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These are the results of my very very very informal analysis but I think this is better than nothing and hopefully will help some people:

Children receiving intensive ABA (more than 20 hours of “intervention time”/week plus high parental involvement) or clients who received ABA (around 20 hours of “intervention time/week plus parental involvement) and just tried alternative interventions made the most progress.

Children receiving less than 20 hours of ABA and alternative treatments (diets, supplements, etc) made the least progress. Graphs below will further explain this. 

Average Outcome: 100 = Mainstream, 50 = Moderate progress, 25 = some progress

Number of clients by treatment type and outcome

It wouldn't let me post the color code. GREEN = Mainstream YELLOW = 50% progress RED = Less than 50% progress

The above graph shows the number of children receiving each type of intervention and the progress that was made. Parents were most likely to do less than 20 hours of ABA. Parents were least likely to do intensive ABA and alternative treatments. 

Outcome by type of Autism: 100 = Mainstream, 50 = Moderate progress 25 = some progress

BLUE = Classic Autism YELLOW = Comorbid Disability GREEN = PDD NOS ORANGE = Comorbid Medical

Children who presented with classic autism (little to no language, repetitive behaviors, tantrums) had the best outcomes overall. Most likely to acheive mainstreaming with either intensive ABA or ABA and just trying alternative treatments.

Children who presented with PDD NOS (some language, most affected in areas of social skills and play) made significant progress with less than 20 hours of ABA. Parents of these children were more likely to just do ABA, to do less hours of ABA, and to not try alternative interventions. 

Children who presented with comorbid disabilities (symptoms of autism: little to no language, repetitive behaviors, tantrums and symptoms of other disabilities: difficulty attending even to preferred materials, slow progress in all skill areas, etc) and children who presented with comorbid medical issues (seizures, chronic constipation/bowel difficulties, high probability of getting sick, etc) did not make as much progress. Parents of these children were more likely to do ABA and alternative treatments. None of the children received just intensive ABA. This is not to say that these children will not make progress but that based on the information I had, it was more difficult to make progress with some of these children. 

Please keep in mind that I am a behavior analyst so all of my information relates to children receiving behavior analytic services. I also think this information is important as it can help inform further research. 

If training is optional or the importance of training is not emphasized, then it will be very difficult to conduct training. Parents are typically very busy so unless they know that training is a crucial component of successful intervention, it is not very likely that they will participate in training. At the end of this blog I will post my policies relating to training so that you can see what I tell parents and how I determine termination of services due to lack of participation. These policies were developed during my time as Clinical Coordinator. I had to experience a lack of a requirement/termination policy in order to develop one. Services are much more effective and parent training is much more successful when the requirements are laid out from the beginning. If you do not currently have policies in place, simply write up a policy and let your clients know that effective a certain date this new policy will go into effect. I have to do this all the time as new issues arise. 

Depending on the needs of the child, you may have several topics that the parents need to receive training on. I typically determine what all of the topics are by observing/assessing the child and discussing with the parents/staff what they would like more training on. I then make a list of these topics and train on 1 topic at a time starting from most important AND easiest and moving down the list. I try to do one topic at a time so as not to overwhelm the parent. I also try to pick a topic that is important to the parent but will be fairly easy to train. This is so that the parent has a positive training experience. 

After you have assessed the behaviors and determined a plan that you would like to use with the child and that you would like to train the parent/staff how to do, try to take baseline data. Make an integrity checklist of the steps to follow for the specific topic that you are training on. Do not show the checklist to the parent. Set up a situation and observe the parent in the target situation. Fill out the integrity checklist to record what behaviors the parent is currently doing and what behaviors the parent is not doing. The purpose of the baseline data is to show that your training was effective (pre/post scores on the checklist), to determine what areas the parent might need more training in, and to give the parent feedback on the current performance. When going over the checklist with the parent, make sure to point out all of the things that the parent did correctly on the list and then let the parent know that you will teach them how to do the other things. See the end of this blog for an example of an integrity checklist.

I always type up a training packet for the parent that includes a description of what we will be doing for training, a modeling section, a role play section with an integrity checklist, and a in situ observation section with an integrity checklist. As I go over the procedure with the parent, I also make sure that everything is feasible and works for them and modify as needed. After I explain the procedure, I model for them all of the steps. I then have them role play the steps with me and fill out an integrity checklist. I will give them feedback using the integrity checklist and then have them try the skill with their child. Sometimes it is not possible to have the situation occur on cue so I will keep the integrity checklist with me and use it whenever the situation does occur while I am at the house. After each occurrence of the situation, I will go over the checklist with the parent. I always provide positive feedback and try to limit my corrective feedback so that training is a positive experience. See the end of the blog for an example of a parent training packet. 

