I already have a post with tips for evaluating the quality of your in-home ABA provider.

But what about those families who want clinic/center (these words are pretty interchangeable, so for this post I will just use "center-based ABA") based services? What questions should families ask during intake? What are some potential red flags? Should parents directly observe sessions or is that too distracting?

Keep reading, and hopefully I can help answer these types of questions.

As ABA therapy services continue to grow and expand (fueled largely by increased funding, which leads directly to increased providers/companies) center based treatment is becoming more prevalent.

When I was first certified as a BCBA, there were less than 5 center options in my local area. Today, I would estimate that number to be over 100. If you are reading this and you live in a fairly urban or metropolitan area, then you likely know of at least a handful of ABA centers in your area.

Parents contact me all the time with so many questions about center based treatment. When it comes to ABA therapy, the experience can be quite different from other therapies. 

Many families have experienced center based treatment via Speech Therapy, Physical Therapy, Counseling or other Mental Health services, or Occupational Therapy. But these are usually 30 to 50 minute appointments that occur once a week. ABA therapy is often highly intensive, and sessions can occur daily. There is also (usually) a focus on setting up a day that resembles a preschool experience, including large group instruction, recess, school readiness instruction, toilet training, lunch/meals eaten as a group, Art or Music, etc. It is a busy, very planned out, full day experience.

Centers differ as far as policy and procedure, so there will be variability from one company to the next regarding how parents are included in the intervention process. There will also be variability related to state laws, funder requirements, or if the center is part of a chain (usually owned by massive private equity firms) or a small center with an owner on-site. So just know that some of the suggestions below may be more or less applicable to your situation.

First, let's answer a few questions-

"Which is best, home or center based ABA?" - There is no concrete answer to this. It depends on your child, their needs, the priority of intervention, etc. Obviously, if peer/social interaction is a priority then center based services have the advantage of peers being on-site. However, many parents have concerns that their children will pick up new challenging or inappropriate behaviors if they spend their whole day with other disabled children. So as you can, there are pros and cons to center -based treatment, just like with home -based treatment.

"Why do we have to agree to block scheduling?" - A block schedule is when the center only offers a few options for scheduling. For example: 'Part time - 8am-12pm, Full time 8am-5pm'. This usually has to do with consistency in scheduling staff, and the major disruptions to other clients that can be caused by changing staff schedules. For the most part, centers do not have the same scheduling flexibility as in-home treatment. If your family needs a more flexible, adaptable schedule that can change from time to time, then you probably would not be a good fit for center based treatment.

"My spouse and I both work full-time and center based is easier because it has the same schedule as day care/preschool" - Yes, many parents prefer center based intervention due to the schedule (child is there all day). However, ABA is not respite. It is important to look beyond the ease of the schedule, and to determine if a center based setting is the best fit for your child and their needs. Also, 2 working parents can make parent involvement very difficult when it comes to center based intervention. Which brings me to the next commonly asked question........

"How does parent training/caregiver support happen at a center if both parents work full-time?" - This can be challenging. Usually, for center based intervention at least one parent will meet with the case BCBA on-site, each month, to go over client progress. If neither parent can do this on-site, this meeting could be held via Telehealth. If that still is not a feasible option, then it is likely center based intervention isn't a good fit. I would suggest home based services that occur in the evening hours or on the weekend, so parents can be actively involved with treatment. 

Now, let's talk about indicators of quality-

High-quality center based ABA providers will look like a high-quality home based provider for the most part. There should be credentialed individuals (e.g. RBT or BCaBA) working directly with your child and overseen by a BCBA, there should be an initial assessment conducted to create an individualized treatment plan, there should be ongoing monitoring of the intervention and data analysis, and there should be clear, transparent billing, supervision, and staff training policy and procedures. 

As a parent, you should know who is working with your child on a weekly basis (this may vary, due to staff vacation, illness, or changes, but you should know when it varies). You should know what goals are being targeted with your child, and how they are being taught (most parents never ask). You should know the Behavior Intervention Plan, or the strategies being used to reduce harmful or inappropriate behaviors. You have the right to watch/view these procedures and be trained on how to implement them at home. The center facility should be clean, appropriately staffed, have both passive and active play areas, have an appropriate person to bathroom ratio, doors and windows should be secured (monitored with alarms, locks, etc.) to keep clients safe, there should be ample toys and materials, etc. Not only should you be able to tour the center as a parent, but you should be able to see where your child receives 1:1 intervention and to examine the therapy space.

And of course, I cannot leave out potential red flags. Occurrence of any of the items below should raise your concerns, and lead to an action step (Speak with the facility Director or Manager, talk to your case BCBA, and if necessary, remove your child from the program)- 

