When it comes to ABA therapy services?


Oh yeah.

This is 1000% true.


*Suggested post: Parents We Need You

If your child was participating in any therapies before this global crisis began, those services likely transitioned to a telehealth model within the past 30 days or so.

Ideally, this process was explained to you, along with potential benefits vs risks, and you feel competent as a parent/caregiver to utilize this remote model of therapeutic intervention.

If not, you are the the reason for this post.


For far too many families, the decision to move to telehealth for ABA services was made for them, or presented as a "take it or leave it" option. This could be due to staffing issues (as more and more people are self-quarantining), more funders allowing for telehealth, or just the preference of the service provider. Maybe you are filled with anxiety and confusion as to how telehealth will be effective for your child. You may think your child is too young to benefit, or too old to benefit, or can't attend to a screen, or attends TOO much to a screen, etc.

Whatever your particular situation may be, I hope to help alleviate some of your concerns by providing an overview of Telehealth ABA.

Let's dive in...

Before our current quarantine reality, telehealth was being used quite effectively to provide ABA services to consumers in under served areas, to supplement in-person services, and to work with consumers internationally. I have also found benefit of telehealth when it comes to illness or travel (basically, being unavailable). If someone in the consumer home has a contagious illness, I can still support my client remotely using telehealth. Or if I am traveling for a professional conference, I can check in on my clients using telehealth. So even if you aren't currently a fan of telehealth, know that it does have benefit for many families.

To provide a definition, Telehealth is the use of communication technology to assist in education and treatment of health related conditions (Ferguson, Jenny et al. 2019).


Telehealth is not something to just jump into. Like any other therapeutic service, there are some foundational steps to complete first. Before beginning ANY telehealth therapeutic treatment, you and your service provider should be openly discussing the following:


1. Technology Capability - As a caregiver, how comfortable are you with using technology? Do you have access to reliable wi-fi? Do you have a quality web cam, camera, or cell phone to use for video chats or calls? Will you need to purchase a headset or microphone, or are your computer speakers fine to use? Do you have a scanner and printer, if needed? If not, who will help you get up to speed with technology?

2. Scheduling & Availability - Are there time zone differences to consider? What is your schedule of availability to virtually meet with the service provider? Does telehealth increase or decrease your availability? What time of day would work best for your child? Are they more likely to be attentive in the am or pm? Is the telehealth schedule being created based on what works for your household, or just when the service provider says they have time?

3. Caregiver Participation - Are your current stress and emotional levels at a point where you can do this? Has it been explained to you that telehealth may require an adult in the home assist with the session, for the duration of the session?  Do you know how to manage challenging behavior in the absence of the service provider being physically present? Do you understand how to provide reinforcement to your child, in the absence of the service provider being physically present? What will your other children be doing while you are assisting with the telehealth session? If you are also doing school at home right now, can you do both that and this?

4. Unique Client Needs - What does your child need in order to benefit from this? Visual supports? Token boards? If your child is very active and reinforced by physical touch or play, how will that happen virtually? Will it be upsetting or confusing to your child to see and hear the service provider, but they aren't physically there? Should the treatment goals be reduced for telehealth sessions? What abut the session length; can your child participate in a virtual 2 or 3 hour session? Will there be a Registered Behavior Technician (RBT) or direct therapist with you, as the Board-Certified Behavior Analyst (BCBA) joins in virtually? Or will it just be you and your child? Which is likely to be more effective?



There are 3 main services delivered by ABA providers: Supervision, Direct Service, and Family Support (commonly referred to as "parent training").
I will explain how each type of service could look using a telehealth format. Remember, the specific service that is selected for a telehealth modality should be decided by you and the service provider based on what would be most effective for your child. In other words, direct service via telehealth may not be a great idea, just depending on the specific needs of your child and the unique demands of your household.


