act as if nothing in their environment need ever change. That just isn't real life. We need to help the learner by introducing small, intentional changes (start super small) and then helping them tolerate that change. Speaking of tolerate....
  4. Help the learner develop a "plan of action" when they are triggered. This will be highly specific to the individual learner, so I cannot give a recipe for this. What is most important is to utilize function based intervention to teach a strategy to the child for de-escalation. For example: When there will be a substitute teacher at school, inform the learner. (If possible) Talk about how they feel about this change. Empathize with their distress, and do not minimize it. Engage in action steps such as pacing, squeezing a stress ball, humming, and deep breathing with closed eyes. Remind the learner of the things they can control/the things that are unchanged. For example: "I know you're angry that Mr. Walker is not here today. That's disappointing. We can go in the hallway and take a break, and when we come back in you let me know if we're doing our writing journal or sight word folder first. Okay?".
  5. In Step # 4 I referenced "Empathy". I know it can be frustrating and stressful when your client/child/student explodes over a moved seat, a different bowl at breakfast, or a broken toy. You might think "WHAT IS THE BIG DEAL?!". Well, do you like change? If we're honest, most of us do not like unexpected, unrequested change. It makes us angry, and we feel annoyed. So even if you can't fully relate to the size of the explosion, you can relate to the feeling, right? That "relating" is empathy. Put yourself in the learners shoes, and treat them the way you would want to be treated if you were that upset and agitated.




**More resources below:


Rigid Eating Habits

Food Selectivity

Inflexible Thinking

Use Inflexibility to Teach Flexibility

SuperFlex Curriculum

Intentionally Changing Routines

Poljac E, Hoofs V, Princen MM, Poljac E. Understanding Behavioural Rigidity in Autism Spectrum Conditions: The Role of Intentional Control. J Autism Dev Disord. 2017 Mar;47(3):714-727. 



 




A current criticism of the ABA field/industry is that as more and more investors come in, expand existing companies, and open new and large, multi-state companies, quality assurance is decreasing.

 

How are we intentionally and systematically evaluating the effectiveness of treatment, client outcomes, and individual client response to intervention? Not just at a large, across clients level, but for each individual case/client/treatment plan (e.g. "For THIS specific client, was treatment effective?").

 

There has been criticism aimed at ABA that it doesn’t work, lacks large group data comparisons, is only effective with specific ages/ability levels, or is less effective at lower treatment hours. (See recommended reading below for more on this).

 

Sometimes this criticism is in itself, flawed and misinformed. Such as many funders viewing “successful treatment” as reducing or eliminating common Autistic characteristics, i.e. Stimming. Ethically, a qualified BCBA or practitioner will not intervene on a behavior unless there is a demonstrated clinical need to do so. The goal of ABA is not “normalization”, so if we are measured by a “normalization” measuring stick, then yes…. We will fail.

 

But, in other instances the criticisms about our field need to be heard, and embedded into how we practice.

For example, when an organization is reporting on “client success rates”, common variables that are included are things such as: amount of time from 1st parent contact to services starting, how much of the insurance authorization is being consistently utilized, how many states is the company in/what is the new market expansion rate, etc.

But what about: Are the caregivers/parents satisfied with treatment outcomes? Measuring social validity of the specific strategies and techniques used? And very important--à What does the actual client receiving services have to say about it? Is their experience of ABA positive? Negative? Do their own self-determination goals and life needs factor in to the ABA treatment plan? Was the client consulted and collaborated with as the treatment plan was being compiled?

And, oh yes: Are we measuring practitioner satisfaction rates? At the direct staff and supervisory level? If you think revolving door RBT’s, burned out BCBAs, and underpaid and undervalued practitioners will have no effect on the quality of treatment provided to consumers, you are living in a fantasy world.

 

I see few outcome measures like this in the field, but I do see more of this starting to happen. Starting to become more prevalent at both the practitioner, and the organizational level. Which is wonderful. There are some companies out there working very hard to go against the tide, and to stand out from the pack.

 

We have to look beyond progress to goal mastery/completed targets, and completing the assessment grid, to evaluate if our services are truly effective or not. And by “evaluate”, I mean putting on our clinical hat and collecting the data, examining the data, making decisions based on the data, and letting the data guide how we do business and serve consumers, day in and day out.

