Is my child in a quality ABA program?

For a lot of parents with learners in ABA therapy, especially if the therapy happens in the clinic setting away from the home, it can sometimes be difficult to tell if the services you are receiving are high quality. As a BCBA (Board Certified Behavior Analyst) myself, I’ve seen some great programs throughout the years and I’ve seen some that I would not feel comfortable sending my child to. I think it’s extremely important for parents to be able to readily tell the difference between the two, not only because quality therapy is so important to their child but also because it’s probably the only way we will see some significant changes for the better in the ABA world. When parents start holding clinics to a high standard, and not just with the obvious red flags that apply to any business or medical facility like being rude or inconsistent, but ABA-specific things that directly impact the quality of their child’s therapy. Traditionally this has been difficult because ABA has not been successfully and sufficiently demystified for parents. I’m a big proponent of parent-led therapy, which means that parents are not only aware of the details of their child’s therapy but also in charge when it comes to therapeutic decisions. I want to share with you some things to look out for when you’re auditing a new ABA program for your child or if you’re just trying to evaluate whether the program they are currently in is ethical and effective.

First, let’s talk about some parts of the process that happen before any teaching even begins. A quality ABA program will perform a detailed caregiver interview in order to find out as much as possible about not only the learner’s needs and challenges, but also the needs of your family as a whole. They recognize that, although they might be the ABA experts, you (the parents) are the experts in your child. They will realize that you know your child better than anyone and their continued care and everything that happens outside of therapy delivery is in your hands. They will want to know about your priorities as a family before they even begin coming up with potential goals for your child. This might include paperwork, assessments and questionnaires but should also definitely include an actual free-form interview where you just sit down with them and they ask you more about your day to day, things you guys like to do as a family, your future plans, any goals that might be very important to you, your child’s previous learning or therapy history, any medical history or previous ailments, how they eat, how they sleep, their typical schedule and so on. Even if they know their history from previous paperwork or whatnot, they should want to know your thoughts on it. They will also want to know things about you, the parent, which might present barriers to consistency in intervention. What is your schedule like? What is your stress level like, what are your biggest concerns, how much time and money and effort are you able to put in without burning yourself out? Great ABA programs recognize the value of parent input and constant cooperation because it’s THE best way to ensure therapeutic interventions or activities can be seamlessly integrated in settings outside of the clinic, but they will not make demands of the parent which are unrealistic or which will cause extreme stress to them or the family.

After the interview, they will want to assess your child’s skills in an official assessment or evaluation. This is different than the diagnostic evaluation your child probably underwent in order to get their diagnosis, and has to do specifically with figuring out the level of your child’s skills across certain domains, usually things like communication, responsiveness, social skills, self-care skills and so on. There are a number of developmental and functional assessments they can do so I won’t go into detail about them right now but just know that, if the interview or assessment process is skipped, it’s a huge red flag.

So now let’s say your learner is assessed, you were interviewed and you’re ready to start. Before therapy begins, the clinical staff should go over your child’s treatment plan with you. Of course, the plan is not going to be set in stone because things might change as they get to know your child better. The important thing is, there’s a plan. It’s on paper, it’s ready to go, they’re sharing it with you and making sure they tell you about what’s in it. They will probably want you to sign off on it saying that yes, you agree that these goals are important for your child to work on, you know what’s in the plan, you consent to the plan being put into place officially. It’s called a treatment plan, sometimes an ITP or IEP, and it’s basically paperwork stating exactly what your child will be working on, how they’re gonna do that, what the criteria actually are for the skill to be considered “mastered” and an estimate for how long that will take. So it might say something like: in 6 months time, Johnny will respond when his name is called in 80% of opportunities over 3 different people. Ask for a copy, go through it at home and really think about each skill named in there. Is it relevant to your child? Is it what you discussed in the interview? Are there things in there you don’t agree with or care about, or things you think might be super difficult for your child? Can you see a functional purpose for each of those goals as they relate to your child?