  • Supervision is most often provided by the BCBA for a percentage of the hours the RBT or direct staff work with your child. Some providers may choose to have RBT's continue coming to your home, with the BCBA joining the session virtually. Other providers may have both the RBT and the BCBA conduct virtual sessions. There is no set answer to this, and it will vary by area and by provider. This is also a funding decision, as not all funders permit non-BCBAs to provide telehealth. In the event that you are only receiving services from a BCBA, they do not require supervision. However, RBTs and Board-Certified Assistant Behavior Analysts (BCaBAs) cannot practice independently.
  • Direct service is most often provided by the RBT or direct therapist. If the RBT you work with is able, in-person direct service can still occur with the BCBA supervising remotely. If not, the RBT and/or BCBA may provide direct service virtually. Depending on the unique circumstances of treatment, direct service may need to be modified for telehealth. For example, goals may need to be reduced or placed on hold temporarily, like goals that require peers or going into the community. Any issues with your child attending, leaving the instructional area/running off, or trying to hit/disrupt the video call equipment can be addressed with the BCBA. They will be able to tell you how to help your child benefit from telehealth services. Please note that direct service provided virtually will most likely require an adult in the home assist with the session as far as prompting, delivering reinforcement, managing challenging behavior, troubleshooting technical difficulties, etc.
  • Family support can occur with any parent or legal guardian, and will have specific goals and measurable outcomes. Family support can include your child, and it can also occur with just you and the BCBA (most funders only permit BCBAs to provide family support). Keep in mind that due to the virtual format, family support time may steal your attention and focus away from other household activities. For example, if the BCBA needs to virtually meet with you to review progress and discuss changes to the treatment plan, it may be unrealistic to try to do this as you simultaneously cook dinner or engage your other children. 


Depending on the specific service being delivered, the amount of upheaval and stress in the client household, the current functioning of your Autistic child (will telehealth work for them??),  and caregiver ability to fully participate, telehealth can be more or less beneficial to families.
And that is OKAY.

You are not required to continue therapy services in the midst of a global pandemic. Think about the pros vs the cons, and make the best decision you can for your family.



*Resources & Further Information:

ABA Parent Training using Telehealth

Behavior Babe

Central Reach

Benefits of Telehealth

ABA Parent Training via Telehealth video 1, and video 2 

Podcast: ABA services in a global pandemic




ABA employers/managers: During this crisis, are you actually listening to your staff? Because without them, there really is no company.





"Leaders who don't listen will eventually be surrounded by people who have nothing to say." 
Andy Stanley

Here we all are, in the midst of an unprecedented life event and trying our best to continue providing ABA services to the clients who need our help now more than ever.

So yeah, no pressure or anything. :-)


Prior to this pandemic, maybe you had some clinical telehealth experience, maybe you didn't, but either way I hope to provide either a review of information you already know, or a crash course in Telehealth 101. 

I suspect that for many of us even after the current crisis ends, telehealth could become the New Normal as far as the way we do our jobs. Don't you think? 
If so, then it's pretty important to get your skill set up to speed with using technology to serve consumers.


So take a breath, relax, and let's dive in to some strategies for implementing your ABA magic remotely!

You can listen to the audio presentation here.



* HUGE* resource file for this presentation: Click Here to Download
Sharing is caring, pass this resource along to your ABA colleagues! We're in this thing together.



Today's quote of the day is from ..... Me!


See below for an excerpt about knowing your identity as a clinician, from my newest book, The Practical ABA Practitioner:




*Recommended Reading:

Runnin' on Empty












If you haven't experienced it yet as a supervisor/Program Lead/BCBA, you will: Being in charge of those who want no one in charge of them.

Sounds like a riddle or something. But in real life, it's much less humorous.

As someone in a leadership position (regardless of your actual title), you probably imagined your job would include lots of mentoring, providing support and encouragement, staying available to your team, selflessly putting their needs before your own, and definitely.. absolutely.. NOT being like that one supervisor you had who was just the worst.
You probably imagined your team or supervisees would accept your teaching and support with gladness, gratitude, and a huge "Thank you so much, you're the best!".

So it can be a pretty big let down when instead your efforts are met with disdain, condescension, irritation, or just flat out insubordination.
When no one is implementing your behavior plan.
Or no one on the team ever replies to your emails.
Or your supervisee requests to work with a different BCBA.

Again, if you haven't experienced this yet, just give it time. It's darn near impossible to move into a position of leadership and never have to deal with difficult people. Actually, I would say the higher up in leadership you climb, the more opportunity you have to deal with difficult people.

