Birthday parties. Let's talk about it.


Parties, gatherings, events, picnics, etc., where there will be lots of people, noise/music, activity, chatter/laughing, and hidden, unspoken rules for "appropriate" behavior.

The event may even be outdoors, which brings a whole host of safety concerns.

Or, the event could be near a body of water (pool party), which definitely adds even more safety concerns.


For parents with Autistic children, or another disability, do you just not go??? Is that the way to do this? How do you get a child through elementary school without ever attending a birthday party?? These days, kids have to invite the whole class. So in an average school year, your child may receive several birthday invitations, to loud, active, parties full of running, screaming kids, hopped up on sugar and soda.

Before we jump into what to do, let's back up a bit and describe the challenges: Why are birthday parties sometimes so not fun, and so very hard

Birthday parties/large gatherings are (often) loud, full of junk food/ice cream/candy/cake, full of people, tantalizing presents, music or entertainment, and the expectation to socialize ("You kids go play"). All of this can combine for quite the sensory nightmare.

Your Autistic child may find the event overstimulating, scary, uncomfortable, or painful (overstimulation that one cannot leave can be painful). Your child also may be unable to tell you any of that, which leaves demonstrating the discomfort through their behavior.

I have seen this up close many times, both "on the clock" and off the clock. I've been at kids birthday parties and seen that girl or boy seriously struggling and having an awful time, or attended birthday events with clients to provide support during the party. 

I think its critical to reset expectations and have a clear understanding of just how scary parties can be for Autistic children or adolescents (I'm not mentioning adults because, typically, adults with disabilities are not forced to attend events they seem not to enjoy, the way small children are).


The questions below should be carefully considered based on your child's age, temperament, sensory profile, and support needs, with strategies in place in case the party experience goes badly. Have a plan, then have a backup plan, and don't go it alone. Bring at least 1 other adult with you, or if you are hosting the event, assign helpers among family ands friends who know what to do and will quickly jump in if your child is having a hard time.


Things to Consider:

Do you have to attend/throw the party? No really, think about that. What would happen if you just...didn't go? Or what would happen if your child didn't have a 4th birthday party? I'm pretty sure the earth would still keep spinning. Sometimes, the level of support that would be needed as well as the needed accommodations aren't feasible. In that case, is it better to force your child through something they are unlikely to enjoy, or to just skip it? I'm not saying forever, and this could even be a case by case decision. Small party at a neighbor's home? Sure. Huge community pool party with 6 clowns, a DJ, and group party games? Maybe not.


- Don't try to stay the whole time, instead play it by ear. For some children, they aren't excited about the cake (feeding issues are common with Autism). They don't care about the social games or group activities. They don't yet have the ability to wait, so they won't understand why they can't start ripping into set aside food or activities (and may not understand why they can't open someone else's gifts). What will YOUR child do at the party that they find fun, entertaining, and is safe? Think about that, before you take them to a 2 hour birthday party.

- Understand that vigilant supervision may be needed. This does mean dropping your child off may not be a safe option (as the party host will be super busy), and if you stay with your child, you may need to keep them in eyesight at all times. It isn't unusual for my clients to 100% "veer off from the group" during parties, only to be found sometime later upstairs in a closet, or trying to access YouTube on the family laptop, or casually digging through someone's refrigerator. These can be very embarrassing moments, that could easily be prevented by keeping a close eye on your child, especially if the party or event will be held outdoors.

- Speaking of embarrassing, there is nothing embarrassing about accommodations or supports. If you are taking your child to a party or event where they can't wear their noise canceling headphones, or freely STIM (family members, sadly, can be very judgmental about stimmy kids at birthday parties)  without being treated poorly, that may not be the kind of event you want to attend. Again, parties are overstimulating for many Autistics. So it makes sense that they will do MORE of what helps them calm or regulate in response to being at the party. In other words, if most of the kids are quietly playing Candyland, but your child is in a separate room happily squealing and jumping, while chewing on a straw, will this be a problem for other people at the party? If so, I don't think your child is the problem.

- Take preferred foods, toys, and leisure items with you. Please do not expect that your child who eats 3 foods at home, will magically attend a birthday party and chow down on Cheetos, cake, and pizza. If they won't eat it at home, they likely won't eat it at the party. Also, don't withhold stim items or comfort toys because the child is in public, and other people will see. Those favored items may help keep your child calm and comfortable, in a chaotic and loud setting. On that note, it can be helpful to bring items your child may grab, snatch, or steal, if they see it in public. For example, I worked with a boy once who loved to suck on pencils. If he was out somewhere and saw a pencil, he would try to grab it and put it in his mouth. So in that situation, I'd recommend bringing oral sensory items with you so the child doesn't need to hunt throughout someone else's home for something to satisfy that chewing desire. Think about things like this in advance, and plan accordingly.