We have to look beyond just decreasing and increasing behaviors, because did we decrease/increase the behaviors most salient to the individual receiving services? Or to their parent? The word “effective” can encompass multiple complex variables, which means it will require input from multiple sources (funders, caregivers, clients, practitioners, and organizations/agencies).

 

We have to #DoBetter both as practitioners, and as organizations. There is far too much at stake here for the clients we serve, the families we support, the stakeholders we report to, and the public perception of our field.

 


*Recommended Reading:


"Does ABA Therapy Really Work?" 

"Why is ABA Therapy not working?" 

"When ABA Therapy Isn't For You"

'US Govt. Reports that ABA doesn't work

"Parent Perceptions about ASD Influence Treatment Choices"

"Why Caregivers discontinue ABA"

"An Evaluation of the Effects of Intensity and Duration on Outcomes"

"Systematic Review of Tools to Measure Outcomes for Young Children with ASD"

"What is Social Validity?"

'ASD Intervention: How do we measure effectiveness?'

'The controversy over Autism's most common therapy'






Today's QOTD is an amazing & fun discussion that I had the privilege to join, with the dope people over at: "ABA Inside Track".

"Special interests" are what we used to refer to as "obsessive interests/ritualized play/info dumping" or restrictive, repetitive interests or conversation topics.


If you are an ABA peep, or a caregiver of an Autistic, then you know exactly what I'm referring to. For non-Autistics, it can be hard to understand the intense interest (often to the exclusion of other important tasks and activities) in Toy Story, or Thomas the Tank Engine, or obscure 1970 bands, or construction sites, or objects that spin, or Mickey Mouse Clubhouse.


A unique special interest is an item, show, song, toy, etc., that sparks a very intense, and very elaborate fascination. If there is a toy or figurine, then ALL the figurines must be purchased. If there is a DVD or TV show, then the ENTIRE show must be watched, with 0 interruptions. If the interest is a place or location (such as a special interest of watching garbage trucks), then we MUST go watch the thing, at the place, right now.


There is an urgency to special interests that makes it difficult for teachers, therapists, caregivers, to transition the individual to other activities, or away from the special interest.


So how do we deal with this?


Well, the old way is to try to remove or lessen the fascination. To try to block or put away the interest, particularly if it isn't "age appropriate". To say "no, not right now", or "we're done with that", or "stop talking about that".


But is that the way we should approach this? Is that helpful or healthy, long term? And what does that say to the person with the special interest? Who may not cognitively understand why we CANNOT watch elevator videos on YouTube all day, every day.


Instead, let's talk about ways to include, embed, and incorporate special, unique interests into everyday life. Into instruction, into therapy, into school, into intervention. Think it can't be done?


Well, research would disagree with you. ;-)


Take a listen! This is good stuff.



ABA Inside Track Podcast, Episode 160










*Recommended Reading:


Autistic 'Obsessions' and Why We Really Need Them








I don't work with adult clients often, but I do regularly work on life skills/building independence, and pre-vocational training stuff with children and adolescents.


The thing about adulting is that trying to shove a bunch of information and life lessons into your grown child is a bit too late. Especially if we're talking about Autistic adult children who may or may not ever live independently, may or may not hold down steady jobs/have a career, and may or may not attend college or technical school.


Wayyyy before you think you need to start teaching this stuff, is when I recommend teaching this stuff. :-)


For any parent, its a hard thing to look at your 10 -year- old and start thinking about teaching them to do laundry, independently grocery shop, change a flat tire, or shop online. But, if you expect your child to do all these things one day as an adult, then yes, absolutely start teaching it early.

Your teen or adult child can start learning today, to do things like:


  1. Personal care/Hygiene/Grooming
  2. Shopping & Money Management
  3. Electronic Use & Internet Safety
  4. Vocational Training (*which should be a natural extension of interests, hobbies, or strengths)
  5. Driving or Navigating Public Transportation
  6. Time Telling/Time Organizational skills
  7. Employment Seeking (resumes, interviews, etc.)
  8. Self-Advocacy/Assertiveness ---- probably my #1 Adulting 101 skill to teach


For children with disabilities (not just Autism), it may take more time, more repetition, and more real-world practice for these skills to be taught. Which means starting sooner rather than later is the way to go. Think about your own adulting for a second-- when you first left home, did you know how to scramble eggs without burning them? Or manage a credit card responsibly? Or negotiate with a pushy salesman when buying a used car? If you answered "yes" to these questions, then you were far superior to most of us! 