Once i have trained a parent on a skill, I will continue to do integrity checklist until they have mastered the skill. I will then continue to provide social praise when I see them do the skill. I usually will try to train on 1 new topic per week until all topics have been covered. However, if a certain topic is difficult or involved, I will focus solely on that for a while and then move on to other topics. I try to allow the parents to determine what topics we cover so that I can address their concerns first. However, I sometimes I have to provide training to them on a topic so that their child can make more progress. I also continuously assess what areas are of concern to the parent so that I can update the training topics frequently. 

Participation Requirements

Participation in monthly meetings: parent/guardians are expected to be present for each monthly meeting because their child’s treatment programming will be discussed and changed at this time. It is imperative to have the parent/guardian present in order to provide the best treatment to the child and to receive feedback and input from the parent/guardian.

Participation in training regarding child’s programming: Parent/guardian actively participates in training conducted by the consultant. 

Implementation of reduction behavior protocols: Parent/guardian actively participates in training on how to follow protocols set in place by consultant in order to reduce behaviors. Parent/guardian implements behavior protocols consistently and notifies consultant if the protocols are too difficult to follow. Parent/guardian allows therapist to conduct integrity checklist and provide feedback on adherence to protocols. 

Generalize and Practice targets with child: The parent/guardian will be informed by therapist what skills their child is working on. The parent/guardian when practice these skills throughout the day in the child’s natural environment to increase generalization. 

Following through with day-long programs: Parent/guardian follows the protocol for day-long programs such as toilet training, feeding programs, or sleeping programs. 

Procedure for Lack of Participation

The following is an explanation of the steps that will be taken if a parent/guardian is not participating in their child’s programming.

1. The first time that a parent or guardian does not meet one of the participation requirements, the consultant will provide the parent or guardian with a verbal warning reminding the parent or guardian of the participation requirements. The consultant will explain clearly to the parent or guardian where their participation is lacking.  The consultant will offer more training if this is part of the issue. 

2.  The second time that a parent or guardian does not meet one of the participation requirements, the consultant will provide the parent or guardian with a written notice reminding the parent or guardian of the participation policy. The notice will clearly explain to the parent or guardian where their participation is lacking. The consultant will offer more training if this is part of the issue. 

3.  The third time that parent or guardian does not meet one of the participation requirements, the consultant will meet with the parent or guardian and provide them a final written notice reminding the parent or guardian of the participation policy. The notice will clearly explain to the parent or guardian where their participation is lacking. The case manager and consultant will work closely with the parent or guardian to provide the training necessary to correct the issue. Additionally, the notice will explain to the parent that if the parent or guardian does not meet the participation requirements again, the child’s services will be discontinued. 

4.  The fourth time that a parent or guardian does not meet one of the participation requirements, the child’s services will be discontinued on the grounds that I cannot provide effective treatment if the parent or guardian is not participating in the child’s programming. The consultant will meet with the parent or guardian to explain to the parent where their participation is lacking. Services will be faded back according to a fade plan that will be individually determined for each child. 

Working Together for the Success of Each Child

Megan will work closely with every parent or guardian in order to ensure that parent participation is as easy and enjoyable as possible for every parent or guardian. When issues do arise, the cconsultant will work closely with the parent or guardian to determine how to resolve the issue. When parents or guardians participate fully in their child’s programming, they should see more progress from their child and have a better understanding of how to respond to various behaviors. 

The checklist wouldn't post properly but it should be a table where there is a column for Yes, No, NA and a row for each step.

Mand Training Checklist

Yes	NO	NA	Checklist Item
			Environmental Set Up
			-Restricts access to preferred items by placing them out of reach
			-Requires XXXX to request item before allowing access
			Shaping Requests
			-Allows immediate access to item if XXXX makes appropriate request: eye contact, clear, full sentence
			-Follows prompt hierarchy to shape request if XXXX doesn’t make appropriate request: expectant look, reminder, full prompt
			-Allows access to item only after XXXX makes the request with eye contact and a clear full sentence
			-If XXXX uses wording that is not appropriate, prompts XXXX with more appropriate wording
			-Only allows access to item if XXXX says with appropriate wording, eye contact, and clear full sentence
			Allowing Access
			-If XXXX makes appropriate request: eye contact and a clear full sentence, allows immediate access to item
			-When XXXX is highly interested in an item, requires him to complete a few demands before allowing access
			-Occasionally takes turns between engaging with toy and completing demands
			-does not always require XXXX to complete a demand and does not always provide immediate access to the item

FEEDBACK:

Items that you did really well were:___________________________________________

________________________________________________________________________

Things to work on:________________________________________________________

________________________________________________________________________

SIGNATURES:

Monitor____________________________________

Trainee______________________________________

Example of a Parent Training Packet

Parent Training 

Client: XXXX

Date:

Purpose: The purpose of this parent training activity is to train XXXX’s parents to appropriately respond to inappropriate behavior in order to reduce the occurrence of the inappropriate behavior. Once the training is completed, XXXX’s parents should be able to identify the type of situation and how to respond appropriately.