- The biggest tip, and the one I see cause parents the most pain and distress, is this: Please don't expect your child to be a different person socially, just because you're at a birthday party. If your child is not very social at home, they likely won't be very social with 23 other kids present. In fact, they may exhibit new behaviors you usually don't see at home (such as pushing, swatting at, or running off to get away from the other kids). This can be very hard for parents to watch. So can bullying and stigma, such as if your child DOES want to join the play, and the other kids are being mean or cruel to your child. Remember that earlier tip about close supervision? It's very important to watch how your child interacts with the other children, so you can stop any bullying or rudeness in its tracks, and so you can monitor when your child's social battery is "full". Most of my clients fill up that social battery very fast.....maybe 15-25 minutes of social interaction, and they're done. And that is OKAY. Not all children want to "Go play" with their peers for hours and hours. Observe your child, redirect them to solo play or maybe a calming activity as needed, and when they seem to be all done with being around so many people, its time to head for the door so the event can end on a high note. Don't be ashamed or embarrassed to say "S/He's ready to go now. Thanks for inviting us, bye guys!". 



I hope the largest theme coming across in this post is that large events/birthday parties aren't necessarily about you, as the parent. They aren't about the party host, the games, the clown, catching up with friends, hanging out, etc. They are about helping your child be successful, in what is likely a highly overstimulating scenario.

It is important to provide your child with the support and tools they need to engage with the event, to endure the event (again, consider if it would be best not to go if they seem to just be "enduring" parties), or to excel at the event. Whether the bar is set at engagement, endurance, or excelling, will depend on your child. 
And don't lose hope and feel defeated if right now, you are at an endurance level. That doesn't mean things will always be that way! As your child grows and matures, and most importantly as they develop more skills and abilities, they may begin to enjoy parties. Maybe even, to have fun at parties.
Give it time, and be patient. Both with your child, and with yourself.





*Recommended Resources & Resources:




Ghanouni, P., & Quirke, S. (2022). Resilience and Coping Strategies in Adults with Autism Spectrum Disorder. Journal of autism and developmental disorders, 1–12. 






 



I have been presenting/speaking, writing, and training on the topic of ABA Reform/anti-ABA sentiments for some time now. I have spent time engaging in intentional community and dialogue with people who disagree with ABA, and even have traumatic experiences from therapy services (some which really should never have been called “ABA”), as well as doing the work daily in my sphere of influence to train up/mentor/coach supervisees on this topic. Lots of listening, closing my mouth, being open to changing my own mind, being open to critique and feedback, and letting people tell their own stories.

 

I’m not alone in this. I know many ABA clinicians and providers who are also moving away from defensiveness and being closed off to criticism or shutting down Autistic voices because they disagree with ABA. I know people personally who have completely changed the way they practice, and I have mentors in this field that I look up to who have helped model for me the way forward, towards a more compassionate and respectful ABA. There is still lots of work to be done, and I know many providers committed to doing that work, every day, across all their clients.

 

However—

 

I get lots of comments, questions, and emails, from anti-ABA people who want me to do more. They want me to close up shop, rip up my certification, terminate all my client contracts, and find something else to do. They want ABA to just go away. Reform isn’t enough, changed mindsets isn’t enough, and listening to the Autistic community isn’t enough.

 

To that, I want to openly and publicly say: I respect your point of view, and I’m not here to tell people what to think. You have formed an opinion and are 100% convinced it is correct.  You believe ABA is conversion therapy, it is abuse, it is terrible, and that any ABA provider must therefore be terrible. You aren’t interested in dialogue or collaboration, you want ABA providers to shut up, and go away.

 

I hear you.

 

But I’m committed to change. For myself, for those professionals within my sphere of influence, for the clients and the client families I support and work with every day, and for the field in general, as far as my own advocacy and activism will allow. I speak out regularly about better ways to do ABA, issues with this field/industry, and the need to better support clinicians, and better train Technicians. I feel strongly about ALL of these issues.

 

To Autistics I say: keep speaking up and keep speaking out. Yes, you will find that trying to dialogue with some ABA providers or company owners will be an exercise in futility. But, there are those of us out here who WILL listen. Who won’t shut you down, who are willing and interested in engaging in respectful communication and truly want to learn. We are here.