Some things to look out for here are: if the plan focuses on increasing neurotypical behaviors, like increasing eye contact, decreasing stereotypy, playing with toys in a “typical” way and so on. We have heard from many autistic adults who have been able to relay that these things just encourage “masking” or “hiding their autism” to please others or to fit in. This has been connected to things like depression, anxiety and increased suicidality later on. It’s also a warning sign that this provider might still be using other outdated methods of teaching like escape extinction and planned ignoring, which can be traumatic, especially to young children. The only exception I’d make here is stereotypy that is harmful - sometimes we see things like skin picking, pulling hair out, applying significant pressure to the eyes etc. These may cause harm in the future so these behaviors do warrant decreasing, but this should be done in an ethical way. BCBAs are ethically obligated to exhaust all reinforcement (reward) options before considering an intervention using any “negative” consequence. In addition, sometimes our kiddos have really frequent, intense stereotypy that seems like it competes with learning. Clinicians might try to decrease even harmless stereotypy in order to increase learning opportunities for an individual and allow them to interact with their environment in a more focused manner. While the goal of these interventions is understandable, research has shown that stereotypy naturally tends to go down as engagement with items and activities goes up. So a lot of times, we have it backwards - instead of working hard on lowering stereotypy to get item engagement up, we should first try to work hard on finding engaging, fun, preferred activities for our clients to engage in, and most often we will see stereotypy lower without a specific intervention designed to decrease it. If the child is stimming so much in therapy that they’re not actually able to learn or attend, it’s often a sign that the therapy setting itself is not enriching enough.

If your learner does not have functional communication, if they are not able to get their needs and wants met reliably with people other than close family, that should definitely be a priority goal. In your treatment plan it might be called manding or requesting and it’s one of the most important things we can teach to a child who struggles with communicating - just like we see stereotypy go down when the environment is enriched, we also see challenging behaviors like aggression, self-injury, elopement and tantrums decrease naturally as communication skills go up. A treatment plan with insufficient communication goals, or one that focuses on compliance over communication, is a huge red flag. Also, if your child is not a vocal communicator and there’s no progress with speech in the first month or two, alternate forms of communication like sign, picture communication or augmentative devices should be considered. The child’s ability to communicate is more important than the development of speech, per se, although we will never stop working on and encouraging vocal production.

The treatment plan should also contain a fading and discharge plan that makes sense for your child. The goal of ABA should be for kids to be able to move out of ABA and into what we call a “less restrictive” environment as soon as possible. This might mean going from working in a 1:1 setting to working in a small group, then maybe a larger group with just an assistant, to ultimately school or daycare with an assistant, and so on. We can’t really know how therapy is going to look a year from now but there should be something in place that tells us clearly when therapy will start being faded (whether in hours or in ratio of student to instructor) as well as when they will officially be considered “graduated.” Of course, this plan might change and get adjusted as therapy goes on but it's important that a fading plan exists that says when these things are planned to start happening.

In addition to the treatment plan, there should also be a behavior intervention plan or BIP that specifies for direct staff not only how to react to your child’s behaviors that might be targeted for reduction, but also how to make environmental modifications to decrease the chance of them happening, what to teach instead, and so on. The results of the assessment, treatment plan and behavior plan should be available to you as the parent at any time.

Okay, so now you’re interviewed, assessed and you’ve read and approved the treatment and behavior plans. It’s time for therapy to start, yay! Here’s the thing, though - in the first week or two, there shouldn’t be a lot of therapy-ing going on. In that time, your child’s team should be taking what’s called baseline, which means figuring out the level your child is currently on with their skills and behaviors. How will we know if our intervention is effective in steadily reducing daily tantrums, for example, if we don’t know how many times a day the learner engaged in the tantrums in the first place? Data is suuuuper important in ABA, and to put it simply, if the program your child is in does not routinely take data on their progress with skills and behaviors, it’s not ABA.