Inappropriate Behavior in Response to a Demand:

XXXX occasionally engages in inappropriate behavior when asked to do something that he would prefer not to do. 

Definition of Behavior: Any instance of XXXX saying “stupid,” saying “go away,” whining, crying, screaming/yelling, dropping to the floor, aggressing towards others or objects or throwing items in response to a demand. 

Procedure for decreasing behavior:

• Repeat the instruction while providing a prompt.  Using the Least-to-Most prompt hierarchy to prevent prompt dependence.  Prompt him through the instruction while eliminating eye contact and minimizing talking to only the instruction.  Prompt hierarchy:
• Gestural prompt (point to item/activity)
• Model prompt (show him what to do, this may not always be applicable)
• Partial Physical (start to physically guide him to or through activity)
• Full Physical (physical guide him through entire instruction)
• Provide 3-5 seconds between each prompt level to give him a chance to respond
• Repeat the instruction each time a new prompt is delivered
• Ignore any aggression/problem behavior
• DO NOT talk to, look at, touch, reason with, or try to console XXXX while following through with the demand. Simply provide prompts to complete the task.
• Upon responding, provide differential praise depending on how much prompting he needed 
• If he cried the entire time and needed a full physical prompt, after prompting him through it, say in a neutral tone “that’s coloring”
• If he complied with only a gestural prompt and was no longer crying, tell him enthusiastically “Great job coloring!”
• Remember to always praise enthusiastically with hugs/tickles etc when he complies with ANY instruction the first time he is asked (come here, let’s go outside, clean up toys etc).  He should not have to engage in problem behavior before receiving praise.  Decrease the amount of reinforcement when there is an increase in assistance.
• Try to get XXXX to use his words, upon precursors to tantrum behavior such as turning in the chair, or slight whining prompt XXXX to ask for a break by asking him “Do you need a break? Say ‘I need a break’”.
• Deliver a few simple instructions until XXXX complies without prompts so he gains access to reinforcement 

Procedure for Increasing Appropriate Behavior

• Throughout the day when XXXX does comply with a demand, make sure to praise, give tickles, high fives, etc EVERY time he complies with a low preference demand. 
• When you are about to present a demand that XXXX doesn’t prefer, prompt him right away to use his words. Example “XXXX it is time to clean up, use your words” Then you can prompt him to say how he is feeling “Say ‘I am mad. I don’t like cleaning up. First I clean up, then I watch t.v.’ “ Or other phrases that might be appropriate.
• Only prompt XXXX to use his words and give him words to say if he is calm or just whining. Do not prompt him if he is intensely tantruming because you might reinforce the behavior and/or see the tantrum escalate.
• Remind XXXX during NEUTRAL situations that if he listens to mommy or daddy he is a big boy and can do fun things, but if he doesn’t listen, he doesn’t get to do fun things.
• BE CONSISTENT. If you tell XXXX he must complete a demand in order to get a reinforcer, DO NOT give him the item unless he completes the demand.
• DO NOT BRIBE XXXX. Set out the consequences PRIOR to placing the demand. “We need to clean up, then eat ice cream.” Or if XXXX asks for a highly preferred activity, you can work off the motivation “Oh, you want bubbles, let’s clean our room then do bubbles.” DO NOT do this “XXXX clean your room.” (XXXX resists) “Oh come on XXXX if you clean your room, I’ll give you candy.” Then you are allowing XXXX to manipulate the situation. You should be the one setting the consequences.

Now that we know what the procedure is. Let’s role play and practice so that you can follow it with XXXX. I will be looking for the behaviors/steps listed in the checklist below:

Checklist for inappropriate behavior in response to a demand – Role Play

Yes	NO	NA	Checklist Item
			-Presents demand
			-XXXX knows what the consequence is for completing the demand
			-Upon occurrence of inappropriate behavior:
			Does not react to the inappropriate behavior (no touching, talking, eye contact)
			Repeats instruction and provides lowest prompt level
			Continues to work up the prompt hierarchy until compliance is achieved
			Presents 2 or 3 more easy demands before providing a break
			-Prompts to use words when inappropriate behavior begins
			-Prompts what words to say “I’m Mad” etc and still follows through with demand
			-Discontinues prompting for using words if inappropriate behavior escalates
			-Uses differential reinforcement for compliance: if complies quickly, provides praise; if needs prompts the whole time doesn’t praise just acknowledges being done
			Doesn’t bribe, provides consequences before presenting demand