 

You may not want to speak to us, you may not want to dialogue with us, and you may not want us to continue supporting individuals and families, but again: We are here. We will remain here, and we will commit to growth, own up to our mistakes, and stop acting like we know it all. We don’t know all. No one knows all.

 

So for those who ARE interested in learning, growing, communication, collaboration, and improving the quality and soul of ABA services: We are here.

 

Let’s work together.

 


** Recommended Reading:

What is ABA/Can it be Reformed?

Toward ABA Reform

A Perspective on Todays ABA

https://www.iloveaba.com/2020/11/aba-haters-pt-ii.html

https://www.iloveaba.com/2021/08/trauma-informed-aba.html

https://www.iloveaba.com/2018/03/normalization.html

ABA Reform Movement podcast episode

List of ABA Facebook Groups

Toward Trauma Informed Applications of Behavior Analysis 

What is Trauma Informed ABA podcast episode

Taylor, B. A., LeBlanc, L. A., & Nosik, M. R. (2018). Compassionate Care in Behavior Analytic Treatment: Can Outcomes be Enhanced by Attending to Relationships with Caregivers?. Behavior analysis in practice12(3)

Compassionate Care in ABA


 



"McABAs" is my own created term to refer to the low-quality, murky billing practices, mass produced interventions ("cookie cutter" programs), undertrained or nontrained RBTs, and overworked and harried clinicians, kind of ABA providers.


Similar to how when your body is hungry and in need of sustenance, I don't recommend reaching for a greasy fast food bag of empty calories, if you are in need of high-quality, professional, ethical behavior analytic services I don't recommend calling up a McABA.





The problem is, low-quality providers may not look/seem like a low-quality provider. Unlike fast food chains, you can't just look for the obvious golden arches or the blatant drive thru window.


As a caregiver, parent, or person seeking ABA services for themselves, it is critical to learn to weed through your options, weigh one place against another, and look for red flag concerning signs and indicators of a low-quality provider.



The following resources should help:


https://www.iloveaba.com/2018/04/weeding-out-bad-youre-fired.html


https://www.iloveaba.com/2012/10/choosing-aba-agency.html


https://www.iloveaba.com/2011/08/how-to-have-very-short-career-in-aba.html


https://www.iloveaba.com/2021/07/choosing-aba-provider-pt-ii.html


https://marybarbera.com/tameika-meadows-finding-good-aba-therapy/









 Autism Awareness 2022.


It's April again.


If you haven't read my thoughts on moving from awareness to action, see HERE.


Advocate. Support. Inform. Educate. Accept. But please do more than just be aware.







 


Across multiple industries, staffing deficits are a big problem right now. 

There are many different explanations for this, but certainly in a post-COVID world all of us are redefining work, evaluating our priorities, and learning how precious our time is…..if people are unhappy at work/in their career, it makes sense that the past 2 years would push them to DO something about that.

 

But let’s talk about RBT’s, specifically.

 

The RBT credential is an entry level position into this field. When a clinician company hops, it is usually for a different BCBA position. After all, there was tremendous time, energy, money, and schooling that went into the decision to become a BCBA, so most will try a new company out before trying a new profession.


For RBT’s though, many are not that connected to the field. They may still be figuring out if this is what they want to do long-term. Or, they may already know that they plan to pursue education, mental health, counseling, or other degrees, and are working as a RBT now for valuable experience. The point being, its often true that RBT’s not just company hop, but industry hop/leave the field. Especially right now, when the impacts of quarantine and the pandemic are still lingering. Client cancelations, health scares (e.g. sessions canceled for a week until a clear COVID test), companies lowering rates or decreasing benefits to ease financial strain, funders decreasing reimbursement rates, etc. All of this contributes to the experience of the RBT.

I mean, just look at current gas prices. If you think that isn’t impacting the job satisfaction of RBT’s who spend most of their day driving from client to client, then you are deluding yourself.

 

So, what can be done?

 

What is often attempted is increasing incentives. Things like: pizza day, bonuses, raffle drawings, trivia nights, casual Fridays, referral bonuses, public recognition/"Shout Outs" from management, use of a company iPad, etc.

Here’s the problem though: did anyone ask for that

 


What are your frontline staff asking for? When people leave, WHY did they leave? When people turn down an offer, or decline moving forward in the interview process, WHY did they lose interest? What happened? When staff complain or bring up concerns, are they addressed and resolved? Or bounced from person to person in the company? Is management toxic to deal with, unprofessional/gossipy (especially in center based settings), incompetent, etc.? Toxic managers are one of the largest reasons why people leave otherwise good companies.


