When Therapy is Too Short & Not so Sweet

*Recommended Reading: Therapy Intensity/How Much Therapy

Behavior analytic research as well as best practices for ABA treatment recommend robust/intensive treatment for the most significant results. Typically, "focused" treatment would require at least 15 hours a week of therapy, while more "comprehensive" treatment would require at least double that. 

There are many reasons why therapy hours could be low. Maybe the funding source only approved half of the service authorization (e.g. BCBA asked for 30 hours per week, the insurance company approved 12). Or sometimes the family isn't available for therapy very often, or the child has multiple other therapies and a full day at school.

Regardless of the reason, if treatment hours will be low does that mean its pointless to pursue ABA therapy at all?

No. It does not.

BUT, it does mean that the goals selected for treatment and the modality of treatment need to be super, super realistic and practical.

It's hard to know in advance how long it will take a client to progress through goals, or to reach mastery with a specific skill, but for the most part complex or multifaceted goals are going to take lots of repetition and time. So during intake, when I meet a family and they are discussing goals like toileting, language acquisition, severe problem behaviors, school refusal, etc., I explain very clearly that these goals will need a more comprehensive approach. ABA therapy every Tuesday for 2 hours, is not going to make much of a dent when it comes to comprehensive goals.
However, if the family is requesting help with more focused goals such as shoe tying, eating with utensils, or following instructions, then such comprehensive treatment may not be necessary.

So to parents: If your child has been receiving ABA services for some time with minimal progress, the problem could be that treatment is not intensive enough (doesn't occur at a high enough frequency).

Beyond keeping treatment goals highly realistic/practical, if a client receives minimal therapy hours I also recommend the following:

1. Intensive parent training: If the ABA professional is only going to see the client once a week, what is the best use of that time? Working directly with the child, or the parent? If the professional works with the parent, then outside of session time (and when services end) the parent is now equipped to teach their child, handle challenging behavior, and modify the home environment to help the child be successful. To me, it just makes the most sense to teach the parent as much as you can during the time you have together so they can keep the demand on when you leave.

2. Self-management/Coping skills: If appropriate for the client, teaching using more self-management strategies and less of an instructor-led format is very beneficial when therapy hours are low. I am a huge fan of implementing activity schedules/checklists/task analyses with clients, and showing them that they control their own reinforcement (not me). As long as they are doing what authority figures need them to, they will always be able to access what they want. Also, if behavioral issues are occurring and there is inadequate time for implementation of a comprehensive behavior plan then teaching replacement behaviors, or coping strategies, could be very helpful for the client. For example, when the client escalates and gets upset instead of the adults present reacting to that, the client can be taught how to independently de-escalate. 

3. Self-help/Adaptive functioning: Think of adaptive goals as those daily living skills that are non-optional. You either do them, or someone has to assist you/do them for you. Examples: getting dressed, feeding, toileting, cleaning up after yourself, etc. I have *sadly* had some clients with therapy hours far-r-r below what they actually needed. In situations like that, at a bare minimum I need to know from the family what day- to- day issues are causing the MOST difficulty in the household. Then we start to tackle those, being sure to take small bites of the problem rather than try to squeeze multiple goals into a 1 hour therapy session. For example, if the client fights the morning routine everyday before school and it's causing them to regularly be late to school, that is an awesome place to start. Just helping the parents tackle that one problem with clear strategies, visuals, and support, will make a huge impact in the day- to- day stress levels for the household. 

With low therapy hours, the focus should zoom in and get very practical and answer the question, "What can we do today, to make a difference in this family's life".

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