FEEDBACK:

Items that you did really well were:___________________________________________

________________________________________________________________________

Things to work on:________________________________________________________

________________________________________________________________________

SIGNATURES:

Monitor____________________________________

Trainee______________________________________

Checklist for inappropriate behavior in response to a demand – with child

Yes	NO	NA	Checklist Item
			-Presents demand
			-XXXX knows what the consequence is for completing the demand
			-Upon occurrence of inappropriate behavior:
			Does not react to the inappropriate behavior (no touching, talking, eye contact)
			Repeats instruction and provides lowest prompt level
			Continues to work up the prompt hierarchy until compliance is achieved
			Presents 2 or 3 more easy demands before providing a break
			-Prompts to use words when inappropriate behavior begins
			-Prompts what words to say “I’m Mad” etc and still follows through with demand
			-Discontinues prompting for using words if inappropriate behavior escalates
			-Uses differential reinforcement for compliance: if complies quickly, provides praise; if needs prompts the whole time doesn’t praise just acknowledges being done
			Doesn’t bribe, provides consequences before presenting demand

FEEDBACK:

Items that you did really well were:___________________________________________

________________________________________________________________________

Things to work on:________________________________________________________

________________________________________________________________________

SIGNATURES:

Monitor____________________________________

Trainee______________________________________

Inappropriate Behavior in Response to Being Told “NO” or Access to Tangibles

XXXX also engages in inappropriate behavior when he is denied access to an item or an item is taken away. 

Definition of Behavior:  Any instance of XXXX saying “stupid,” saying “go away,” whining, crying, screaming/yelling, dropping to the floor, aggressing towards others or objects or throwing items in response to a demand.

Procedure for Reducing Inappropriate Behavior:

• Offer XXXX a choice of something else he could do.  Be sure to do this quickly, right after you say “No we can’t have tv right now but you can have either dress up or books”
• If he doesn’t make a choice and continues to whine, start ignoring the behavior by turning away from him and not talking to or looking at him.
• If XXXX is trying to aggress toward you or one of his siblings, you can either remove him from the situation or remove the other children so that they are not harmed. Do whichever is easier.
• Only tell him each option one time 
• If he starts to engage in the activity, wait for 5 seconds of quiet and praise him for participating.
• If he calms down at any point, praise him for being calm and try to redirect him to a different task.
• If he continues to whine, do not provide any attention, including: talking, eye contact or head movement in his direction, it may help to engage in an activity (play or paperwork) yourself so you are not just sitting there listening, this may also help to reengage him.  
• Upon the occurrence of whining/screaming to get access to items that you are willing to give him ( i.e. wants a snack but starts yelling) you can then prompt XXXX to “ask nicely.” Try not to do this until he is calm for a second so as not to reinforce the whining.
• Do not allow access to the previously denied item at any point.
• When redirecting XXXX to a different task after whining/tantrumming has occurred DO NOT engage him in his MOST PREFERRED activity because this will reinforce inappropriate behavior. Pick an activity that is preferred but not highly preferred. 

Procedure for increasing appropriate behavior:

• We are going to start a “wait” and “accepting no” program for XXXX. Both of these should help build up his repertoire for tolerating “no” and being denied access to activities. Training will occur on this next time.
• Make sure to praise XXXX every time he calmly accepts no, uses his words, and/or picks a new activity to engage in.
• When you are about to deny XXXX access to an activity or have him wait, make sure to prompt right away to use his words. “You can’t have pizza right now say ‘I’m mad, when can I have pizza.’ “ Prompt XXXX with exactly what he should say so you can help him work through the situation.
• Only prompt XXXX if he remains calm or is whining slightly. Discontinue prompts and start ignoring the behavior if the behavior escalates: he starts to get aggressive, begins screaming and crying, etc.

Now that we know how to react to the behavior, let’s practice.