 When I speak with unhappy RBT supervisees, the issues they describe to me tend to be systemic/management level problems (meaning, the supervisee cannot fix the issue), or a symptom of RBT mistreatment/low regard. For example:


  • Low pay/Pay rate has not budged since hire/Low hours (hired as FT but only working PT hours)
  • Client cancelations or schedule changes that cause loss of income
  • Poor fit to clients on caseload/Working outside of clinical competency
  • Not supported by BCBA/Minimal supervision
  • Issues with admin or management (rude, unprofessional, incompetent, etc.)/Inaccessible owner, management, or HR/Management does not support or "back" the RBT when there are issues with the client parent
  • No company policy on parent involvement or participation/No company policy on respecting the staff or employees/No consequences when client families regularly arrive late to sessions or cancel frequently
  • Excessive driving (only client is 2 hours away)
  • No benefits/No healthcare due to unable to maintain FT hours
  • Company does not provide needed equipment and supplies to perform job/RBT must provide their own supplies
  • Being expected to do extra work for free (required to train new hires for free)
  • Insufficient training on company required technology (required to use data software, but minimal training on it or support when it isn't working correctly)


If I was working with a client, and providing access to pizza, gift cards, and trivia nights, but the target behavior was not improving, my conclusion would be that I need to reevaluate my reinforcers. Looks like they aren’t so reinforcing after all!



Okay, then let’s apply that same conclusion to our workforce. If they are continuing to quit in large numbers, the reinforcers and motivating variables are lacking. Something is wrong, something is off. And as owners, bosses, managers, and stakeholders in this conversation (supervising BCBAs may not actively hire or employ RBTs, but we can certainly advocate and speak up for them in the workplace) we need to do better for our highly important RBT workforce.


 

So, what do RBTs want?

Heck, I don’t know. 😊

 


You need to ask THEM that. Individually. Consistently. Intentionally. At the onset of employment. As well as on a recurring basis once they take the job.

 

Don’t wait for people to become unhappy and dissatisfied and only then start pouring on the incentives, gift cards, and bonuses. Be proactive and intentional about building a strong workforce, demonstrating value (link), and probing individual employee preferences and reinforcers, so that the workplace can be an enjoyable setting (and reinforcing stimulus) for the people wo work there.

 


…… Or it’s highly likely they won’t work there for long.


 

*Recommended Reading & Resources

Improving Employee Retention

Predictors of Burnout in Behavior Technicians

Reinforcer Preference Assessment 

Identifying Staff Reinforcers 

How to Retain Great Employees


 

 



"The mind is not a vessel that needs filling, but wood that needs igniting" Plutarch


"Autism isn't something a person has, or a shell that a person is trapped inside. There's no normal child hidden behind the autism" J Sinclair 


There used to be a school of thought in the Autism world that the individual was somewhat of an "empty vessel" waiting to be filled. A blank slate, trapped within a hard to understand shell and wanting to emerge.


No. 

And what a harmful, disparaging view of individuality.


Autism is not being without/lacking, it's being differently tuned with interacting with the world, environment, people, and situations. 

It's sometimes being MORE when the situation calls for less, or being LESS when the situation needs more....Less attentive, less sensitive. Or possibly more attentive or more sensitive. 

There is no one clear way to be Autistic. 

What is super important to know is that every client you work with already is full of information and knowledge when you meet them. Some cannot share or demonstrate that knowledge, but that doesn't mean it isn't there. Or maybe they show it in a way you aren't used to, or aren't prepared for. 

Regardless, the capacity to learn and grow is within all of us. 

 Recommended Read: Toxic Staff 



If toxic staff is 1/2 of the conversation about what creates and perpetuates sick, dysfunctional work culture, then toxic leadership is definitely the other 1/2 of the conversation. You can't discuss one without discussing the other.

Unhealthy work demands, narcissistic managers, unrealistic productivity metrics, all of these contribute to the "revolving door" staffing issues that many, many ABA companies face.


Who is at the top? Who is getting promoted to the top (and who isn't)? And what characteristics and concerning behaviors do those in leadership consistently exhibit?