So if I may, I'd like to offer some tips for this daunting challenge. Here is what I've found helpful in the past:



First, check yourself -

1.      Are you making a difficult situation worse by being overly offended, getting all wrapped up in your feelings, and assuming the person hates you just because they don’t listen to you? Guess what? When you are the boss, everyone won’t like you. There really is no way around that. Stop taking things so personally.
2.      Have you calmly and clearly communicated your expectations, specified the areas where they aren’t being met, and helped the difficult person create an action plan? No? Why not?
3.      Do you spend more time at work complaining about the difficult person, rather than talking to the difficult person? Come on, be honest.
4.      Have you lost your objectivity? Do you get tense, sigh heavily, and roll your eyes every time this person calls you or sends you an email? If so, then your irritation is likely coming through in your interactions with this person.



After you have honestly looked at your own behavior (do not skip that part, it’s really important), now it’s time to take a good look at your supervisee/employee -

1.      Is this an issue of poor fit? Sometimes you have to taste the food to know you don’t like it. Similarly, some people need to start working for the company, or hold the position, before realizing it isn’t for them. Have an open conversation with the difficult staff about their current contentment with their role/the company.
2.      Look at the reinforcement history: has this person had good supervision/leadership experiences before? How do you compare to their previous leaders? Are they simply not used to having high expectations placed on them? It's hard to follow when you've never been led.
3.      What career goals does this person have? One of the most effective ways I have found for dealing with difficult supervisees is to help them connect their personal career goals to their current work performance. For example, if you know the staff is pursuing their BCBA then help them connect the dots between being able to accept feedback now, and how much more challenging it will be to accept feedback you don’t agree with as a BCBA. These clinical “soft skills” only become more important the higher up you go in this field, so it’s important to learn professionalism and humility now.
4.      Lastly, are you dealing with a toxic employee? If so, then move straight to GO, and collect $200. 😊 Unfortunately, a toxic employee has the potential to bring so much harm to staff morale, client satisfaction, and work culture, that it may be a better decision for the sake of the whole team to part ways, and wish them the best of luck with their next employer.





** Helpful Resources:








"Bad bosses compel good employees to leave"
www.Forbes.com

"The way your employees feel is the way your customers will feel. And if your employees don't feel valued, neither will your customers"
Sybil F. Stershic

"The only thing worse than training your employees and having them leave not training them and having them stay"
Henry Ford

"Strive not to be a Success, but rather to be of Value"
Albert Einstein

"You don't get paid for the hour. You get paid for the value to bring to that hour"
Jim Rohn





Get Excited!

For those of you out there, laboring away, giving your all to your clients, working from 8am to 8pm every day (and getting paid for 1/2 that time), typing up 25 page reports at 2 am, laminating flashcards until your fingers are sore, putting hundreds of miles on your car, going to work bruised, discouraged, and exhausted, and eating your lunch in your car...I have something for YOU.

My newest book, 'The Practical ABA Practitioner', uncovers and openly discusses all aspects of ABA practitioner life, as in the good, the bad, & definitely the ugly. ;-)
This book is all about the practitioner experience working in this field, the day-to-day reality, how to plan out a successful career, and what common pitfalls to avoid. Especially for those of you brand new to the field, or newly certified.


If you want to work in this field, you need to read this book.
If you're tired of working in this field, you need to read this book.
If you LOVE working in this field, you need to read this book.

In preparing to write this book, I talked to lots and lots of practitioners about their experiences working in this field, reached back into my own early days as an in-home ABA therapist, and I also perused the resources out there about ABA as a career: What's it like being a BCBA? What are the pros and cons to becoming an RBT? What are the joys, the pressures, and the challenging to meet expectations of this industry?