The reality is that whether your child will ever be able to live separately from you or not, as a parent I'm sure you want to help them be as independent as possible, and be able to make decisions about their life/have a say in their own life. Teaching some common 'Adulting 101' type of skills can be the way to do this, and be sure to combine that instruction with actual real world practice. Despite what we may like to think, school will not teach our children everything they could possibly ever need to know by graduation day. Nope.


What do I mean by real world practice? Well, I've worked with high school age clients before who received vocational/life skills training at school, or through a special program that helped them get part-time jobs. The problem was, these skills didn't generalize outside of those settings. If Charles learned to cook chicken breasts at school with Ms. Larson, that did not automatically mean he could cook chicken breasts at home, with Mom and Dad. If Kacey helped out in a local daycare classroom every Tuesday afternoon, that didn't not mean she could successfully baby-sit her younger brother at home.

Like any other skill, life skills need explicit, intensive instruction, as well as multiple generalization opportunities in real world situations. Multiple generalization opportunities means that the instructor/supervisor needs to differ. The setting needs to differ. The materials/items used need to differ.

Don't just teach your child to wash/load the dishes at home. Let them practice at the neighbor's home, at Grandma's house, etc. The steps of the skill will vary a bit as it is generalized across opportunities, and that's a good thing! There are very few adulting tasks that are done the exact same way, every time. We also know that many Autistics lean towards rigidity and sameness of routine, which can be a good thing or can be highly detrimental to learning if it gets in the way of doing something differently. For example, if the sink, dishwashing liquid brand, or the equipment used (e.g. type of dishwasher) change, can your child still wash the dishes?


It is hard to look at your children when they are young and know with certainty what their future holds. That has nothing to do with Autism, I think any parent would agree with that. Since we don't know what the future will bring, it makes sense to start preparing our children for an uncertain future now.


You may be wondering, "How young is too young to focus on this?". It may surprise you to learn that I start teaching life skills (Adulting 101) with clients as young as 2 or 3. Yup, its true. 

A toddler can learn to clean up their toys. A toddler can learn to put their empty cereal bowl in the sink. A toddler can learn to pour their own juice. A toddler can learn to put dirty clothes in a washer, or pull clean clothes from a dryer. Why not?? If your children are young and you don't know where/how to start with this, just start with teeny-tiny baby steps:

  • Let your child help as you complete household chores.
  • Slow down before leaving the house, and let your child put their own shoes on, or put their own coat on, or grab their own bookbag.
  • Cooking is a life skill. As early as you can, introduce no-heat recipes such as making a sandwich or fruit salad.
  • When in public settings, help your child pay for their own meal, or hand the cashier money for purchases. Let your child place items on the conveyer belt at the grocery store, or teach them to shop by giving them a visual grocery list.
  • Allow older children to have some responsibility for younger children. Let your 6 -year-old help you care for the 1-year-old.

There are SO many resources out there for teaching life skills and increasing adaptive functioning. This doesn't need to be hard or overwhelming! 
Ask your child's therapists for help and ideas, or talk to their school and see if there are any specialized trainings, classes, or programs available for students on the Spectrum. Most school districts have far more programs and community connections than most parents know about.


You got this!



RESOURCES- 



Essential for Living  Assessment Tool





Organization for Autism Research: Transition to Adulthood

The Life Skills Lady

Transition to Adulthood Research Findings


 




As an industry, ABA is a billion dollar market with large, multi-state, companies becoming more and more common in the US. 

There are many reasons for this massive boom, such as the increasing visibility of ABA as a career field, which drives more people to pursue credentialing and certification, and ultimately to seek ABA employment. The insurance mandates across states has also led to this boom, with more and more people now able to access ABA treatment through their insurance plans (removing cost as a barrier to treatment). ABA as an industry has become very attractive to investors and equity firms, which means more businesses and clinics being opened, or existing businesses and clinics expanding and multiplying. Lastly, the increase of ABA services outside of the world of Autism has led to an overall increased demand for/awareness of  BCBAs, with clinicians moving into areas such as criminal justice, the business world, education, geriatrics, and policy change. 

Unless you live in a very small town (or outside of the US) you've probably already seen ABA businesses and clinics pop up in your community, with a more aggressive presence than before.  