Checklist for inappropriate behavior in response to “no” – Role Play

Yes	NO	NA	Checklist Item
			-When denying access, provides a choice of 2 other activities
			-Immediately prompts XXXX to use his words after denying access
			-Upon occurrence of inappropriate behavior:
			Ignores inappropriate behavior – no touching, no talking, no eye contact
			Only gives choices ONE time
			Engages self with one of the other activities to help redirect
			Doesn’t engage with a highly preferred activity
			Doesn’t try to talk the child into coming over to the activity
			Only allows child access to the new activity if calm
			-When child calms down, praises for being calm
			-Doesn’t provide access to previously denied activity
			-If previously denied activity is allowed to occur, only allows access if child asks nicely

FEEDBACK:

Items that you did really well were:___________________________________________

________________________________________________________________________

Things to work on:________________________________________________________

________________________________________________________________________

SIGNATURES:

Monitor____________________________________

Trainee______________________________________

Checklist for inappropriate behavior in response to “no” – with Child

Yes	NO	NA	Checklist Item
			-When denying access, provides a choice of 2 other activities
			-Immediately prompts XXXX to use his words after denying access
			-Upon occurrence of inappropriate behavior:
			Ignores inappropriate behavior – no touching, no talking, no eye contact
			Only gives choices ONE time
			Engages self with one of the other activities to help redirect
			Doesn’t engage with a highly preferred activity
			Doesn’t try to talk the child into coming over to the activity
			Only allows child access to the new activity if calm
			-When child calms down, praises for being calm
			-Doesn’t provide access to previously denied activity
			-If previously denied activity is allowed to occur, only allows access if child asks nicely

FEEDBACK:

Items that you did really well were:___________________________________________

________________________________________________________________________

Things to work on:________________________________________________________

________________________________________________________________________

SIGNATURES:

Monitor____________________________________

Trainee______________________________________

Miscellaneous

• Keep in mind that we ALWAYS want to be giving lots of attention for APPROPRIATE behavior and very little to none for inappropriate behavior
• A lot of XXXX’s behavior is attention maintained, if he starts whining, or engaging in inappropriate behavior and you are thinking to yourself “ I really wish he wouldn’t do that” DO NOT attend to the behavior. This applies to when people leave, when he comes home from school, throughout the day. If there is a behavior you DO NOT want him doing, DO NOT interact with him while he is doing the behavior. You can block him from doing it and redirect him to something else. Let’s practice this.
• Limit the amount of “no” or “stop” you say to XXXX. Only tell him these things and give him attention for those behaviors, if the behavior will harm himself or someone else. All other behaviors can and should be ignored.
• When you do tell him to stop, only tell him one time. Say it in a firm, neutral voice. Do not use exaggerated expressions, or say it in a fun way. XXXX might start to do things just to see your reaction. 
• When you tell him to stop, if he doesn’t stop, make sure to follow through and help him stop. We always do: Say, show, do. This means tell them what to do, show them how to do it, hand over hand guide them to do it if necessary.
• If you absolutely must attend to an in inappropriate behavior, make sure you make up for it by attending 4x as much to appropriate behavior: Ratios should be: for every 1 “negative” feedback the child receives 4 positive feedback statements. (this is research based).

Research in the field of behavior analysis and autism treatment in general indicates that parent training and tutor training are crucial to the success of an intervention package. Lynn and Robert Koegel have done an extensive amount of research on parent training and consistently show that parents serve well as the child's teacher and parent training leads to gains for both the child and the parent. I will provide summaries of other research regarding parent training at the end of this blog. 

Most children receiving behavior analysis services only receive a few hours of treatment per week (around 7-10) but the recommended intervention amount is 30-40 hours. If the parent does not receive proper training, you are looking at countless hours that are being wasted and possibly un-doing the work that the therapist is doing during her 7-10 hours with the child. If the tutor/therapist doesn't receive proper training, you are looking at even less progress for the child because the few hours of therapy that are being provided, are not as effective as they could be. Sometimes I will see children who make wonderful progress with poorly trained tutors/therapists and parents and it saddens me because they could be making at least double that progress if everyone was trained.