Dying for some specific details about the book? Sure!
 "The Practical ABA Practitioner" addresses:

  • Professional Burnout. Yup. I dedicated an entire chapter to discussing loving what you do, but hating the way you have to do it, and being eternally exhausted. You're welcome.
  • The end of the book is a huge treasure trove of practical practitioner tips and resources (handouts, job performance tips, staff satisfaction surveys, suggested parent policies, etc.) that will help you do your job better. Seriously, its just pages and pages of stuff. :-)
  • Work-Life balance as a busy full-time BCBA: Fiction or Reality?
  • Developing and refining your clinical identity as an ABA practitioner.
  • What are employers looking for when hiring RBT's? What about BCBA's?
  • Should you pursue BCBA certification? Is it really for you?
  • How to revitalize your passion for this field.
  • What kinds of pitfalls should newbie BCBA's watch out for (because they're vulnerable to these issues)?
  • Why are the staff retention rates in this field so terrible? To put it another way, why are so many ABA companies bleeding staff?
  • Tips for choosing between various employment options, and red-flags to look out for.
  • How to BE the change when working in less-than-ideal conditions.
  • Holding this field accountable for the way we treat direct staff/ABA implementors.
  • How to to develop your personal value system in this field, and practice with integrity.
  • How to be truly successful as a practitioner, for years and years to come.
  • What are some of the main reasons why quality practitioners walk away from this field, and don't look back. And how we can keep them from walking away.




Treat yourself, and do something GREAT for your career... get this resource and be encouraged and strengthened.

Click here to find this brand new resource on Amazon!







ABA employers: You listening?


'You don't build a business, you build people.
And then people build the business'

Zig Ziglar






"Burnout is the process of spending too much time doing things that don't properly utilize your unique Tool Kit" - Runnin' on Empty


If you are new to this field or perhaps if not new, recently became a BCBA, you may not have a very strong understanding yet of who you are as a clinician.

It's ok, it took me time too... Lots and lots of time.

It's hard to solve a problem you don't realize you have, so this is something I didn't even think about for many years in this field. I accepted work opportunities based on what was available, and when those opportunities didn't work out or left me feeling quite underwhelmed I just moved on to a new opportunity.

But, doesn't it make more sense to intentionally and strategically map out your career based on who you are and how you want to practice? Then why aren't are more of us doing that?


Burnout, which is known fact of life in this field, can very much be connected to a lack of goodness-of-fit. Think about a vegan who works full-time at a BBQ restaurant. Or a pacifist working for a guns manufacturer. Or a daycare teacher who can't stand kids.

How much personal satisfaction and enjoyment do you think those employees would report after a work shift? I'm guessing low to none.

It's easy to just tell someone working in this field that Clinical Identity is important, but how many of us really understand how to ~discover~ our clinical identity?

Expect this process to take some time (I know, waiting is the worst), as knowing who you are not doesn't happen in the blink of an eye. It will also take perspective, which means you need to do more than one thing. If you've always worked with adult populations, or always worked in school settings, then how do you know what else might be a good fit for you? You kind of can't know that, if you only do one thing over and over.

Let's start at the beginning by first defining what is meant by a clinical identity: Defined as one’s professional self-concept based on attributes, beliefs, values, motives, and experiences (Ibarra, 1999; Schein, 1978).

Basically, your clinical identity is a combination of why you entered this field in the first place, combined with what keeps you in it. There you go, nice and simple definition :-)


Still struggling to put your finger on the unique clinical identity that fits YOU? Here are some tips:

  •    Take money off the table (no, I’m serious). If you had to work for free, what would you choose to do?
  •    Think about the last time you were truly passionate about work. What were you doing?
  •   What part of the work you do makes you full (energizes you, excites you, lifts you up)? What part empties you (depletes you)?
  •    Seek feedback: ask people who have worked with you, alongside you, or for you, to honestly list your best and worst clinical attributes
  •   Does your current work allow a place for your unique personality, or does it require minimizing or turning off parts of your personality? *If you’ve never taken a personality inventory before, I super recommend doing that.
  •   Write down your value system. Use this list during interviews to determine if your personal values and the values of the organization are complementary, or if they clash.
  •   Anger can be highly educational. Identify the things that make you the most angry/frustrated/annoyed about your work. Honestly examine why these things bother you so much (they likely conflict with your value system).
  •  What is your ‘niche’? What is it that you bring to the table that no one else can?




*References:

Slay, H.S., & Smith, D.A. (2011). Professional identity construction: Using narrative to understand the negotiation of professional and stigmatized cultural identities. Human Relations, 64(1), 85-107.   