As a clinician, it can be a dizzying process to look at the  vast array of ABA employment options out there and choose the best place to pour your time, energy, and talent into, day after day after day. 

This specific question of "Where should I work?" is something I've posted about multiple times (see here, here, or here).


We talk about clinician burnout, we discuss the problematic high turnover rates in this field, but where are the resources to help clinicians weigh their employment options to select a reputable, ethical, and professional organization to work for?


Beyond just tips and commiserating by swapping stories of companies from hell, I'd like to offer some actual evidence- based action steps (see sources below), to help when it comes to scrutinizing an employer pre-hire, successfully navigating The Contract, and enjoying where you work!

What in the world was the point of all those college courses, 2am study sessions, supervision hours, and textbook paper cuts, if you're just going to get up every day to "clock in" at a company you loathe? Why work somewhere where all you are viewed as is a means to billable hours? That makes no sense at all.


Before jumping into some red flags of unethical organizations, I want to emphasize the importance of the pre-hire process. From that initial email or phone call, all the way up to the point where you sign your name on the offer letter or contract, you should be evaluating that employer just as much as they are evaluating you. It should be a mutual process, or dance, of "Show me what you got". For example:

Who owns the company? (super important question to ask these days) How many BCBAs are in leadership positions? How long has the company been around? What is the mission statement or company vision? How about the company culture? How reasonable is the clinical workload? How much of the work day is paid time (billable hours vs non-billable time)? Why did the last person in this position leave? What is the staff turnover rate? How is value demonstrated to employees, in tangible and concrete ways that are NOT tied to meeting productivity quotas? How does the company make diversity and inclusion a necessity, not just at the practitioner level, but at the executive level as well? Is work-life balance a buzz word, or actually attainable at this company? 


Also, we live in the Jetsons age. Your entire life is on the internet. If you think that interviewer is not looking you up before the interview, you are delusional. Have you looked the organization up online? Have you read over the company reviews, written both by consumers and by employees? Have you searched for any lawsuits/legal action, or ethical investigations the company was involved in? You should.



Identifying Unethical Organizations


  • Pre-Interview/Interview process - Organization does not or cannot provide clear, logical answers to persistent applicant questions, supervision and training as described is insufficient/does not meet best practice standards, cannot explain/no process of onboarding new hires, poor management of client health records (HIPAA concerns), scope of competence is not a consideration when staffing cases, both a very brief or a drags on and on interview process are not good signs, beware of recruiters who make grandiose promises during pre-hire (get it in writing), vague or shifting caseload expectations, cannot explain efforts/no efforts made to accommodate the diverse cultures of client population

  • Evidence Based Practices- Organization promotes/advertises or clearly offers non-behavior analytic services while claiming to be an ABA agency, unethical practices or non-evidence based procedures are observed or discussed (e.g. BCBA supervisor implements Floortime with clients), executive level staff lacks BCBA's or clinicians, minimal to no understanding of Behavior Analytic Code of Ethics, clinical competency is not considered or critical to caseload assignments (e.g. brand new RBT's are placed on high intensity cases), clinical supervision and training is too minimal for RBT's to refine their skillset

  • High-Quality Service - Workload expectations are unrealistic to an amount that impacts clinical quality (e.g. Supervisors carrying huge caseloads), clinician mentoring and emotional support is replaced by micromanagement (incessant "check-ins" that are only focused on productivity), job description is unrealistic/multiple jobs crammed into one position, treatment hours are mandated regardless of client need (e.g. push for "40 hours a week" for all clients), "cookie-cutter" treatment planning, lack of parent training/caregiver involvement in treatment, no company policy or procedures for gaining parental adherence to participation guidelines, no company policy or procedures for families who frequently cancel/show up late/"no show-no call", unethical and/or unprofessional behavior is being modeled by senior or executive level employees (e.g. BCBA supervisor is dating his RBT supervisee), ethical conduct is not taught, expected, or maintained by the organization, company online presence/website is heavy on outdated, Ableist, or anti-Autistic language such as "cure", "recovery", "suffering with Autism", or "saving" children

  • Non-Certified Supervisors or Owner - While not automatically a red flag, the supervisor/owner must be knowledge of the Code of Ethics, must understand that credentialed and certified employees are required to practice ethically, must demonstrate understanding of appropriate clinical caseloads, clinical supervision, and clinical training, must be committed to clinicians practicing within competency,  and must not attempt to make clinical/treatment decisions due to not being qualified to do so