Examples? Sure:

Employees who sacrifice/neglect their OWN families to work long nights and weekends for clients are seen as “go getters” and “customer satisfaction focused”

A lot of hype and focus is placed on giving “110% every day”, with little discussion about how that is also the definition of burn out culture

Leadership decisions are not to be questioned. They are to be accepted. Questioning or disagreeing leads to the employee being seen as "insubordinate", "disrespectful", or "problematic"

“Hit the ground running” is a euphemism used to communicate the expectation that you will jump headfirst into a project or assignment and not bother anyone with questions, or requests for assistance

“Soft skills” like compassion, empathy, or person-centered treatment is retwisted as being “too soft”, “too emotional”, or just weak. You are encouraged to be firmer with clients, “convince” families of hours they don’t want, and project “confidence”

 


And on and on and on. 

Source: www.betterup.com 


Toxic leaders create and worsen toxic work cultures, resulting in staff who are timid, fearful for their jobs, indecisive/do not trust their ability to be a self-directed employee, and hesitant to provide constructive feedback. These are not fun places to work, and the work being produced typically reflects that.

Taking that a step further, what happens when people working in a field intended to help, support, coach, teach, or instruct vulnerable populations, is suffering under toxic leadership? What is the impact on quality of care and client outcomes? I don't think this is a question of "Will this affect the clients", but a question of "How will this affect the clients".

If the point of a leader in a company is to guide, instruct, and lead those under you, then following a toxic leader is like walking on a circular road that doesn't go anywhere. Its a pointless exercise in futility, and a good way to ignite a great resignation



In my latest book, 'The Practical ABA Practitioner', I talk at length about my experiences in this field working for toxic owners/managers. The way those experiences impacted my job satisfaction, my passion for Behavior Analysis, and my emotional and mental health (burnout, anyone?). My experience is not unique. Employees: talk to your colleagues. How many of them have sat under toxic leaders, and what impact did that have on them? Employers: talk to your team. How many of them view their current managers or supervisors as toxic, and how does that impact their day-to-day work?

Dangerous leaders are not just dangerous because of their pathological mindset and questionable behavior. They are dangerous because they expect the people under them to become like them. To focus on profits over people, to "hustle hard"/work until they drop, and to prioritize company health over their own mental health. 


When we examine the rates of position resignation in this field, as well as clinician burnout, how much of that is caused by toxic leadership? Many companies have systems and procedures in place that can actually encourage professional burnout. When employees feel isolated from colleagues and distant from ownership/management (silo mentality), or when unrealistic caseload expectations are presented as being non-optional, staff will try to rely on their smarts and training to get them through these challenges. But sometimes, it isn't the staff that needs to change, it's the system that needs to change.

 How well does the employer evaluate staff for signs of professional burnout? Are boundaries or guardrails put in place so that staff are not experiencing excessive driving, highly variable scheduling, regularly dealing with highly challenging consumers, or working 12 hour days 6-7 days a week? Does the work culture intentionally promote cooperation, teamwork, and open communication? Can staff  directly access management to voice complaints, or even just vent? Or, do staff know that complaining about people higher up than them will lead to swift retaliation? All of these issues can lead to staff who feel devalued and unappreciated on a regular basis.



It takes healthy, rested, emotionally stable people to perform the challenging work of supporting vulnerable populations through behavior analytic interventions in the community, home, and classroom. Toxic work cultures don't only impact your team, they also impact the very clients you are supposed to be helping.

Source: www.hcamag.com 




** More Info:

Preventing Burnout 

Lipman-Blumen J. (2010) Toxic Leadership: A Conceptual Framework. In: Bournois F., Duval-Hamel J., Roussillon S., Scaringella JL. (eds) Handbook of Top Management Teams. Palgrave Macmillan, London.

What is Ethical Leadership?

Developing Leadership in Your ABA Team

Esquierdo-Leal, J.L., Houmanfar, R.A. Creating Inclusive and Equitable Cultural Practices by Linking Leadership to Systemic Change. Behav Analysis Practice 14, 499–512 (2021).

A New Model for Ethical Leadership 









 



Is Telehealth ABA here to stay post-pandemicOr should we wave goodbye to a solution that solved many problems when COVID first hit? What does the future of ABA look like?


Well, definitely across many other industries: Hybrid or Remote work is here to stay.


As COVID continues...and continues, now is the time to start looking ahead and considering where Telehealth belongs in the world of ABA. Front and center? Or a "break glass in case of emergency" temporary solution?

During 2020, many of us relied on remote services and/or technology to teach our kids, bring our groceries, attend professional conferences, receive doctor check ups, or check in on family and friends. Video calls became a way of life. ABA therapy was not exempt from that reality.