The workshop presented by Robert Schramm on instructional control was by far my favorite presentation of the conference. I have already read his book and had been incorporating procedures similar to his for a few years but he has been doing this longer and has refined the technique. In the workshop we learned how to decrease escape and noncompliance without using force, blocking, or nagging. The basic idea is to withhold reinforcement completely and wait the child out. The child's learning environment should be an "oasis of fun" so the child should be so motivated within the environment that he/she doesn't try to leave but if he/she does, that is fine you just stop the oasis of fun until the child returns. Following the 7 steps of instructional control along with a few other techniques not only decreases noncompliance and escape behaviors but it results in a willing and motivated learner. I will write much much more on this topic in future blogs as I will be doing a review of Robert's book. I call this the next step in motivation because pioneers such as Jack Michael, Dr. Sundberg, Dr. Partington, and Dr. Carbone all recognized that the "traditional" method of sitting at a table and plowing away wasn't working. They devised current motivational procedures of pairing the table and therapist with reinforcers and focusing heavily on developing a fun relationship with the child where they see you as a walking m&m. Robert's approach is taking this one step further by not just saying that the therapist or parent should pair with the child but providing more direction on what this pairing should look like, how much of it should occur, and what should happen when the child doesn't want to interact and pair. Most people would say when the child doesn't want to do the demand, force them to but this counteracts all of that pairing you were doing. If you are forced to do something, you don't generally enjoy it and you aren't as motivated. My favorite video that Robert showed was one of a therapist pairing with a little girl who loved music. In most ABA sessions you might see a therapist play music and sing along and the child may or may not enjoy it or even notice the therapist is sitting there, but this is considered pairing. In the video Robert showed, the therapist was swinging the little girl around (which the little girl enjoyed but not as much as she enjoyed the music) and the little girl would sometimes walk away from the therapist. It was ok for this to happen, but the music was paused if the child was not interacting with the therapist. Then when the little girl rejoined the therapist, the music was turned back on. This truly pairs the therapist with the music and it motivates an interaction. This is HUGE when looking at autistic children who are severely delayed with social interactions. If they can only have their preferred items when interacting socially with someone, then the reinforcing value of social interactions will increase greatly. I highly recommend attending a workshop by Robert, reading his book or visiting his website. His book is Educate Toward Recovery and his website is www.knospe-aba.com

I thought I knew everything there was to know about potty training but the informative presentation done by Patrick Friman and Ennio Cipani taught me a few things:

1. Never use aversive methods for accidents when potty training. This point was made by Patrick Friman. I personally have never used aversive methods but I know people who do. The method doesn't even have to be intended to be aversive but if a child finds it aversive, then it is. For instance I had a client who started crying when we praised him for peeing in the potty. We were trying to reinforce him but he did not like it so we had to stop throwing a party while he was peeing. Some places will have you require the child to clean themselves up or help clean themselves up after an accident, some will do positive practice where you take the child back and forth the the potty from the spot of the accident. These are designed to have a consequence for accidents but should not be aversive, if they are then they should be discontinued because you don't want the potty training to be aversive. 

2. Pants Off! while potty training. This was discussed by both Patrick Friman and Ennio Cipani. While I myself have had this idea before I had never thought to phrase it the way they did. For those of you who are behavior analysts out there think about the child's history with peeing. Prior to potty training, peeing is done when pants are on so Pants on is a Sd for peeing. Whereas if the child might try to pee without their pants on while their diaper is being changed, parents might punish that or quickly throw the diaper on. Therefore, pants off is a S delta for peeing, meaning the child has learned when my pants are off I should not pee. This relationship obviously needs to be reversed to have successful potty training. This method is not necessary for all children but should be considered when you have a child who doesn't pee in the potty and literally does not pee until you put their pants/diaper/etc back on after hours of a potty protocol. I have definitely worked with clients who sat on the potty contently for 10 min or longer and would not go so we would put their clothes back on and within seconds they would pee. Clearly they were under the impression that this is where they should pee. The recommended procedure was to keep pants off during the training. As soon as the child goes in the potty, put their pants on for 5 minutes because they shouldn't pee again right after peeing. Then take their pants back off until they pee again. Increase the amount of time with pants on each time the child is successful in the potty. So it would look like this: pants are off, take child to potty every 15 minutes, child pees in the potty, put pants on for 5 minutes, take pants off, take child to potty after 15 minutes, child pees in the potty, put pants on for 6 minutes, take pants off, etc. This whole time you follow the standard potty training procedure described by Azrin and Foxx of scheduled trips to the potty, frequent liquids, and reinforcement for peeing in the potty.

I talked at length with numerous behavior analysts about issues regarding supervision and oversight by the BACB. While a good number of behavior analysts are trained well and provide stellar work, the high demand in our field is resulting in an issue with proper training at the newer behavior analysis programs and the online programs. The good news is a lot of BCBAs are aware of this issue and are hounding the board about it and everyone who is concerned agrees changes need to be made regarding supervision requirements/monitoring. The bad news is that a lot of the people in charge of making the decisions live in a little bubble where they are not exposed to some of the issues that others experience on a daily basis. It was good to see people at least talking about these issues and trying to come up with solutions. 