• The absence of any of the criteria described for a high-quality ABA center
• Staff/Director or Manager are consistently angry, upset, or otherwise seem miserable. Do you want to work with people who are miserable every day? Then why would your child want to?
• Poor communication/No communication, specifically when it comes to billing/invoices/charges, clinical supervision, conflict with the staff, or behavioral strategies used
• Your child experiences significant regression after starting services at the center
• Massively high staff turnover. I say "massively high" because ABA as a field is known for high staff turnover. But, if you have been at the center less than 30 days and can't keep track of who is on your child's team---> that is a problem.
• Lack of outdoor space where clients can play and get fresh air (many centers today are located in business/office spaces that lack outdoor play areas)
• Lack of toys, materials, or manipulatives for clients to play and explore
• As a parent, you are pushed to sign on for an amount of treatment hours you are not comfortable with, and do not feel are necessary
• As a parent, you are never allowed on-site. Yes, there is HIPAA, and client confidentiality, and all sorts of reasons why parents may not be able to just walk in any time, without exception. BUT, the center should have figured out a way to remediate this issue. For example, a discreet meeting area or conference room where BCBA or Director meetings occur, a waiting area where parents can request to meet with their child's RBT or team members, or discreet observation windows where parents can view their child during therapy unobtrusively
• As a parent, you are pushed to terminate services with other providers to focus only on ABA. Or, you are pushed to terminate services with other providers and swap them out for services offered at the center
• If you do not know what your child is working on (treatment goals), never received any data, reports, or graphs, or your child is working on things you specifically rejected or said you wanted removed from their treatment plan----> that is a big problem.

*Further Resources:

'Choosing an ABA Provider, Part I' 

'Home based or Center based ABA?'

'A Comparative Look at School & Center based Programs'

'In Home, or Center Based: Which is Better?'

Facebook post about treatment hour recommendations

Read more »

Tameika Meadows, BCBA, Blog Author

 

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/low quality, full of impossible waitlists, or if you have funding challenges, you do have other options available to receive ABA intervention for your child.

*Resources:

BACB Certificant Registry 

Identifying a Quality ABA Provider

Questions to Ask a New Provider

How to Find an ABA Provider

Do I Need a BCBA?

Consultation Services

Read more »

Tameika Meadows, BCBA, Blog Author

Fist things first: WHY is diagnosis important??


If you are seeing red flags or concerning behavior in your child, is it absolutely essential that you pursue a formal evaluation?


...Well, no.


But, the benefits of obtaining a diagnosis of Autism can include access to services/treatment/an IEP, access to specific funding or disability resources or support, possible reduction of parental/familial stress or anxiety about the child's behaviors or differences, and an increased understanding of your child's unique needs and motivations. Basically, the sooner you know what is causing the red flags you are observing, the sooner you can DO something about it.



Many Autistic adults report having gone through life feeling different, odd, or struggling socially, and express wishing they had known much earlier in life that they weren't "wrong", while everyone else was "right". It can be extremely helpful for a person to know how their brain works (and why), so even if as a parent you aren't concerned if your child could be Autistic, your child may want to know one day.




TIPS

· Ask questions about alllllll the things! Make a list before you even arrive, just to make sure you get all your concerns out when you are face to face with the clinician. This is the time to express your concerns and get answers

· Don’t over or under report. What I mean is, describe what typically happens as truthfully as possible. It will be very clear to the clinician if you are glossing over serious concerns, or if you are minimizing strengths

· Make sure your child (and you!) are in a good place for the appointment: fed, rested, calm, etc. While many parents bring along a tablet to keep their child entertained on the way to the appointment, keep in mind that tablet will have to be removed at some point. It may be a good idea to bring a less powerful reinforcer so you don’t push your child into a full tantrum right as the appointment starts

· Avoid jumping in to help/guide your child, or directing your child to attend to the assessor (e.g. “C’mon Ally, push the red car!”). I know, it’s hard to just sit and watch your child perform poorly. But that is exactly what the assessor needs to see. Don’t worry, there will be parts where the assessor needs your input.

· Don’t expect this whole process to be wrapped up in one 2-hour appointment. Proper assessment takes time, you may encounter waiting lists, and most likely there will be more than one office visit required.



WHAT TO EXPECT

Regardless of the diagnostic tool used, there are certain commonalities you can expect. To name a few:

· The “majority example”. If your child exhibits a certain behavior 5% of the time, and a different behavior the other 95% of the time, the assessor will focus on what they do 95% of the time.

· Difficulty leaving/separating from the caregiver, even if that person is in the same room. This is very common, don’t feel embarrassed if your child clings to you and refuses to interact with anyone else.

· “Who is this child?”. By this I mean it is very common for the child to behave differently during assessment than what the parent is used to seeing. If the child babbles at home, they may be silent during the appointment. If the child bites and pinches at home, they may be sweet as pie during the appointment. It is also important to understand that the assessor must make decisions based on what they are seeing. This is why the evaluator will likely have you complete multiple checklists or forms, so they can compare what you typically see against the snapshot of the child they are seeing.

· Super, super short attending to tasks (e.g. child stays seated for .5 seconds). VERY common. Don’t become fearful that the assessment will be ruined, or full of errors, because your child just flits from one task to another or will not participate in any tasks. This is actually part of what the assessor needs to see, and it provides valuable information about functioning.

· Don’t expect to get to the end of the appointment and hear the assessor say “Welp, he’s Autistic”. ALL of the data, scores, and observations must be compiled and analyzed, and this process takes time. While it is very okay to ask the evaluator their initial impressions, please give the evaluator time to properly review all of the data before confirming any diagnosis.



NEXT STEPS

· After the diagnostic appointment, it will likely be a few weeks (or longer) until a follow-up appointment. The follow-up appointment is where the evaluator reviews the results with you and will go in depth to discuss recommendations.

· The formal diagnostic report will be long, detailed, and jargony. Kind of like reading a technical manual upside down. Be prepared to ask questions, and then ask more questions, until you actually understand the clinician’s report.