But many ABA companies that were forced to embrace Telehealth during the height of the pandemic are now starting to look into moving away from Telehealth, re-opening clinics at full capacity, going back to school based services, and reintroducing group therapy formats (such as social skill groups). Carefully, of course, and while following local and state level mandates.

I see lots of discussion and news content focused on should ABA Telehealth continue for clients (Is this the best decision for the clients). But little focus on "What about for the professionals?". Do ABA providers have a preference between Telehealth services and non-Telehealth services?

The answer to that question may vary according to comfort level/familiarity with technology, age of client/populations served, and the specific ABA provider. RBT's may be less comfortable with Telehealth than BCBAs. Or, vice versa. There are pros and cons on both sides of this issue, but the main takeaway here is this type of clinical decision needs to be made with all parties involved. And that includes the professionals/providers, not just company owners/employers, or clients and client families.


First, let's clarify what is meant by Telehealth:

Telehealth ABA services are provided virtually through HIPAA compliant means, usually a combination of video and audio that occurs live-time during the session. Typically, funding or clinical need is most appropriate for Telehealth BCBAs. While RBTs can work virtually as appropriate for the client, funding does not always allow for this.

Telehealth typically is utilized for homebased services, although clinic or school based providers can utilize Telehealth as well.

Virtual service delivery already has a long, established history in other fields such as Mental health counseling, Psychological services, and Medicine. Telehealth is not new. However, the field of ABA embracing Telehealth IS fairly new. Prior to COVID, many insurance funders did not even have billing codes for Telehealth services.

At the BCBA level, all service delivery can utilize Telehealth (as appropriate for the particular client), including assessment, parent support, and RBT supervision.


So why the pushback against Telehealth? Why do some funding sources, employers, or practitioners seem so against Telehealth? Well, sometimes Telehealth is applied with a broad brush to clients it may not be appropriate for. I know of clinicians who are currently very anti-Telehealth because of how they've seen it done, or having it thrust it upon them at work with little to no training or support. If you are a BCBA who hates Telehealth, did anyone take the time to train you on its use? Do you have someone to reach out to with troubleshooting and questions? If you are a RBT who hates Telehealth, was it explained to you at the onset of the case? Did you know going in the BCBA would not be on-site with you? Its important to separate personal bias and preference from the use of technology to provide services. Just because you do not like Telehealth, does not mean its all bad.

When utilized in an evidence based and ethically sound ways, Telehealth has numerous benefits. I have been utilizing Telehealth to service families since 2010. If it had not been an option, these families may have gone without help and assistance. For international or rural families, professional help may not be located up the street. It may be located in a different state, or country.

Telehealth allows me to clinically supervise in discreet, non-disruptive ways that minimize client reactivity. It allows me to easily hold progress meetings with client families who may not be available during scheduled therapy sessions. I can have a 20 minute videocall with a client's dad while he's on his lunch break at work. Trying to do that in person/on-site would present many logistical challenges. 

Telehealth allows me to work for a living while also being home to support my OWN family, during this pandemic craziness. I have a few close friends who are new moms, and if they did not have the option to work via Telehealth through their maternity leave and beyond, they would have been left with no choice other than resigning from their positions.


Lastly, I think the largest benefit of Telehealth ABA services may be explained in this data:

  • United States – 1996 BCBAs in the state of MA
  • United States – 107 BCBAs in the state of Nebraska
  • United Kingdom – 321 BCBAs  
  • Australia – 111 BCBAs 
  • United Arab Emirates – 104 BCBAs
  • Russian Federation – 33 BCBAs
  • India – 27 BCBAs
  • Spain – 26 BCBAs
  • Brazil – 10 BCBAs
  • Nigeria – 1 BCBA
(Source: www.QBS.com)

These numbers are a very sober reminder that Telehealth is not just about personal preference, pandemics, or open-minded employers. As the demand for ABA continues to grow, the supply is not keeping up. We have far more people in need of service, than qualified providers available to help.

Telehealth makes it possible for 1 BCBA to service clients who may live in different zip codes, states, or countries. It helps companies with dire staffing deficits open up their services to more clients, it helps RBT's in dire staffing areas receive clinical support and BCBA help, and it attracts (and possibly retains) BCBAs located out of area. 

Gone are the days where the ABA provider needs to spend 7 hours in their car crisscrossing the city to see 3 clients. Now with Telehealth, not only can those 3 clients be seen WITHOUT traffic jams, but the provider could add on more clients in the same day. Removing the commute means staff spend more time working, and less time sitting in traffic (aka increased productivity). 