  • Contract Terms - Offer letter or contract contains terms, restrictions, or information never previously mentioned or explained during pre-hire (e.g. "surprises" in the contract), information that was verbally stated is not put in writing/not in the offer letter or contract, highly restrictive and punitive non-compete or non-solicitation clauses that prohibits the employee from reasonably working in the field during, or post-employment, length of employment conditions that require the employee agree to work at the organization for a specific amount of time ("handcuffing" employees to the organization), requirement to sign any document after accepting the position (e.g. 10 days after signing offer letter, only then is employee asked to also sign a non-compete agreement), huge bonuses/perks/incentives that only kick in after a specific duration of employment (indicates the company has high turnover rates), being offered an independent contractor position if you are a RBT or BCaBA (you cannot work independently)

**References:


BHCOE Position Statement on Non-Compete Agreements


Brodhead, M. T., & Higbee, T. S. (2012). Teaching and maintaining ethical behavior in a professional organization. Behavior analysis in practice5(2), 82–88. 


Brodhead, M. T., Quigley, S. P., & Cox, D. J. (2018). How to Identify Ethical Practices in Organizations Prior to Employment. Behavior analysis in practice11(2), 165–173. 


Brown, K.J., Flora, S.R. & Brown, M.K. Noncompete Clauses in Applied Behavior Analysis: A Prevalence and Practice Impact Survey. Behav Analysis Practice 13, 924–938 (2020). 


Kazemi, E., Shapiro, M., & Kavner, A. (2015). Predictors of intention to turnover in behavior technicians working with individuals with autism spectrum disorder. Research in Autism Spectrum Disorders, 17, 106–115. 


Rubenstein, A. L., Kammeyer-Mueller, J. D., Wang, M., & Thundiyil, T. G. (2018). “Embedded” at hire? Predicting the voluntary and involuntary turnover of new employees. Journal of Organizational Behavior, 40, 342–359. 

 Yup, pretty accurate.




Need more tips? Well, if you want a surefire way to generate clinician burnout, be sure to hire highly qualified, intelligent, and experienced practitioners, and then micromanage them to death.

Lather, rinse, repeat.


 *Recommended reading: What to expect from a BCBA



If you are unfamiliar with ABA services, you may first hear about it as a recommendation post-diagnosis. Or, from a school system recommending behavioral services. Or, you might seek out an ABA provider if persistent, challenging, or harmful behaviors are happening in your home, in the community, or at your child' school.


For most people, the process of starting up ABA services will involve multiple steps, an extensive timeline, and lots & lots of paperwork (seriously.... a mountain of paperwork). To briefly summarize, the child must be diagnosed, an ABA provider must be found/identified, an intake assessment must occur, insurance authorization has to happen, staff must be assigned to the case, and only then do services actually begin. I would say a best case scenario would be all of that occurring within 1-2 months. Unfortunately though, best case scenarios don't always happen.


Just like there are valid, honest reasons why ABA therapy isn't for everyone, there are valid reasons why starting services with the ABA agency/clinic up the street isn't the best idea. Sometimes it will make much more sense to work with a solo practitioner/BCBA.

If you aren't familiar with the title BCBA, a Board-Certified Behavior Analyst is someone trained in the science of Behavior Analysis, holding a Masters degree or higher, who has gone through roughly 1-2 years of highly regimented supervised experience and passed a rigorous exam. BCBAs can practice independently, so this means you do not need to go through a company or agency to work with one. Similar to physicians, BCBAs have specialties. All BCBAs will possess a standard skillset/range of knowledge on behavior, but the specialty will be a combination of an individuals post-certification experiences and training. For example, some BCBAs specialize in feeding disorders. Others have worked with early intervention populations exclusively, and others focus more on OBM (Organizational Behavior Management) rather than special needs populations. 


For most families, it seems like a simple equation: need ABA services ---> call up a local company ----> start services. But, there are some scenarios where this would actually be a bad idea:


  • Brief or Short Term Consultation - Most ABA companies are focused on servicing clients needing intensive, multi-year therapy for many hours each week. If you have a specific behavioral need or only need short term help, it actually would be faster, and simpler, to just work directly with a solo BCBA.  And on that note, lets talk about speed of services starting up....