Michael Tomlinson & Denise Jackson (2019) Professional identity formation in contemporary higher education students, Studies in Higher Education


*Recommended Resource:

Carving out your Clinical Identity





Impairments in social communication are a key deficit of Autism, and can be seen across the varying range of the spectrum.

Social communication is a big word that can include many difficulties, such as making friends, maintaining friendships, being appropriate near peers, sharing or turntaking, empathy or perspective taking, initiating peer play, joining ongoing peer play, responding to peers, self-advocacy, conflict-resolution, etc. 
When clinicians throw around the term "social skills", we are really talking about a lottttt of skills!

Some people have the mistaken belief that ABA therapy only focuses on 1:1 instruction, and therefore isn't appropriate to target peer social interaction. Nope, not true.
ABA therapy can absolutely include targeted social skills instruction. Depending on the age of the learner and their specific social deficits, that will impact how social goals are assessed and selected. 

Parents of very young children usually want to work on: sharing, playing with peers instead of isolating, playing with toys instead of hoarding toys, reducing aggression towards peers, etc.

Parents of teens or young adults usually want to work on: initiating conversation, increasing MLU (jargon translation= you want your child to use more than 1-2 words to make a statement or answer a question), buying items in the community, talking to community helpers (e.g. a police officer), etc.


There are also many ABA programs that offer formal social skill groups to families, where learners are grouped together based on interests, abilities, age, or other factors, to participate in games and activities as a group. But the games are far more than just "games", they are actually carefully designed to target specific social skill deficits. If you are already receiving ABA therapy services, ask if your child can participate in a social group with other clients.


Behavior Analysis has many empirically validated strategies to add to the social skills conversation, and also (depending on the funding source) the ABA provider can target social skills in a group format, at school, or out in the community, to ensure proper generalization. For example:


  • Reinforcement for the win! Social skills training should include reinforcement individualized to the learner, and also should work to pair (transfer) reinforcement to peers, as pre-intervention the learner may not find interacting with peers to be all that fun ;-(
  • Data collection. If no one is collecting data, reviewing that data, and evaluating that data to make treatment decisions then what is happening is not ABA.
  • Generalization. Also known as, "real life". Learning social skills in the ABA clinic, or at school, or on the playground, will not necessarily generalize to other settings and other kids. Intentional generalization into real-world, real life scenarios is a must.
  • Structure. This may sound weird, but it does NOT mean that the learner must do the same thing, in the same order, for each peer interaction. It means that the learner should be able to predict what will happen in social group today, they know the rules of social group, and they understand what rewards they contact during social group. These things should be somewhat predictable, from the perspective of the learner.
  • Break down concepts visually or tangibly. Help learners understand abstract concepts through video modeling, games, visuals, or manipulatives, that they can touch, see, etc.
  • Follow an evidence based curriculum.....just not too closely. While it is important to have a tool to create the lesson plan for social instruction, I'd also recommend individualizing the curriculum as much as possible across learners. Modifying the curriculum to make the content more relevant to the learner will go a long way to helping social instruction gains "stick".
  • Behavior management. So obviously, challenging or disruptive behaviors will interfere with learning during social interaction time. These behaviors can also frighten, intimidate, or annoy other children present, which works against the goal of interacting with peers. This is why ABA providers are a qualified to implement these kinds of interventions, because we already have the tools to decrease inappropriate behaviors and increase appropriate behaviors, and keep the social interaction on track.




*Resources:


Crafting Connections (I love this book!)

Social Skills Training for Youth with Autism Spectrum Disorders, Otero, Tiffany L. et al. Child and Adolescent Psychiatric Clinics, Volume 24, Issue 1, 99 - 115

A Review of Peer-Mediated Social Interaction Interventions for Students with Autism in Inclusive Settings, Watkins, L., O’Reilly, M., Kuhn, M. et al. J Autism Dev Disord (2015) 45: 1070


Baker, J.E. (2004). Social Skills Training: For Children and Adolescents with Asperger Syndrome and Social-Communication Problems. Shawnee Mission, KS: Autism Asperger Publishing Co.



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