One of the other talks I went to that was rather interesting was about psychotropics. I haven't attended any talks on psychotropics so this was rather interesting. I do not recall who all presented but the main message was that most psychotropics don't work, they are over prescribed, and a lot of the reasons given for needing them are false. For instance, I thought it was well established that depression and/or schizophrenia are caused by chemical imbalances. There is actually NO evidence to indicate this and it is still merely a theory that has yet to even come close to being proven. Yet, pharmaceutical companies imply links in their commercials and get the psychiatrists on board to prescribe the meds. This isn't to say that some people don't need meds but MOST people do not. There was also discussion about the lack of effectiveness of meds and the side effects. For instance Zyprexa is not very effective, led to serious side effects in 22% of the clients and 20 people died. Yet psychiatrist down play these side effects. Also to become FDA approved the drug companies only have to prove some effect and they can do this by doing as many studies as they want. So they might do 10,000 studies and only have 2 that show an effect and become FDA approved. They also will stop studies in the preliminary stages if they are not seeing the results they want. And they pay half the cost of the FDA approval process. On the other hand one person presented on the effectiveness of exercise to decrease depression, anxiety, and other mood disorders. In one study more than half of the participants no longer had depression after following the exercise protocol. This is definitely an area of interest to me but I am still in love with autism more than anything else. 

What does it mean to say child is done with ABA?

The two main reasons a a parent or behavior analyst would have for saying a child is done with ABA are:

1. The behavior analyst is not trained to work on the skills the child needs
2. The child is where he/she needs to be and the parent is adequately trained

1. Behavior analyst is not trained to work with the skills the child needs

I have seen numerous situations where a program or individual behavior analyst will "graduate" a client saying that the child no longer needs ABA. The child still has deficits typically in social skills and more advanced language/academic skills. The parents typically have no idea how to work on these skills and unfortunately the behavior analyst thinks he/she doesn't either. Rather than tell the parent that the behavior analyst has gone as far as he/she can with the child based on his/her training, the behavior analyst tells the parent that the child has graduated and can be done with ABA. This happened so many times at a previous place I worked and the parents were so upset. Then they were left wondering what to do to help their child continue to make gains and mistakingly thinking that ABA could no longer help them. 

Some programs recognize that their main training is with early learner skills and will tell parents when starting that they only work with children of certain ages. There are early intervention programs that only work with a child to age 3, and then there are some programs that only work with a child to age 6, etc. When children are done with these programs, it is the duty of the program based on the behavior analysis code of ethics, to recommend options for the parent so that the child can continue to develop skills. If a behavior analyst has not told a parent that they will end services when their child reaches a certain age, but the child reaches a point where the behavior analyst is not adequately trained to work on the skills the child needs, the behavior analyst should not just end services but either receive training and research how to teach the skills or recommend other behavior analyst who are trained to work on the more advanced skills. 

A lot of behavior analyst also use the ABLLS or VB MAPP to develop programming for a child. Often, once the child has completed all or most of the programs in these assessments, a behavior analyst might say that the child is done with ABA but the child still has deficits in language, social skills, academics, academic skills, etc. So what is the next step? Typically in this situation the behavior analyst ends services and the parent seeks out other types of programs. Some examples are relationship development intervention, brain training, other social skills curriculums, social skills groups, tutors, etc. Will these programs be helpful for the child? It is hard to say because it will depend on: if the programs address the child's areas of deficit and whether or not the programs make use of behavior analytic techniques. A child might make progress using these other programs without the input of a behavior analyst but the most effective method of incorporating these programs is to use the curriculums while incorporating the principles of behavior analysis. In this situation there are three options: 

1. The parent can find someone whose main training is in the areas that the child still has deficits but is not in behavior analysis 

2. The parent can find the person mentioned previously and have the behavior analyst consult on how to incorporate behavior analytic principles 

3. The parent can ask her behavior analyst to incorporate curriculums that are needed for the child and/or to recommend another behavior analyst who has experience with the deficits. 

No matter which solution is chosen, the best results will always be achieved when the principles of behavior analysis are incorporated. So the best solution would be either number 2 or number 3.  A lot of other curriculums/approaches will say that behavior analysis isn't used but when you break down what is done during the sessions, the programs incorporate many principles of behavior analysis. Whether a program wants to admit it or not, or even know it or not, effective programs are always incorporating the principles of learning. I could go into more detail but that is a topic for another blog. 

2. The parent is adequately trained

The other situation I have seen where services are ended with the behavior analyst are when the parent is adequately trained. This means the parent as learned through direct training and experience with the child how to incorporate the principles of behavior analysis into everyday life and apply them when necessary with the child. Typically, in these situations the parent will remain in contact with the behavior analyst and consult as needed. Otherwise, the parent continues to determine the curriculum and programs needed for the child and incorporates the principles of behavior analysis. The parent might hire a tutor or someone to help determine the curriculum but the parent directs the tutor on how to work with the child. The parent also continues to follow the principles of behavior analysis when responding to inappropriate behaviors and throughout the daily routine. 