  • Delay to Onset of Services - I regularly talk to families who are sitting on wait lists to access services. Or, their child completed an initial assessment with a company, but they haven't heard anything for 30, 60, days and counting. There could be many reasons why you experience a significant delay to start services, but the most common reasons would be staffing (no available staff), and funding issues (problems with getting services authorized or company is not in network with your insurance provider). If you need help now, I strongly suggest contacting a solo BCBA rather than a company/agency.

  • Wanting Highly Experienced Staff - As part of my role, I regularly conduct intake assessments with families new to ABA. Many times they will ask me if I will be the one working directly with their child, and I then explain that ABA treatment utilizes a tiered-service delivery model. In a tiered model, the supervisor/BCBA is usually the most degreed and experienced person on that case. The individual working directly with the client, is usually called an ABA Therapist, or Registered Behavior Technician (if they are credentialed). The education and experience of the direct staff can vary, and a high-quality company will have a rigorous training and onboarding process for direct staff before they can work with clients (a poor quality company will not). If you want Masters degree level clinicians working with your child, that can be hard to find at a company. 

  • Rural/International/Low Supply Area - I have worked privately with families as a Consultant for many years. The main reason why these families chose to hire me instead of going to a company/agency, is because in this was not an option for their area. Some of these families lived in very rural areas with no ABA providers for miles. Others lived outside of the US, where knowledge of ABA can be minimal or absent. For others, there were TONS of ABA companies in their area. The problem with that though, is that high demand can = insane wait lists. I'm talking sitting on a wait list for 1-3 years. In these situations, it makes far more sense to work with a solo BCBA via Telehealth/technology. I do not recommend sitting on a wait list for any significant length of time without also pursuing other options.

  • No Diagnosis/Non-ASD Diagnosis - In most states that have Autism mandates for insurance coverage, a diagnosis of Autism is required to receive ABA treatment. If your child is not diagnosed, you're stuck on a wait list just to get a diagnosis (which can happen), or your child has a non-Autism diagnosis, then you may not be able to receive services from an ABA company. Not all companies accept private pay clients, especially the very large ones. In this situation, it would make more sense work with a solo BCBA.

  • Funding Issues/Insurance Issues - Similar to the above point, there can be challenges with accessing ABA therapy through your insurance. For some, a high annual deductible must be met before insurance will kick in. Or, per session co-pays might be very high (keep in mind there will be multiple sessions per week). Sometimes the insurance may cover an amount of ABA that is very minimal, or does not allow for quality supervision of treatment. I have worked with families  where due to their specific insurance plan, I could only see them once a month. That is not enough for high-quality services. 

  • Language Barriers - If you live in an area where that predominate language is not your first language, you may experience a barrier to accessing treatment. For example, many families in Atlanta speak Chinese or Spanish as their first language. But not all ABA companies in Atlanta have Chinese or Spanish speaking staff, or translators available. So what does this mean? It means it can be challenging to initiate services, participate in assessment, and understand what is going on in therapy. If this is your situation, you may want to find a solo BCBA who speaks your first language for ease of understanding and communication. Another bonus is this BCBA would be able to provide translated documents and paperwork to you, in your dominant language.

  • Professional seeking Consultation - Lastly, what if you are not a parent seeking services for your child, but rather a related professional who wants to collaborate with a BCBA? Maybe you are a teacher, SLP, Psychologist, or PT, and you have a particular client/student with challenging behaviors and need some help. This is not a scenario that would be appropriate for calling up an ABA company. It would be far more feasible (and faster) to locate a BCBA and ask about individual consultation. Keep in mind that ethically, the caregivers of the specific client must consent to this consultation as well.



There will be exceptions to all of the points above, depending on the area where you reside, the funding sources available, the quality of local providers, and your specific behavioral needs. 
For example, it is often more difficult for parents of older children or adults to access services. Also, not all agencies accept all insurances. Or maybe your current ABA provider seems to have a revolving door of staff, and just when you acclimate to the team members: they change. These are all scenarios where you may want to consider private consultation.

Just keep in mind that if services in your area are lacking, full of impossible waitlists, or if you have funding challenges, you do have other options available to receive ABA intervention for your child.



*Resources:





 *Recommended Reading: ABA Haters 


I feel very unqualified to write this post.


The ABA Reform movement (also referred to as Autistic Activists & Allies) is not new, but you may be unaware of it. Many ABA peeps are. 