· If your child is not diagnosed, sometimes this can mean additional diagnostic tools are recommended, the child may currently be on the cusp and another evaluation is recommended for the following year, or there may be other explanations for the red flags besides Autism.

· If your child is diagnosed, this just means that in most cases they now become eligible for a myriad of services. It does NOT mean anyone can predict their future, tell you they will never (fill in the blank), or tell you that (fill in the blank) will always be a struggle.

· Please be prepared for more delays. In a perfect world, families would move seamlessly from diagnosis to treatment. Unfortunately, in our actual world, there are far more people needing services than providers offering services. There may be a wait to access various therapies, get into your school districts Autism program, apply for SSI, etc.




*Recommended Reading: After the Diagnosis

*Here is a parent perspective of the diagnosis appointment

Read more »

Tameika Meadows, BCBA, Blog Author

Suggested Reading:

The "Why" of Selecting Intervention Goals



A large part of the BCBA role is designing treatments/intervention. There are many tools to help facilitate this process, such as caregiver or client interview, administering a full assessment, record review, observation, Functional Analysis, etc. A competent BCBA will collect information from a variety of sources and then compile the information to come up with a plan of action.

In an ideal world, this plan of action would be as comprehensive, detailed, and lengthy, as it needed to be for the individual client to benefit from treatment. But since this is rarely an ideal world, all kinds of issues and constraints can lead to having to prioritize treatment goals. Basically, this means to ask (and answer) the question: "What are the MOST important things to work on?".

While many clients may need some level of support for the rest of their lives, often therapy services have a specific timeframe or clock to work within, as well as limits on how services must be provided (what location, at what intensity, etc.) that are set by the funding source and not by the clinician.

The 1st thing to know before jumping into prioritizing goals, is to throw any pre-formed ideas out the window. I will give some general guidelines below, but even with these guidelines the most important variable to consider when prioritizing ABA treatment goals is the individual receiving treatment. Yes, this is more important than looking at the assessment grid.

The context of the learning environment, individual reinforcement history, the needs and concerns of caregivers, level of family stress, and the functionality of specific skills are all highly important variables that must be weighed carefully against clinician recommendations.
Just because I think an 8 -year- old should know how to independently ride a bike, that doesn't mean bike riding is an important skill for the family. It also doesn't mean that bike riding is functional for the particular client, or even a preferred interest. So it would be foolish to attempt to prioritize treatment goals without looking through the lens of the individual receiving services.

Once a thorough assessment of client needs and strengths has been conducted, then the guidelines below should be helpful for deciding what needs to be targeted, and in what order of priority:

1. Developmental Functioning - For the clients chronological age, what should they be able to do? Particularly with very young clients (under 5) I recommend having a solid knowledge of developmental norms to be able to help the client contact success across settings. Being able to sit and attend in a group for 10 minutes may not be a big goal for the parents, but you can bet it's a big goal at school. ASD impacts developmental functioning, so it's important to prioritize intervention goals that will help the client access age-appropriate settings, activities, and social experiences.
2. Current Problem Behaviors/Barriers to Improvement - This is likely the #1 reason why consumers reach out to ABA professionals for help, so it's usually no mystery which challenging behaviors are causing the most stress to the household. Tantrums, spitting, elopement, biting, no play skills, etc., all put a strain on the entire family. However, it will be very important to prioritize where to begin with behavioral intervention as to avoid overwhelming either the client or the household with an 88- page behavior plan. Start small, but with high impact.
3. Functional Skills/Daily Living Skills - This is my 2nd favorite area to target for intervention, because most consumers who initiate ABA therapy services due so because daily life is hard. In order to make daily life less hard, it's critical to focus on practical, self-help skills. For example: requesting, making choices, toileting, dressing, tooth-brushing, establishing a bedtime routine, independent eating, etc. When daily living skills improve, it lessens the weight and stress placed on other members living in the household. Improving daily living skills also helps to increase the independence of the client, for years to come. 
4. Parent & Caregiver Training- My favorite area to target for intervention! If the client has low treatment hours, minimal availability for therapy, minimal access to other services or treatment, less than ideal educational placement, etc., then really the #1 goal of treatment should always be parent training. When parents or caregivers are trained in behavior analytic methodology, they are empowered to help their child themselves. This is the equivalent of handing someone a fish, vs. teaching someone HOW to fish. When you teach parents how to fish, you give them the ability to teach their child for years to come, to advocate for their child's needs, and to recognize low-quality therapies and clinicians before precious time, energy, and money can be wasted.

*Further Resources:

How to Prioritize ABA Therapy Goals

3 Important Things to Consider When Starting Intervention

10 Essential Life Skills for Students with Autism

Read more »

Tameika Meadows, BCBA, Blog Author

Inevitably (sorry, but it is somewhat inevitable), somewhere on your Autism treatment/therapy journey you will suddenly and unpleasantly find yourself wait listed.

A company or provider may explain that while they may accept your insurance, accept clients the age of your child, and serve the area you are located in, at the moment they are going to have to wait list you.

So why does waitlisting happen? And how should a parent/caregiver respond?