The first couple of weeks are also when a really important process called pairing happens, which is essentially your child getting to know and getting comfortable with the people on his team, the therapy environment, their peers in the program and so on. They should not only get comfortable, they should really enjoy being there. A child that has not sufficiently paired with their environment will NOT want to go - now obviously some kids will struggle with separation from their parents no matter what, especially if it’s their first time in services, but this should go away really quickly. If the child is consistently very resistant to going, it might mean the environment or the people are just not rewarding enough, which also means they’re not motivating enough to foster learning. This negatively impacts learning but also can be pretty traumatic overall for your child and it definitely warrants looking into.

A lot of learners entering into ABA therapy are there not only to learn important skills, but to get help in reducing behaviors that might be dangerous or very disruptive to them or their environment. Be aware of the way your child’s behaviors are being handled. These strategies should be focused on being proactive, rather than reactive. Reactive strategies involve things like time out, any type of seclusion like calm down rooms, physical management like transports and restraints, and so on. These do have a place in crisis situations when there is risk of imminent harm, but we have research based ways of working on even the most severe problem behavior without actually causing it to happen. If your child has those types of behaviors, it’s very important for the BCBA working on their case to either be familiar and experienced in applying those methods, or be willing to search them out and learn them. As BCBAs, we are obligated by our code of ethics to continuously educate ourselves on new research and techniques in the field, and there are many which allow us to work on reducing harmful behaviors with minimal risk to our learners’ safety or dignity. Of course, behaviors still might happen sometimes depending on the learner, but if they are happening daily then some modifications need to be made. If environmental modifications are not affecting the behavior, we might consider medical factors. Now, if the modifications that have been made help your child stay safe throughout the day, that’s great! However, we still have to make sure to work on increasing the skill that was missing in the first place. Most behavior is some sort of communication or a sign that there is a skill deficit somewhere - for example, i might not be able to communicate that I’m thirsty or cold or bored or in pain, maybe I haven’t learned to wait, maybe I want something or want something or someone to go away, maybe I don’t have coping strategies to deal with certain stimuli or I have a hard time taking turns or transitioning from an activity I love to one I love less. These should all be factors your child’s team considers when making a behavior intervention plan so that appropriate skills can be taught.

Your child should not be stagnating in what they are working on for a long time. If they are not progressing in a certain program, modifications to the teaching strategy or program itself should be made in a timely manner. Lack of such modifications and continuing to work on the same program for months without seeing progress might be a sign that their program is not under adequate and consistent supervision.

Another warning sign of a low quality program is extreme staff turnover. With direct staff, like behavior technicians or RBTs, unfortunately turnover is pretty high across the field. We know this, so the best programs work very hard to create a positive environment for staff to be able to learn and thrive in. If it seems like your child is working with a new person every few weeks, it is definitely something to bring up with the supervisor. Turnover of supervisors is also a big red flag - if your child’s BCBA is changing every few months, that’s a problem that might lead to serious inconsistencies in therapy.

You should be a very important piece to your child’s therapy from the start of the program, and should be not only encouraged but required to regularly participate in parent coaching where staff will coach you on how to apply the intervention and teaching strategies in the home or community. Insurance companies require there to be home goals for parents to progress through as well, and you should not only know what those goals are for you, but also should have had a say in what those goals will be. Coaching should be accessible, understandable and applicable - if they are using too much jargon or not giving you actual, actionable ways to put what you’re learning into practice, that’s a red flag. You should also be able to observe your child doing therapy. Some programs will discourage parent observation due to something called HIPAA, or the health insurance portability and accountability act which aims at protecting the privacy of other clients. While this does mean you might not be able to observe within their classroom with peers around, depending on the policies of the clinic, there are ways to work around that. You should be able to watch them work, even if it’s in a separate room or through video, or you might be required to sign a confidentiality statement.

In general, if there is something about your child’s therapy that makes you worried or uncomfortable, or if there’s something you don’t understand, ask for clarification. Your child’s team should be approachable and available. State your case and don’t be afraid to let your child’s therapy team know what is important to you. If they refuse to take your concerns seriously, it might be time to consider other options and get another opinion.

I hope you found these tips helpful. If you need additional assistance in figuring out where your ABA provider stands with any of this, feel free to contact me and I’ll do my best to help. Toodles!