Opening up Telehealth services means getting families off of waiting lists, and starting up services. No more waiting months to locate and hire a BCBA in the area.

Also, sickness/illness: What about minor but still contagious illnesses, such as pink eye, stomach virus, strep throat, rashes, etc.? The provider doesn't need to cancel the session when they can just implement Telehealth instead.

What about when staff move out of area? Instead of losing quality providers, forcing the family to accept the transition, and disrupting care, how about the BCBA remains on the cases via Telehealth?

Just being able to offer Telehealth/work from home as an option to employees/staff means being a more open-minded, accommodating, and future focused employer. It is attractive to applicants when a work setting provides options. 


Again, Telehealth may not be the appropriate choice for every client or family. But, when appropriately utilized Telehealth can make the job of the ABA clinician easier and more efficient. And what employer isn't a fan of efficiency? ;-)


*Further Reading/Resources:

What does Telehealth ABA Look Like?

Telehealth for Children with Disabilities

Telehealth ABA - Best Practices

Moving Forward while Staying Home 

Practical Guidelines for Telehealth ABA

Therapy During COVID 19

Telehealth: Challenges & Solutions

Rapid Conversion from Clinic to Telehealth ABA 

Guidelines for TelePsychology 

Guidelines for Telehealth Related Ethics

Is Telehealth ABA Here to Stay?


 


See Part I, which is helpful for families needing to know how to prepare the home for ABA services.


I couldn't just leave this topic 1/2 complete. 


Of course, it is important for families to know what to expect of home-based ABA services and general "Do This" & "Don't Do This" guidelines, but it's also important for ABA staff and clinicians to know when home based ABA services are inappropriate, the home setting is unsafe or hazardous, the home setting needs stricter guidelines, or is downright dangerous to staff and/or the client.

I'm not ignoring ABA that occurs in other settings, but for clinic or school based ABA services the environment/facility is typically set up in advance. It is monitored and controlled by management or clinicians, and regularly cleaned and maintained. Certain items are prohibited to be on-site, there may even be security or at the least, janitorial staff. 

The home setting is unique because as the staff going in, we do not have full control over the environment. We don't know what hazards are present unless someone tells us. Sometimes we don't even know how many people (or animals) will be in the home from one session to the next. We may not know what is broken/damaged in the home, or may pose a health concern when we arrive on Day 1, ready to work.


So, this is a pretty big deal. 

To all the company owners and supervisors/BCBAs, this kind of "home safety checklist" needs to be developed with a home inspection occurring before the case starts (during intake/assessment). RBTs should not have to walk blindly into the home of a stranger, with no idea what dangers or challenges may be present.

I recommend that whoever schedules the assessment and makes initial contact with new families explain the company policy related to home safety, make sure to answer any parent questions or address parent concerns, and do a walk-through inspection (this could also occur virtually).

Companies will vary with what is required or expected of the home setting, and sometimes state regulations or funder specifications will apply. 


Unsafe/Inappropriate conditions in the home may negatively affect the client, such as: profuse sweating through the session because sessions occur in the non-ventilated and dusty attic, the parent blaring loud rock music throughout the session, or being unable to let the client play in the backyard due to huge amounts of dog feces.

Unsafe/Inappropriate conditions in the home can also negatively affect staff, such as: excessive and unwanted flirting and sexual jokes from the client's father, having to park in a nearby unsafe area as only street parking is available, or bringing pests into your own home that crawled into your materials bag during the session.

How exactly is learning or teaching supposed to occur under these conditions??


I could fill this post with pages and pages of home-based horror stories, but instead I'll just simply say: Home based ABA won't be possible for every family that wants it, for a variety of reasons. 

And that's ok

Services may need to occur at school, at the clinic or center, or in the community (such as at a library) until issues in the home can be adequately and safely addressed both for the benefit of the client, and staff.



**Resources:

Free checklist download to help set policy/establish minimum requirements for home-based ABA services to occur. 

Home Based Employee Safety

Ensuring Safety during In-Home sessions

Firearms & Home-Based ABA: Considerations for Safe Practice




Its common, its common, its common.



That is the first thing that needs to be said to any caregiver who ended up here while researching "picky eater" + Autism. You are not the only one experiencing this.

Autistic individuals (because this is not just an issue for children) exhibit higher rates of food refusal, and a more limited food repertoire, when compared to typically developing individuals (Bandini et al, 2010).

Examples? Sure.