First, let's look at some reasons for being placed on the dreaded wait list:

• If a provider is in the process of credentialing (securing relationships with funding sources), they may have to temporarily wait list clients until the set up process for billing is completed
• If the provider/company is brand new, then there could be renovations to the physical location, staffing needs, or legal red tape on the part of the company that is causing a wait list
• If a provider is expanding into serving new areas, there can often be a wait list for services because they would need a certain amount of clients in the new area to be able to hire staff
• If a provider is going through significant unforeseen changes (e.g. a critical member of management abruptly quits), this will absolutely cause a temporary wait list situation for all new clients
• If a provider is new to your particular funding source (i.e. a grant or waiver for therapy), you could be temporarily wait listed while they go through the process of securing funding, and completing any documentation the funding source may require

As you can see from the list, there are varied, and very understandable reasons why a provider may say, "We can help you, but just not right now". If a company does not have enough staff to cover your case, or is in the process of properly training or onboarding a new hire, then there will be a delay before you can access services. Being placed on a wait list is not always a bad thing, although it may feel like it is.

What many, many parents want to know is what they are supposed to be doing while on that wait list. For that and other common parent questions, please see below.

- "Is there anything I can do to prevent being wait listed?" - To a degree, yes. Keep in mind that the service you are trying to access is probably in very high demand, with a a limited supply of clinicians/professionals. This is true for ABA therapy, Speech therapy, Occupational therapy, etc. Across the board, we need more qualified professionals serving Autistic populations. But, as a parent you can request parent/family training by a BCBA (this doesn't require RBT level staff), just to complete the Initial or Functional Behavioral Assessment, or ask if you can start as private pay to speed up the process. Depending on the reason for the wait list, any of these options may get things moving more quickly.

- "How long will I be wait listed?" - This is the absolute wrong question to ask. I don't say that because there is something wrong with you asking. I say that because the reality is the answer will be a guess. The problem is, people drop off and get added to the wait list constantly. Add to that unforeseen challenges or road blocks, and that "2 month wait" someone promised you could easily stretch to several months long. Also asking "Well how many people are on the wait list?", is typically a question providers won't answer.

- "Okay...then what should I ask instead?" - Instead of asking, try telling. Decide how long you will give this provider/company to be available to you, and inform them of your decision. For example, "Yes, please add us to the wait list but after 6 weeks we will be reaching out to other providers". This way you already have a plan B ready to go, but just in case a spot becomes available you still have plan A.

- "What should I be doing with my child while we are stuck on this wait list?" - Something. Yes, that's intentionally vague. I couldn't possibly know what your child needs to do while you sit on a wait list, but I do know the absolute last thing they need to do: NOTHING. The worst mistake you can make is to be placed on a wait list, and then just go back to life as normal. Obviously, you are requesting therapy services because you need help. So still pursue ways to get help, while you are waiting for the professionals to step in. Especially with the technology options today, you could consult remotely with a BCBA, take online courses in ABA or behavior change, attend conferences to learn, join an Autism support group, etc. What you will be able to do while you are on the wait list is going to vary depending on your local area, and the resources available to you.

- "How long should we remain on a wait list for treatment?" - And this is the #1 question I hear from parents/families. I don't have a specific answer for you, but instead I would emphasize the importance of treatment. Think of this way: If you arrived at a restaurant and were told there wouldn't be any tables available for 3 months, would you just sit in the waiting area and not eat for 3 months? No, right? Well, the treatment you are trying to access for your child is as critical as food and water. You do not have time to waste. If you have been idly sitting on a waiting list, not hearing from the provider, and not receiving any updates, it may be time to move on.

* Further Reading:

After the Autism Diagnosis

Adventures in Early Intervention

Read more »

Tameika Meadows, BCBA, Blog Author

This post will focus on making sure your child is therapy ready before an ABA session, and what exactly that means.


When the ABA professional asks you to please have your child "therapy ready" when therapy sessions start, what do they mean?

• If the child is ill or experiencing unusual circumstances (e.g. child slept only 2 hours the night before) the therapist should be notified before arriving to the home
• The child has been fed, or offered food recently
• The child's diaper is dry, or they've been taken to the bathroom recently
• The child is awake (therapist should not have to wake a sleeping child)
• Preferably, the child is not engaged with their most preferred items or toys

The point of these guidelines is to make sure the therapist does not arrive to the home to work with a child who is hungry, crying, wet/soiled, tired, or fixated on a specific toy or item. Any of these scenarios is likely to start off the session on a bad note.

For the therapy sessions to be most beneficial, the child should be in an attentive learning state, calm, and ready to contact reinforcement (if they are already contacting valuable reinforcement, they may be less motivated to work with the therapist). 

Throughout the session the therapist will present multiple demands and lead the child through frequent transitions, often at a quick pace. Many parents want to know what to expect of a therapy session, especially if they are new to ABA. I could walk into 1,000 homes and see ABA sessions happen in 1,000 ways. So a very general example of how a therapy session could look is detailed below:

Therapist arrival: Greet client and family, take time to set up for session

Transition: Therapist transitions client to work area, takes time to build rapport and engage with established reinforcers

Transition: Reinforcers are put away, and demands are presented/specific goals are targeted. Contingent upon performance and correct responding, breaks or reinforcement are intermittently delivered

Transition: Outside play time, or more adaptive teaching opportunities are embedded into the session such as a snack, playing basketball outside, sibling interaction/family games, or going for a short walk

Therapist departure: Therapist informs the client and family the session is complete, takes time to clean up work area, collect data, and record session note

It is easy to see from this brief session outline that if the child is sick, tired, hungry, etc., the session could quickly grind to a halt and dissolve into extended problem behavior. Most of the time (not always, but very frequently) if my staff contacts me to after a session to discuss how horrible the session went, after some digging I find out that the session started on a very bad note....and probably should have been rescheduled.