Behavior Analysis is Technically Never "Done"

While services with a behavior analyst might be done, incorporating the principles of learning and behavior analysis should never be "done." Even if someone intentionally ends  their formal ABA program, if the child is still learning and making gains, principles of learning are still at play. The most progress will be made though if those principles are intentionally incorporated.

Principles of behavior/learning never go away. The field of behavior analysis aims at identifying in real life what factors, methods, techniques result in behavior change/skill acquisition. Making use of this knowledge can result in changes not just for autistic children but in schools, colleges, work places, nursing homes, and society in general. Whether the parent is interested in trying RDI, Brain Training, Social Skills Training groups, etc when any curriculum or programming effectively incorporates principles of behavior/learning you will see more progress than when the program does not make use of these principles. 

A behavior analyst may always be needed to some extent for a child on the spectrum if a parent does not know or does not feel comfortable with applying these techniques/principles. It will also depend on the extent that a child needs to have these techniques effectively applied. Even for typically developing children, parents or teachers who make use (either knowingly or just by natural tendencies) of principles and techniques of learning will have children who acquire skills faster than parents who do not have this knowledge and might not be effectively teaching their children. This holds true for professors, bosses, etc anyone in a position of requiring behavior/learning.

If a parent acquires the necessary skills to know how to prompt, reinforce, and adjust the environment when necessary (among other techniques), then their child will not always need a behavior analyst. This of course will depend on the child’s deficits and behavior. Even for a child who has a lot of deficits or intense behavior, if the parent or others working with the child are trained well enough, the level of input needed from a BCBA may be minimal. 

So the point here is even if you end your formal programming, it is always best to still incorporate the principles of behavior analysis/learning so that your child will make the most progress. 

Ending a formal ABA program

I am not sure if there is any research on this topic but my preferred way to end a formal ABA program is to fade the behavior analyst out of the situation and remain consultation on an as needed basis. If the parent typically receives services a few days/week, services are dropped to 1x/wk, then 1x/2wks, 1x/month, 1x/3 months (if needed), 1x/6 months (if needed), and 1x/year. Using the fade out procedure ensures that a child/parent really is ready to no longer receive input from a behavior analyst. A lot of times a child will do well so the services are just ended and then all of the old behaviors/issues arise again. Fading out the behavior analyst allows the parent to receive training and feedback on how to continue to achieve results with their child. Even during the less frequent times, the behavior analyst or a behavior analyst should always be available for a consult when necessary. 

Examples of situations:

Here are some examples of situations where a parent or behavior analyst might decide to end formal services. 

A student possesses most necessary skills to succeed academically and socially. The student is staring soccer and art classes. Does the behavior analyst need to be involved? 

If the parent is able to provide training and guidance to the coach and art teacher, then the behavior analyst is most likely not necessary. If the parent does not feel comfortable or is unable to provide guidance, then the behavior analyst might be involved initially and then fade out. A trial soccer practice/art class might also be done to see if the coach or art teacher even need input from the parent/behavior analyst. It is possible that the child will do so well that no guidance is necessary. 

A Student is advanced academically  but lacks social skills.  The BCBA lacks training in social skills and the parent does not feel comfortable being the person responsible for teaching these skills. Should the BCBA continue to provide services?

There are several options for this situation. The parent could enroll the child in social skills groups. When doing this, the parent should find groups that incorporate the principles of behavior analysis to promote learning and acquisition of the skills. If the group does not incorporate principles of behavior analysis, the behavior analyst can provide consultation on how to teach the child. If a group does not exist, the behavior analyst can either research social skills curriculums and develop programs for the child based on the child's deficits or refer the family to a behavior analyst who has training in teaching social skills. 

A Student is advanced academically, possesses social skills, but still engages in intense outbursts/aggression occasionally for different reasons. The parent adequately implements behavior reduction programs with the guidance of the BCBA but needs assistance when the behavior changes. Should the BCBA continue to provide services? 

For this situation, the BCBA might not be needed on a frequent basis but should still provide consultation services to the client. If the child still engages in intense outbursts/aggression and the parent is not always capable of responding appropriately, the behavior analyst can develop plans and provide training when needed. 

A Student  has completed ABLLS-R but struggles academically and with certain skills such as language comprehension and auditory processing. The BCBA's training is mostly with using the ABLLS-R but the BCBA is willing to research other curriculums/programs. Should the BCBA continue services? 

There are a couple of options for this situation as well. If the BCBA is willing to research other curriculums and programs, the services should be maintained because they will be able to effectively incorporate the principles of behavior analysis to help the child gain skills. If the parent is unsure of the BCBA's ability to determine new programming, the parent might want to seek the input of a provider with experience addressing these skills and have the BCBA consult on how to teach the child.