WHAT TO CONSIDER WHEN
LOOKING FOR A QUALIFIED
LOOKING FOR A QUALIFIED
Collaboratively Written by:
Dr. Cathy Pratt, BCBA-D: Indiana Resource Center for Autism
Dr. Susan Wilczynski, BCBA-D: Ball State University
Kim Dodson and Michele Trivedi: The Arc of Indiana
Dana Renay: Autism Society of Indiana
Dr. Angela Tomlin: Riley Child Development Center
Like many approaches to serving individuals with an Autism Spectrum Disorder (ASD), Applied Behavior Analysis (ABA) is an approach that focuses on helping people develop skills that are very difficult for them. ABA does this by looking at factors in a person’s world that undermine their success, and then carefully changing those factors to teach different and more appropriate ways of responding. There is a lot of research that shows ABA works - not just for people with ASD or with disabilities, but with all children, adolescents and adults. In truth, while the goals may be different, ABA can be effective with any of us at any age.
Parents realizing the importance of early intervention and the research behind ABA, often have questions about choosing specific ABA programs and providers. As the demand has grown, so too has the number of options available. ABA providers and centers are multiplying across the state. In some areas of Indiana, the options are fewer or harder to access. In areas that offer a lot of options, parents often have a difficult time choosing the right center/provider for their child and family. Because these centers/providers use somewhat different approaches and interact with families in different ways, it is hard to know how to most effectively use their services.
This article is not intended as a critique or endorsement of any individual provider. Instead, our hope is to provide some thoughts and criteria to guide your decision-making when choosing a provider to meet your child’s and family’s needs. Like you, we realize that each child is different. What works for one child may not work for yours. Our hope is that these guidelines will help you think through some issues that may be important as you explore options for your child and family. This guide will focus on the following issues:
Understanding What ABA Is (and What It Is Not)
Investigating Providers or Centers
UNDERSTANDING WHAT ABA IS (AND WHAT IT IS NOT)
People use the acronym ABA in many ways so it is sometimes confusing to know exactly what someone means when they say ‘ABA.’ If you are confused about this, you are not alone!
• An ABA work group was convened in Indiana to address statewide ABA issues. This group agreed upon the following definition: ABA is a field of study that is dedicated to improving the human condition by making changes in environmental conditions that are supported by data and which result in socially meaningful improvements.
• For more clarification on ABA, visit the website for the Behavior Analyst Certification Board (BACB) at www.bacb.com. The BACB’s definition is: “… professionals in applied behavior analysis engage in the specific and comprehensive use of principles of learning, including operant and respondent conditioning, in order to address behavioral needs of widely varying individuals in diverse settings. Examples of these applications include: building the skills and achievements of children in school settings; enhancing the development, abilities, and choices of children and adults with different kinds of disabilities; and augmenting the performance and satisfaction of employees in organizations and businesses.” In other words, ABA can be used with any person and can be delivered in any setting (e.g., schools, homes, and clinics).
• Realize that there is both good and bad information on the web. As with all websites, we recommend that you critically and objectively review the information provided on various websites. Information supplied by organizations/individuals providing ABA services should be viewed. At the same time, read information from non-providers to obtain a balanced perspective. Remember that those providing ABA services may want to help your child, but they are also trying to “recruit” your business.
• ABA is not simply 40 hours a week of one-on-one instruction sitting at a table. When most think about ABA, they are thinking about a 20-40 hour per week intensive treatment/therapy program or early intensive behavioral intervention. ABA as a therapeutic approach can be more focused on specific skills and can be conducted across shorter periods of time as well across the person’s lifetime (e.g., a teenager who needs to be desensitized to going to the dentist). The level and intensity of programming should be driven by the child’s needs.
• ABA is not only discrete trial teaching. Instead, ABA includes a range of strategies including reinforcement, shaping, chaining, and many others.
• ABA is not something that happens in only one type of setting, but can happen in any setting, including home, school, or clinic. The goals and curriculum used in these settings may differ. In a clinic setting, the focus is on treatment and treating the neurological condition of ASD. In an educational setting, the focus is on teaching and achieving educational goals aligned with state curriculum standards.