If sessions are consistently starting off on a bad note, that means goals are consistently not being targeted intensively, which means data scores are consistently dipping or decreasing, which means ultimately = the child will not progress as they should. So this issue of "therapy ready" is actually quite serious.

It's important to plan to set your child up for success before therapy sessions, so that in the long term they are regularly contacting success during sessions and progressing through treatment plan goals. I usually give my clients several tips to help them set their child up for success, I will include a few below:

• Using language or a visual, inform the child that it is almost time for a therapy session. It may be helpful to show them a picture of which therapist is coming (e.g. "Look, Ms. Nicole will be here soon"). It should not be a shock to your child when the front door opens and the therapist is standing there.
• Set aside the most valuable reinforcement (and let your child see you do this) and explain that they can have it when the therapist arrives. As a BCBA, I do this all the time during supervision sessions by arriving with valuable reinforcers, and then telling the child "I'm going to give this to Ms. Nicole", to increase motivation to work with the therapist.
• Have your child engage with a neutral activity shortly before therapy starts (example: coloring, Play Dough, etc.). The activity should not be overly stimulating or too reinforcing, but should help the child get into a calm, on task, and alert state before therapy begins. It may be helpful to have them engage in this activity in the same area the therapist will work with them. Often, therapists arrive for a session and the child is having free play, or unstructured time spent running, jumping, climbing things, etc. In a situation like that, the child is very unlikely to be motivated to come over to the therapist and sit and work. 
• If problem behavior begins to happen right before the therapist arrives, this can be an amazing opportunity for learning. Don't feel the need to quickly calm or soothe your child, but instead use the therapist's arrival as an opportunity to ask for help. Example: "He fell out on the floor right as you were pulling up, now in this situation what should I do??"

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Tameika Meadows, BCBA, Blog Author

*Recommended Reading on Parental Involvement:

The Role of Caregiver Involvement in ABA Therapy
Parents: We Need You


I get asked lots and lots of questions by parents when we begin the therapeutic relationship, but if I sorted all those questions into 2 main categories they would be:
"How do I teach my child" and "How do I reduce behaviors".

That's it.

 All of the questions I get can be boiled down to 2 essential questions, that pretty much every parent raising a child with special needs (or any child, really) wants to know.
I can boil it down even more than that. These 2 questions are really getting at: "While you guys are working with my child and implementing this fancy treatment/therapy, what am I supposed to be doing?".

THAT is the million dollar question.
To that question I say: You are supposed to be learning.

The typical parent I work with is not an educator, child expert, or a Behavior Analyst. Behavior change is not common knowledge, unfortunately. Much of what I teach parents initially seems counter-intuitive, illogical, or just downright odd.
 For children without any diagnosis or disability, parenting is hard enough. I can't imagine how much harder this process must be when your child learns/develops in unexpected ways, you need a team of professionals to help your child, and that team of professionals knows a LOT of information that you do not know.


So what's a parent to do? Well here is what NOT to do: open the door to let the therapy team in the house, disappear for the duration of the session, and then open the door to let the therapy team out of the house.
Or: drive your child to the treatment clinic, go about your day, pick your child up from the treatment clinic.

Neither of those scenarios will help you learn anything about your child's progress in treatment or therapy. But for a long time in this field, these scenarios describe what I saw. I saw parents briefly when I entered or left their home. I saw parents briefly at the start of the day at the clinic, or at the end of the day at the clinic. Quite non-surprisingly, these parents always reported a slew of challenges and issues outside of therapy sessions that the therapy team just didn't see. Yeah....that isn't surprising.


I am huge on parent involvement and parent coaching, I strongly believe that if the people who hired me do not do the heavy lifting alongside me, then there's no point in me being there.

To the parent or caregiver reading this: Now that you know what you are supposed to be doing while your child is receiving treatment (Learn), you may be wondering how exactly to do that? Glad you asked.