Across my clients, I regularly see issues with:

Rigidity around meals (where to sit at the table, what plate to eat off, which spoon to use, must have the tablet in order to eat)

Food refusal challenging behavior (throwing plates, flinging cups to the floor, spitting food out, tantrums, pouring liquids out onto the floor)

Highly selective food intake (daily diet consists of less than 10 foods, likes chicken nuggets but only from a specific fast food place, will only take specific liquid from a specific sippy cup or bottle)


To define the term, a picky eater can be described as regularly refusing foods, or consistently only eating the same foods with little to no variation permitted.

Many parents of toddlers deal with a picky eating phase at some point or another, and often the child outgrows it.

So, what is the critical determining factor when it comes to Autism that tips the scale from someone who is just "picky" to a serious health problem/eating disorder and concern? Usually, it is a combination of variables that must be examined and weighed:

How old is the individual? If out of the toddler phase, how frequently is this issue happening (weekly? daily? or only at holiday meals?)

Does food refusal occur with challenging or aggressive behavior?

Is this impacting school/daycare, or the ability to go into community locations?

Will the individual skip several consecutive meals (refuse to eat across more than one day)?

Is this impacting the individual's weight, organs, toileting/digestion, skin, hair, or nutrition? Is your doctor concerned?


The key factor for seeking out intervention for this issue is when the food selectivity is causing harm to the individual. When any specific behavior impacts the health/body of the person exhibiting it, that is clinically referred to as a "self-injurious" behavior. Self-injurious behaviors should not be ignored, and often require intervention and treatment.

So what to do? 

 It may be helpful to reframe the way we view picky eaters. Sometimes families can view this behavior as their child willfully choosing to make meals a dreadful adventure. Choosing to be difficult and fling plates across the room in order to cause chaos. However, challenging behaviors often occur for complex or multifaceted reasons. Some Autistics use the term "sensory eater" and not "picky eater" to describe this issue, and explain it like this:  

"Picky eaters don’t like a variety of foods, much like the sensory eater. However, when picky eaters try new foods, it doesn’t cause a sensory overload....There is a sensitivity to textures, where children can only handle one texture, such as smooth, pureed foods. In this case, they might be able to eat yogurt, however, hand them a bag of chips or a slice of turkey and they immediately begin to gag" (www.researchautism.org).


If a specific food texture, smell, sight, or tactile experience is causing significant distress, if there are tooth or gum issues making eating painful or uncomfortable, if the individual has trouble swallowing, or if unknown allergies are present, making digestion painful or uncomfortable, doesn't it make sense for the individual to refuse a food (or eventually, any food that looks like THAT food) or exhibit excessive selectivity? Now, imagine the individual has no means to communicate how food makes them feel. Doesn't it make sense that they may cry, spit, hit or punch, or fling a plate onto the floor? 


When seeking out Feeding Intervention (which is a clinical specialty), it is important to first obtain medical rule out. This means first speaking with your doctor to discuss the issue, and see if the individual's health has been impacted. The doctor may also be able to make a referral to a qualified specialist.

Not every professional will be trained in feeding interventions, so this isn't as simple as just asking the current therapist to also target feeding. I see families do that a lot, without also asking about the therapist's qualifications to address this issue. 

It probably doesn't need to be said, but feeding challenges can have serious health complications and you don't want to gamble on unproven treatments, untrained professionals, or questionable practices. Not only could they harm your child, they could worsen/ingrain the problem even further.

SLPs, BCBAs, OTs, Healthcare professionals, and Multi-Disciplinary clinics or facilities, can all incorporate feeding intervention into therapy goals. The Children's Healthcare of Atlanta recommends the following step-by-step process for initiating feeding intervention/feeding therapy:

  • Medical Screening
  • Behavioral Evaluation
  • Nutrition Assessment
  • Oral-Motor Skills Assessment


 Remember, before seeking out therapy or treatment talk to your doctor first. Also, any feeding intervention that occurs on-site will need a caregiver training portion where the parents are taught how to implement the procedure at home/in the community.



*Further Reading:

Autism Feeding Issues

Kinnaird, E., Norton, C., Pimblett, C., Stewart, C., & Tchanturia, K. (2019). Eating as an autistic adult: An exploratory qualitative study. 

Bandini LG, Anderson SE, Curtin C, Cermak S, Evans EW, Scampini R, Maslin M, Must A. (2010). Food selectivity in children with autism spectrum disorders and typically developing children. 

Autism & Picky Eating

Problem Eating

Assessment & Treatment of Pediatric Feeding Disorders

Feeding Problems in Children with Autism

Eating Disorders Can be a Sign of NeuroDivergence


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