• ABA is not a single or one size fits all program. Remember that a one size program fits one child. Instead, ABA is individualized and comprehensive to address teaching all skills that are important for everyday life.
Investigating Providers or Centers
When investigating providers or centers, we strongly encourage you to see if they have a Board Certified Behavior Analyst on staff. If the provider or center serves a lot of clients, they should have more than one BCBA on staff. ABA as a treatment approach cannot be done properly if you have one Board Certified Behavior Analyst who is responsible for making sure a lot of people are getting appropriate care. Some centers will also have Board Certified Assistant Behavior Analyst’s (BCaBA) on staff. These are bachelor degree level professionals who have received some training, but who cannot supervise programs without frequent oversight from a BCBA. While a variety of factors impact caseload size, BACB Guidelines note that oversight of 6-12 clients is the average, with a higher range possible based on circumstances (see page 31 of http://www.bacb.com/Downloadfiles/ABA_Guidelines_for_ASD.pdf).
You can check the website at http://www.bacb.com/index.php?page=100155 to find a BCBA provider in your area. If the provider or center you are investigating does not have a Board Certified Behavior Analyst on staff, ask questions about the credentials of staff that are working there. For example, some psychologists have received a lot of training in ABA but do not have a BCBA credential. Other psychologists have received a smaller amount of related training, but they do not have the precise training required for ABA. Don’t be afraid to ask a lot of questions! Also, realize that any credential only shows that the professional has passed a test and has met a minimum standard of supervised practical training. So make sure you find out about all of their experience with children like yours. For example, how many children have they worked with, what type of children, and how long have they worked in their field. Ask for references and talk to other parents who have used their services.
Often, people receiving ABA services work directly with ‘front line therapists.’ Front line therapists typically are not a BCBA; some may be a BCaBA or have no certification. If your child will be working with a front line therapist, find out about how and how often they are supervised. Is a BCBA providing supervision? Are they providing training on how to help your child more effectively? Ask for examples of their training procedures as you are deciding about a provider or center. Be sure to ask for examples of training procedures once your child is getting services too.
Your child is precious and you need to know that they are in safe hands. Background checks should be considered standard practice and are typically done by schools, centers, and most providers. If your child is young, an adolescent or an adult, a background check is always appropriate. If you hire your own front line therapist or are bringing a provider into your home, you should do a background check. Know that schools routinely require a background check of teachers and paraprofessionals. This is a standard procedure in many professional situations that involve children. You should absolutely not feel uncomfortable asking for a background check to be performed. Typically, the organization that provides the front line staff conducts the background check, and covers the costs. If they do not, that should serve as a red flag. The only time a parent might have to pay for a background check is if they are hiring their own front line staff apart from an organized ABA provider.
Watch how your child interacts with the therapist. Your child just might be the best judge of character. If your child always resists requests to focus on important materials, do not misread or overly focus on negative reactions to a particular therapist. However, you should still monitor your child’s reaction over time to the therapist. f your child’s therapist seems to be unnecessarily or harshly punishing or overly aversive (e.g., excessive restraints, sprays in the face, mouth swabs, etc.), don’t hesitate to question their professional behavior. ABA should not be aversive. In truth, the most effective therapists are those who can establish a positive rapport with your child. Trust your gut instinct. If your child becomes upset in the presence of the provider, they will probably be less effective with your son/daughter. You know your child best and you should make the decision about how your child responds to new people or situations.
Ask to about policies and practices of the agency/provider, including those related to preventing abuse, taking advantage of parents, and protecting parent privacy. What is the approval process for any treatment plan that may contain questionable practices? All parents are encouraged to ask these questions. Any strategy that has the potential to harm your child is inappropriate.
Ask how frequently you are allowed to observe your child in therapy. While an agency/provider may have basic protocols on how to schedule an observation, the ability or inability to easily access your child at any time may be something worth considering. Also, if at any time you notice a procedure with your child that makes you uncomfortable, you have every right to stop the procedure and/or ask for more information about why the procedure is in place, the potential harm and good of the procedure, and about potential alternative procedures. There is seldom, if ever, only one way to change a behavior. If you and an agency/provider don’t agree on the procedure to use, it is the provider who needs to change or you who need to seek out a new provider.