1. Ask questions - Parents don't ask me nearly enough questions, and I remind them of this all the time. The team of professionals you are working with have spent a long time accumulating knowledge, as well as applying it to a variety of individuals. In other words, they may know a thing or three. It is in your best interest to ask questions about anything that concerns or worries you. Let me clarify that just a bit, I don't mean questions like "What will he be like at 22" or "Will she ever get married or go to college". The ABA team are not fortune tellers. I mean questions about treatment, goals, behaviors, etc.
2. Do your research - I know, data and journal articles are not fun to everyone. By research, I don't mean you need to complete a dissertation on Behavior Analysis. What I mean is, do you actually understand the treatment your child is participating in? Do you know what ABA is, and what it is not? If your child has an IEP, are you familiar with IDEA? If your child receives speech therapy, how much do you know about ASHA? If you are signing your child up for therapies you barely understand, then how will you determine if the therapies are being implemented correctly?
3. Read the documentation....All the documentation. Yes, I'm serious. - We can tell when you do not read our documents, whether its the report, the behavior plan, the programs, the handouts, etc. The questions you ask or the strategies you implement make that quite obvious. If you have not read the behavior plan then how can you possibly implement it? You can't. Which will lead to problem behaviors not improving. If what the professionals are giving you to read looks like hieroglyphics, then you can absolutely ask them to translate that stuff into simple words! Or better yet, schedule a meeting to go over the documentation together.
4. W-A-T-C-H - I usually start easing the families I work with into participation by having them just join the therapy sessions, to silently watch. This accomplishes multiple things at once: the parent gets to see the quality level of the staff, the child gets used to mom/dad being in the room but not rescuing them, and the parent gets to see how we teach skills. Observing the therapy sessions or treatment is an invaluable tool that will yield out so much important information.  If you do 1 thing this week to participate more in your child's therapies, please sit and watch the therapists work with your child. It's the best way to learn.
5. Talk to the treatment team as if they work for you, because they do - The treatment team is there to help your child, and to a greater extent, to help your family. That means they are accountable to you. Do you feel like they are doing their job? Are they meeting your expectations? Is your child improving? Can you say that your household is benefiting from the intervention, not just your child? If not, its time to have a conversation with the treatment team.
6. Expect, no--->require professionalism and respectful communication - You have a right to ethical treatment from qualified professionals. Read this post if you need more clarity on that. This one is important: unethical, unqualified, non-professionals are not likely to implement intervention in a way that will actually help your child. I just don't see that ever unfold that way.
7. Tell us when you don't think treatment is working - If you don't think the behavior plan has changed anything, tell that to the BCBA. It's important for us to know when you do not see the benefit of treatment (we call this social validity). As the person who requested our services, you should be the main supporter of our services. So if, for any reason, you have a problem with the way treatment is being implemented then we need to know that. Parent raised issues help professionals discover problems, become aware of blind spots, or shift our perspective.

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Tameika Meadows, BCBA, Blog Author

Photo source: www.pinterest.com

There are many reasons why I stop working with clients: sometimes they move, they lose access to funding, they improve to the degree they no longer need for my services, or for personal reasons the family needs to take a break from treatment.

 Then there is another category of why people quit therapy, it's like that dark, wooded area in the back of the park that no one likes to talk about.

Sometimes clients halt treatment because they started ABA services expecting Happiness, and instead all they got was Therapy.

Maybe you are a parent who tried ABA therapy for your child, but to your surprise, the child cried a lot. Or their behaviors grew worse. Or tantrums got worse. You probably thought to yourself, "Hey! What's going on here? This is not what I signed up for". Actually, it is.

Now's a good time for a disclaimer:

"Therapy" is a treatment intended to help alleviate symptoms of, or to relieve the more debilitating impact of, a particular issue, challenge, disorder, or disease. Therapy is not synonymous with being treated poorly, being treated unethically, or being convinced you need something that you really don't need. If you had bad, poor, or horrific experiences with therapy, it's likely that was not actually therapy, rather it was some unethical and harmful service being sold to you as a therapy. 

End disclaimer.

Now that we have a solid definition of therapy, what should parents realistically expect when initiating ANY new therapy (Occupational therapy, Speech therapy, ABA therapy, Mental health counseling, etc.)?

*Difficulty - Therapy is difficult because areas of deficit are being targeted. The very things selected to work on are things the client either cannot do, or cannot do well. This means therapy will push us outside of our comfort zone, and be uncomfortable or hard at times.

*New challenges - By its very nature, therapy must challenge the client. If therapy does not push/challenge the client, then that is not real therapy.

*Resistance - All the science geeks: you know that every action has an equal and opposite reaction, right? Okay, so what happens when a therapist challenges the client in an area that is already weak? It's called resistance. 

*Commitment Requirement - ABA therapy is not a free sample at the grocery store, or a trial sized bottle of shampoo. You get out what you put in, and commitment is required for progress to stick around. Canceling sessions, starting sessions late, continuing to reinforce problem behavior, or applying different strategies than what the ABA team is doing, will all have an impact on the overall effectiveness of treatment.

Do you see happy in that list? No. 

Does that mean I'm saying therapy is all bad, all the time, and you should expect your child will hate it? Of course not.

But what I am being very intentional in saying is that the GOAL of therapy is not "happy". The therapy team will develop many treatment goals designed to improve quality of life, and quality therapists do strive to be fun, engaging, exciting,  and playful. What we do not strive to do, is keep your child happy all the time. There will be sessions with tears, or tantrums, or anger. This does not shock us as treatment professionals, nor should it shock you as the parent. I have clients who get angry at me because I don't just sit back and allow them to do dangerous things, like jump off kitchen counters. So be angry with me, I'm fine with that.

Treatment is hard. Treatment will take you out of your comfort zone. Treatment will push your boundaries. Treatment will impact the whole household, not just the child receiving therapy. Significant gains must be accomplished through significant amounts of work. The therapist will work hard, you the parent will work hard, and your child will work hard. If this is sounding unreasonable to you, or unacceptable, then it's likely therapy is not a good choice..... And that is okay. 

What's most important is knowing the reality of therapy, what it is and is not, before you jump into it.

Photo source: www.tombruetttherapy.com

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Tameika Meadows, BCBA, Blog Author

Photo source: http://cogop.org, http://www.babasouk.ca

So excited to introduce a new resource, this one is targeted specifically to parents pursuing ABA therapy for their child.