There's a vocal community of Autistics and pro-neurodiversity/anti-ABA parents, individuals, and professionals who work diligently to spread the word about their viewpoint of ABA. Sometimes this is due to actual experience with ABA therapy, but not always. 


If you want to understand why an Autistic dislikes ABA therapy, obviously the best person to ask would be an #ActuallyAutistic.

However, there are a couple of reasons why I am writing this post anyway, despite feeling unqualified to do so:

1. Lots and lots of parents come to my blog as a source of information about ABA. I don't want my silence on this topic to make it seem like I think ABA is perfect with no flaws. I do think this industry has flaws, and I think parents making treatment decisions for their child need to know that.

2. Although there are some in the ABA Reform movement who are pushing more for "eradication" and less for "reform", I think ABA professionals should be a part of this conversation. We are the ones in the field, day in and day out, working with vulnerable populations who don't always have a voice (either figuratively or literally). We cannot just stand by and watch this conversation happen, we need to join the conversation.


If you think ABA, as a treatment or as an industry, is perfection and needs no improvement, you may want to stop reading now. <------------------------------------------


If however, you see the field's issues with clinician burnout, inefficient staff training, low-quality employers, person-first treatment planning, questionable research, teaching Autistics to mask, or respecting client dignity, and want to be a part of the CHANGE for the better, then read on.


My 1st post on anti-ABA'ers, or "ABA Haters" was written quite a few years ago. I keep it up (even though my views have since changed) because I think it's important to see the evolution of change.

Most of us do not change our minds about something instantly. It is a process. We receive new information, analyze that information, reject it and return to old thinking, or accept it and enter into a different level of understanding. Of course, I'm also minimizing the reality of defensive mechanisms, circular logic, and cognitive dissonance, and how these concepts impact our ability to change our mind.

I used to think people were anti-ABA because they had never experienced quality ABA services. I thought if they could see for themselves what ABA can do, how it can help, and how we impact lives everyday, that anti-ABA'ers would "come around".

I have since changed my mind on that.

For those of you that don't know, receiving low-quality/unethical ABA treatment is not the only reason why someone may hate ABA. 

Other reasons could include: being against the idea of "treatment" for a neurological difference, seeing Autism as a cultural identity and not a problem to solve, being against the high intensity of ABA services, taking issue with the tiered service-delivery model ABA uses, viewing the origins of ABA as unethical and inhumane, viewing the current state of ABA as unethical and inhumane, and strong displeasure with the lack of Autistic voices/input in the top Autism advocacy organizations, Behavior Certification Board for Behavior Analysis, leadership/ownership of ABA agencies and companies, and leadership in ABA state associations.

These are valid points, and they deserved to be heard without the lens of professional defensiveness.


Again, there are some in the ABA Reform community who think the best way to fix ABA is to 

Shut. 

It. 

Down.


But there are others who do want to see ABA improved, implemented more compassionately, and become more receptive to Autistic feedback and experiences. More about support and accommodations, and less about trying to change/fix someone.


Below are a ton of great resources for more information about Autistic voices, differing views on ABA, and anti-Ableism advocacy. The best consumer is an informed consumer, and I think it's important to present the information and let people decide what is best for them.


Whether you are a parent, caregiver, or ABA professional, it is so important to be aware of what the main population served by ABA (*It is true that not all ABA professionals work within the Autism community, but a gigantic chunk of us do*) has to say about ABA therapy, and the ways it can improve.


If you aren't willing to at least non-defensively listen, then what you're really saying is you aren't willing to change your mind



*Resources- 

Do Better Professional Movement 

The Great Big ABA Opposition List

Autistic Self-Advocacy Network 

BCBAs + Autistics Towards a Reformed ABA Facebook group

ABA Reform Facebook page

Beautiful Humans Podcast: The ABA Reform Movement Ep. 26

A Perspective on Today's ABA from Dr. Greg Hanley

5 Important Reasons Even "New ABA" is Problematic 

The Controversy Around ABA

Stimming Deserves Acceptance 

Nice Lady Therapists 

"I Am a Disillusioned BCBA" 

ABA Inside Track Podcast: Trauma Informed Care Ep 134 

Behavioral Observations Podcast: What is Trauma Informed ABA Ep 131

What's Wrong with the Autism 'Puzzle Piece' Symbol

"Why Autism Speaks Doesn't Speak for Me"

Avoiding Ableist Language: Suggestions for Autism Researchers 

"Why Autism ABA Goes Against Everything B.F. Skinner Believed In"

Eye Contact for Recipients Validation

"Autism Doesn't Have to be Viewed as a Disability"

"How To Ask an Autistic"



 


*Recommended Resources:

Helping your ASD child cope with COVID

Strategies for supporting learning at home

Homeschooling special needs children

Mastering Homeschooling

Podcast Episode: "Take Off the Cape"


During this global pandemic, schools have been as impacted as everyone else when it comes to figuring out a New Normal. 