ABA may be used for many hours across long periods of time, especially in the early stages of treatment. There is no ABA magic wand. It takes a lot of work by a lot of people (including you) to help your child reach his or her potential. So be very careful of grandiose promises about unrealistic outcomes. Providers who promise instant cures should be questioned. None of us can say with certainty what a child will be able to do in the future. Most children will make progress when provided with effective instruction and support, but each child will progress at a different pace. There are many factors that may impact progress. Factors like your child’s health, behavioral challenges, quality of program, and how challenging it is for them to carry over their skills to important settings (like your home or in the community) all influence how quickly progress is made. Any provider or center that promises your child will be “just like kids without ASD” in a few years is making promises they can’t keep.
You will notice that the definition of ABA we agreed to in Indiana says that programs should teach socially significant behaviors. In the plan developed for your child, skills should be taught that are valued by you and that facilitate skills that can be used in real world settings and that lead to meaningful adult outcomes. For example, if your child has worked on colors for 2 years and still does not have the skill, then move on to something else. Much can be achieved in life without mastery of this specific skill. Programming should facilitate achievement of outcomes that make it easier for your child to go to school, spend time with family, and go out into his or her community. Be prepared to make a list of skills that you and your family value. Be specific in outcomes you want to see.
Plans should address generalization (being able to use a skill in all appropriate situations) and maintenance (keeping a skill once you learn it). The ability to perform a skill in a clinical setting with one person using only one type of instructional material is only the first step in the process. If the program does not expand the skill into other settings with other people, including family members, then the skill has not been truly learned and may be useless. Likewise, there should be a plan for revisiting or building on important skills, so that skills are maintained over time.
There should be a plan to transition the child out of therapy and into less restrictive settings. The ultimate goal everyone should have for your child is that they can learn skills and are maximally successful in real world settings. You should also ask what the criteria for transitioning to a different setting – like school – will be for your child. How are transitions handled? What is their success rate of transitioning? Often, different people need different transition plans, but a provider or center should be able to discuss their process for handling transitions and why successful transitions are a critical goal for your child.
Data and Documentation
Data collection is a critical component of ABA programs. All providers and centers should be able to regularly provide you data in a format that is understandable. They should explain how to interpret the data. Some professionals become so accustomed to using data that they hand you reams of data that simply don’t make sense to anyone. Providers and staff at centers should be able to summarize data so you can see trends that show if your child is improving or not. They should be able to discuss the data and your child’s progress in understandable terms. They should use data to make program adjustments so that your child can progress most quickly – and they should help you understand this process too. It’s ok to ask for clarification, because if you don’t understand what they are telling you, it will be difficult for you to understand if progress is truly being made.
Each provider should have a clear plan and documentation that shows whether progress is being made and be able to clearly explain that plan to you. When you are still in the investigation phase, ask the provider or center how this is done in their organization. Ask for examples. They can remove identifying information for others they serve to provide you an example. After you have selected a provider or center, keep asking about their plan and the documentation they have about your child’s progress. Once your child is in a program, you should have regularly scheduled meetings with your child’s BCBA or supervising provider to review progress, make updates to the program, and to provide you with the skills to help maintain and generalize your child’s mastered skills at home or in the community.
Finding the Right Fit
Although ABA providers hold many core beliefs in common, you will also find that they have differing approaches and philosophies. For example, some embrace sensory and medical conditions impacting behavior; others do not. Some consider the use of visual supports as very important and others do not. Some believe it is best to start with augmentative communication systems in some cases; others only believe in verbal communication. Some focus on constantly creating new and novel situations so your child is motivated; others provide extremely rigid environments. Regardless, know what your child needs and what works for your child. You can find a list of evidence based practices at the website for the National Professional Development Center on ASD at http://autismpdc.fpg.unc.edu/content/ebp-update. Some of these strategies are strictly associated with ABA; others are not. This list includes strategies that have also been validated for schools. You can also order a free copy of the National Standards Project Report from the National Autism Center at http://www.nationalautismcenter.org/nsp/reports.php. This report focuses on those practices also associated with clinical settings.