I regularly talk with people who are seeking ABA therapists, have questions about what ABA therapy entails, or have been waiting and waiting for therapy services to begin and are curious if they should be doing something while waiting (the answer to that is always yes).

Since I am so incredibly brilliant, it only took a few hundred times of this happening before it occurred to me that perhaps creating a parent resource aimed at answering the most common questions would be helpful? Yes. I think it will be quite helpful.

If you are a parent currently in some stage of pursuing ABA therapy, this resource will help you:

• Finally get a straight and simple answer about what ABA therapy is
• Learn what to do about problem behavior, right now
• Learn how to help your child catch up developmentally, right now
• Identify (and avoid) the low quality or unethical therapy providers out there
• Increase your understanding of ABA & "ABA speak", in preparation for working with a team of ABA professionals

However, this resource won't just help parents. For my fellow ABA professionals, this resource can help you:

• Design/implement a parent training or parent resource to give to families currently on your waiting list
• Identify the top questions or concerns most parents have when initiating ABA therapy
• Clearly and plainly teach parents about Behavior Management, and Skill Acquisition

Click here to find this new resource on www.Amazon.com!

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Tameika Meadows, BCBA, Blog Author

 

Photo source: www.wikipedia.org, www. http://grade5eisnor.weebly.com

If there was one blanket statement I could say to any family starting ABA therapy services that would sum up in a nutshell what to expect moving forward it would be: Input Equals Output. Or, put simply “You get out what you put in”.

Two examples that illustrate this concept nicely are crash/fad diets, and cramming.

Fad diets are usually cheap, promise quick results, and have very simple instructions like “Eat 2 apples every day at noon for 3 weeks and drink 3 glasses of water”. Once you follow the easy directions for a short period of time, BAM, you are supposed to drop some serious weight.

Cramming can take many different forms, but usually is a fast and last minute way to prepare for a test or exam. Late as in, quickly reading over your notecards as the exam is being handed out. Funny thing about cramming though, while you may be able to hold on to the content long enough to take the exam, a few days or weeks later that information is gone.

In various ways over the years, I have seen families approach ABA therapy like it’s a fad diet, or like they are cramming for a final. Quite predictably, the results have been disastrous.

ABA therapy is an individualized and high effort intervention methodology that requires highly trained individuals to oversee and/or implement in order for it to be effective and long lasting. So re-reading that sentence, if you approach ABA therapy with a fad diet mentality is it likely to be effective? No. How about long lasting? No.  This could look like: lack of progress, initial progress and then progress stalls out, slow or minimal progress, or variable progress/inconsistent gains. I was talking with a parent recently who told me her son had been receiving ABA therapy for months with no gains/changes. That struck me as extremely odd, but also very illogical. Would you stick with a diet plan for several months if you hadn’t lost a single pound? No, right? Then why would you continue with a therapeutic intervention that had no observable benefits?

If you are a parent who has been on the ABA train for a while now, you can probably look back at when things started and be amazed at how little you really knew about ABA therapy. The crazy thing about this intervention is you CAN see or bring about amazing progress while simultaneously understanding little about the process. Entry level direct staff can be taught to implement very sophisticated programs and behavior plans that they may not understand very well. So to a point, of course I don’t expect families to be ABA experts as soon as I meet them.

…BUT 

Sooner rather than later, as the parent you do need to increase your knowledge base of the therapeutic program you are now participating in. See how I did not say “your child is participating in”? Unless you are new around here (which if you are, Hi) then by now you should know that ABA therapy is not a spectator sport. It’s not watching your child disappear behind a door with a bubbly therapist for 2 hours, and then walking the therapist to the door and going on with the rest of your day. It’s not having a vague idea of what your child is working on, or glancing at the behavior plan once or twice.

If your child is receiving ABA treatment, regardless of the setting (classroom, in home, clinic based) then what you have done is volunteered for a training program. I bet you didn’t even know that! Yes, it’s quite true. You have volunteered to participate in a rigorous and comprehensive training program where both you and your child will learn new skills, learn new ways to understand behavior, and learn new ways to interact with each other. Think of the ABA professionals as your coaches, and you and your child are teammates in this training program.

So as a brand new volunteer participant (your uniform is in the mail) in this rigorous training program, what can you expect moving forward? Super glad you asked:

• It won’t be easy- Hey, nothing worth having is easy right? Just remind yourself of that when it gets rough. Throw “easy” out the window, and embrace “challenging”. ABA therapy does not have to be hard, but it will likely be very challenging. More for you than for me. Why? Well, I don’t have the same emotional attachment to your child as you do. I also don’t have the same learning history with your child as you do. This means your child will give me less pushback, and it also means I am less bothered by their crying or tantrums. I know that on the other side of those problem behaviors are opportunities to learn to communicate, to learn to self-manage, and to exceed expectations. So I can push through initial difficulty in order to have future success. Can you?
• No shortcuts- Think about those 2 examples again, of fad diets and cramming. Did you keep the weight off from that fad diet you tried? What about the cramming, can you still name all the US state capitals? No? Yeah, unfortunately shortcuts don’t tend to offer much longevity. I have yet to meet a family who says to me “Tameika, I want my child to learn to communicate, have less tantrums, and use the toilet…….for 6 months”.  The techniques and strategies the ABA team tells you to implement were selected because they are effective. Not necessarily because they are fast.
• Expect your questions to generate more questions- If I may speak for all the BCBA's out there for a moment, we really are not trying to be difficult when we respond to your question with more questions. It’s just that we need a TON of information about the behavior in order to give you an action plan. For any given behavior, there could be 500 variables maintaining it, especially if it’s a behavior I have not actually seen the child exhibit. So its very typical that a parent will ask what seems like a very simple question, such as “How do I get him to stop (insert behavior here)”. It’s also very typical that the BCBA will respond with something like “Well what does he usually do before that? What about after? What time of day does this usually happen? How do you respond? Uh huh, and then what does he do?”, etc.
• Expect your questions to generate more work – I know, now it IS starting to sound like we are just intentionally being difficult. Let me explain: when you approach the ABA team and ask for help/ask for their advice, what you are actually asking is “Coach, please show me how I can fix this problem”. Any question I get from a client is likely to lead to a new skill acquisition program, additional parent training, or a revision to the current behavior plan. The theme here is that I cannot just answer your question, I have to show you how to improve the situation.

**Recommend Reading-

Now that you know how much work therapy is, need to know how long that work is required? See How Much Therapy?

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Tameika Meadows, BCBA, Blog Author

Photo Source: www.toysrus.com, www.terapeak.com

 

...“Get some flashcards”

Most everyone involved with an ABA program has heard that sentence from someone, at some point, while starting up services. While the goals for treatment will vary, the intensity of treatment will vary, and the duration of treatment will definitely vary, its common that the materials needed for ABA therapy are pretty similar from one client to the next.

Here’s the problem with that though: how much information did you receive about how to select therapy materials? Not how to organize them or what materials to use, but how to tell the difference between appropriate stimuli and inappropriate stimuli. What I often see is this is an area that gets skipped over or quickly mentioned, and many therapists are using inappropriate materials to teach skills….and then wondering why the child is making no progress. Or as I refer to it, the child has a data sheet full of eggs (that’s a score of “0”).

Yes, accurate and precise teaching is important. Quality clinical supervision and oversight is important. Evidence based methodology is important. I am not minimizing any of these treatment components, I am just shining a light on an area I often see lacking: the selection of appropriate therapy stimuli.

Hopefully this will help you make some changes in how you teach, and improve the materials you use regularly. I suspect that if you take the time to review the materials you are using you may find large room for improvement…. which will only benefit your clients.

And look, I even made you a lovely table 

STIMULI/MATERIAL	AVOID THIS	CHOOSE THIS
Flashcards/Pictures	Overly distracting (too colorful, oversized, tiny, busy background, etc.) Use PEC images or purchased cards only Word + image flashcards (unless you are intentionally targeting this) Present stimuli in the same array across trials/Always put the correct response in the same spot Glance at or hover your hand over the correct response	Cards should be simple and only contain what you are teaching (if teaching the client to tact “apple”, the card should not be an apple tree, a basket full of apples, or a photo of Mickey Mouse holding an apple) Generalization is key: use multiple examples Making your own materials is always helpful to be able to use real-life examples (if teaching “bed”, the photo is of the client’s actual bed) Avoid inadvertent prompting! Laminate everything (rough sessions happen)
3D Toys/Manipulatives	Not fully controllable /too distracting (example: if using a toy bus to teach the tact “bus”, you pick a bus that sings songs, has multiple buttons that make the bus talk, etc.) Select manipulatives that are too fun to touch or feel Using known reinforcers to teach skills (unless you are intentionally targeting this) Present stimuli in the same array across trials/Always put the correct response in the same spot Glance at or hover your hand over the correct response	Pick objects that YOU can control during teaching/that are minimally distracting Avoid objects that blink, vibrate, buzz, are scented, etc. Be aware that using 3D items found in the home can pair that object to demand situations Generalization is key: use multiple examples Avoid inadvertent prompting! Maintain control of your materials (client cannot pause mid-trial to play with the materials)
Reinforcers	Look around and grab whatever is near you to reinforce appropriate responding Each session bring out the same tired item/toy that the client worked for once, and assume they will always want to earn that Silently hand the client a reinforcer and ignore them as they interact with it (silently collect your data)	Conduct frequent Reinforcer Preference Assessments Pair novel reinforcers with known reinforcers to gradually expand what the client finds reinforcing Avoid satiation on a reinforcer (switch ‘em up!) Always pair tangible reinforcement with social praise, so praise can be shaped into a reinforcer on its own Pair yourself with reinforcement breaks by talking to the client, giving tickles, or joining their play
Magical-Mary-Poppins-Good-Time-Happiness Bag	Show up to sessions empty handed Expect the parents/family to provide a wide array of materials and reinforcers Assume the client wants to work to earn things that are always at their house	Put together your own therapist “goodie bag” and bring it to sessions Include a mix of reinforcers, sensory items/toys, and other fun things (crayons, glitter glue, etc.) Be aware that some families/households don’t have toys, don’t own an iPad, etc. Understand that you now control access to things the client can only earn when you are present Regularly change the content of your goodie bag

*Source: (this is an amazing article)

Grow L, LeBlanc L. Teaching receptive language skills:Recommendations for instructors. Behavior Analysis in Practice. 2013; 6:56–75

 

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Tameika Meadows, BCBA, Blog Author