The most recent stats indicate that globally, there are 1.2 billion children learning outside of the classroom due to school closures (source: We Forum) . E-learning has increased dramatically, with parents and caregivers now finding themselves thrust into the role of "Home Education Assistant".  

I have multiple clients who are learning at home this year, and both the parents and the children are struggling to adjust to this unanticipated change. 


For the children, it may be hard to understand why they aren't at school, why the regular routine has been so disrupted, and why they have to sit and learn at a computer all of a sudden.

For the parents, this is an added stressor during an already challenging year, it is hard to navigate a school at home schedule while also working from home (or returning to work on-site), and for parents of ASD children there are added unique challenges to help the child benefit from online learning.


Very few of the clients I serve are able to sit and learn through a device/computer screen for an entire school day. That just isn't happening. So what we are doing instead is helping the caregivers in the home learn how best to support their child's school day with this new format. Especially since none of us really know for sure when schools will be "back to normal".


Below are some tips I share with my client families, I hope they are helpful for you and your children:


  • Tip #1 is THE MOST important tip: Talk to your treatment team. By "treatment team", I mean the ABA team/case BCBA, Speech Therapist, Teacher, Counselor, etc. The best person to ask about your child's learning is a professional who already knows and works with your child. Seriously, I have had so many meetings this year with client teachers, and the teachers were all so understanding, accommodating, and willing to work together, because this year is hard for all of us. You will have no idea how much the online school day can be modified until you ask.

  • A daily schedule will be your BFF. It will be nearly impossible to adjust to the demands of school at home without a consistent schedule in place. Create a schedule based on when your child needs to log-on/be active in class vs. when they can work on assignments off-screen/off-camera. Be sure to include breaks (Pleeeeeease don't expect your child to sit at a computer screen all day with 0 breaks. That won't end well), meal times, reinforcement time/play, and calming or sensory activities as needed. Just like the rest of us, your child is probably highly stressed from the challenges of 2020. Though they may be unable to communicate that, just depending on ability level.

  • Seek help if you are physically unable to supervise your child's online learning. I have some client families where both parents are working from home right now. It is tough, but they are able to adjust their day so at least one parent is always monitoring the child's learning. I have other client families where this is not at all possible. Every household is different. Consider having a neighbor, grandparent, older sibling, or family friend monitor your child during the school day. For some families, "monitoring" may be all that is needed. For other families, see the next tip.....

  • DO understand that for some children, sitting at a laptop and attending for more than a few seconds at a time will not be possible. It won't. You are not a bad parent if this is the case. You have not failed, and you should not beat yourself up. This simply means your child will need a high level of support to benefit from schooling at home. I have some clients in this scenario, and it does mean that an adult must sit with the child and help them participate in online school. But guess what? For these types of kids, a 6- hour school day is not the goal. A 4- hour school day isn't even the goal. We work on helping the child participate as much as possible, and then we take breaks. Then we try some more. Then we take breaks....get the picture? Which leads me to my last tip....

  • Let's get real. And I mean, really real. We are in the midst of a pandemic. Families are struggling mentally, emotionally, financially, etc. Your child with ASD may not understand what is going on, and why all of a sudden you are acting like a teacher. Stress levels, anxiety, and depression, are sky-high for many people. You have to assess your capacity as a parent to do school at home. It truly is not for everyone. And that's OK! Please re-read tip #1. Talk to the school. Talk to your child's teacher. Explain your situation, and discuss the barriers to teaching your child at home. See what strategies or modifications the school can make. You might be surprised how many options you have that you just don't know about. You are not Superman or Superwoman, and are under no requirement to be perfect. Do the best you can, in the surreal circumstances we all find ourselves in right now. Best of luck to you!


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