ABA providers and centers charge different rates. Costs will vary greatly. Please do not assume more expensive programs or providers always provide better services. Like other businesses, buildings, marketing and salaries impact costs. Also look at the stability of staff – does the provider or center keep staff for a long time? The faster the turnover the more training they have to provide staff and this can affect both costs and the quality of services that are provided. Make sure you ask about costs of various providers and centers before you make any decisions. And be aware of billing and insurance practices.
The number of hours recommended may differ for each child and will impact costs. The National Research Council recommends a minimum of 25 hours a week for young children (http://www.nap.edu/catalog.php?record_id=10017). Like all therapies/treatments, the number of hours will differ depending on the child’s and family’s needs. Hours of services should be based on getting your child the level of help that is necessary so he or she makes progress in all important areas. Communication, taking care of oneself, spending time with others in play (for younger children) or other activities that happen in adolescents or adulthood are all important because they help your child become happier and more successful in real world settings. Remember that ABA should be individualized and a single program should never be applied to every case in the same way. The cost of your child’s program is likely to vary depending on how many skills they need to develop and how long it takes them to use these skills in everyday life. It will also depend on the setting in which these services are provided.
ABA providers, like all professionals, may use words and language that are not common and that you may not understand. Request that your ABA providers explain things in common terms. Do not be embarrassed to say you do not understand. It is their responsibility to explain things in a way you understand. All professionals have to be careful not to overly use jargon. A lot of ABA providers use many acronyms and may lose sight of how confusing this terminology may be to families. Feel free to remind them!
Parents will often complain about the fragmentation in services for their sons/daughters. If your child attends a school or other program, there should be a discussion about how collaboration will occur. Be cautious of providers, schools, or centers that condemn others to raise their own status. Schools and ABA programs are very different, and function under different laws and regulations. ABA therapy programs are used to treat students who have a medical necessity. Educational programming is based on educational (and not medical) need and programs are collaboratively designed by the student’s school team, including you. The goal is that all of your child’s team work together (and with you) peacefully to ensure maximum progress for your child. Consider signing a mutual exchange of information to allow all parties to share information about current assessments and goals.
Sometimes a combined program (some time in school and some time with ABA providers or centers) is suggested. Be aware that there are state laws about a student’s attendance at school that may have to be acknowledged. Realize that a single approach (reinforcement, token economies) can be done in both settings, but will look different. Another thing that sometimes looks different is the ratio of staff to children. Some children benefit from more individualized attention, but many of them do not require this all day long and will still make progress when the ratio is different.
Most school professionals receive some training in ABA and some school districts are now employing BCBAs. Most schools have an autism consultant on staff that can assist with the transition and development of school programming. Realize that ABA strategies can be done by teachers in schools; it just may look different. Be prepared to ask relevant questions about educational programming in these settings.
A final point
Our hope is that these guidelines can assist in your decision-making process. Remember that you play a critical role in making a choice about the setting or provider from which your child receives services. Anyone in any setting that makes you feel your perspective is unimportant or, worse still, interfering is approaching your child’s needs with the wrong attitude.
This list is not exhaustive. The bottom line is that you trust your common sense and ask a range of people about the services provided. Take both positive and negative comments, and then make a decision based on what will benefit your entire family. Look for a provider that seeks parent perspective and involvement, and that is able to make documented progress in teaching your son/ daughter skills that are important for a lifetime.
Indiana Resource Center for Autism at (812) 855-6508
https://www.iidc.indiana.edu/irca or via email at email@example.com
Department of Special Education, Teachers College,
Ball State University at (765) 289-1241
The Arc of Indiana at (317) 977-2375
Autism Society of Indiana at (800) 609-8449
http://www.inautism.org or via email at firstname.lastname@example.org
Riley Child Development Center LEND Program at (317) 944-8167