Understanding the Therapist’s Role in the ABA Treatment Process

Objectives

  • Describe Applied Behavior Analysis (ABA) treatment for individuals with Autism Spectrum Disorder (ASD)
  • Describe the ABA treatment team
  • Define the role of the therapist (i.e., Instructor, Direct Staff, Registered Behavior Technician, etc) in the service delivery system
  • Review possible therapist eligibility requirements
  • Review possible therapist responsibilities within treatment delivery

Applied Behavior Analysis (ABA)

Research indicates that Applied Behavior Analysis (ABA) is an effective treatment for individuals with ASD.

  • Prominent Studies:
    • Lovaas (1987), UCLA, Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children: Demonstrated that young individuals diagnosed with Autism at an early age who received early, intensive intervention, usually starting between the ages of 2 and 3, and received a high intensity of training hours (40 hours per week) including 1 to 1 direct therapy in-home as well as social facilitation with typical peers, helped supporting those individuals within the community and school as well as parent training that many of those individuals responded incredibly well to this type of treatment. In fact, 47% of those within the control group who received 40 hours per week were indistinguishable from their peers at the conclusion of the study
    • Sallows (2005), MadisonIntensive Behavioral Treatment for Children with Autism: Four-Year Outcomes and Predictors: Twenty-four children with autism were randomly assigned to a clinic-directed group, replicating the parameters of the early intensive behavioral treatment developed at UCLA, or to a parent-directed group that received intensive hours but less supervision by equally well-trained supervisors. Outcome after 3 years of treatment, including cognitive, language, adaptive, social, and academic measures, was similar for both groups. After combining groups, we found that 48% of all children showed rapid learning, achieved  average post-treatment scores, and at age 7, were succeeding in regular education classrooms. Treatment outcome was best predicted by pretreatment imitation, language and social responsiveness. These results are consistent with those reported by Lovaas and colleagues (Lovaas, 1987; McEachin, Smith, & Lovaas, 1993).
    • Howard (2005), California State, A Comparison of Intensive Behavior Analytic and Eclectic Treatments for Young Children with Autism: We compared the effects of three treatment approaches on preschool-age children with autism spectrum disorders. Twenty-nine children received intensive behavior analytic intervention (IBT; 1:1 adult:child ratio, 25-40 h per week). A comparison group (n=16) received intensive “eclectic” intervention (a combination of methods, 1:1 or 1:2 ratio, 30 h per week) in public special education classrooms (designated the AP group). A second comparison group (GP) comprised 16 children in non-intensive public early intervention programs (a combination of methods, small groups, 15 h per week). Independent examiners administered standardized tests of cognitive, language, and adaptive skills to children in all three groups at intake and about 14 months after treatment began. The groups were similar on key variables at intake. At follow-up, the IBT group had higher mean standard scores in all skill domains than the AP and GP groups. The differences were statistically significant for all domains except motor skills. There were no statistically significant differences between the mean scores of the AP and GP groups. Learning rates at follow-up were also substantially higher for children in the IBT group than for either of the other two groups. These findings are consistent with other research showing that IBT is considerably more efficacious than “eclectic” intervention.
    • Eikeseth (2007), Akershus University, Outcome for Children with Autism Who Began Intensive Behavioral Treatment Between Ages 4 and 7: A Comparison Controlled Study: This study extends findings on the effects of intensive applied behavior analytic treatment for children with autism who began treatment at a mean age of 5.5 years. The behavioral treatment group (n = 13, 8 boys) was compared to an eclectic treatment group (n = 12, 11 boys). Assignment to groups was made independently based on the availability of qualified supervisors. Both behavioral and eclectic treatment took place in public kindergartens and elementary schools for typically developing children. At a mean age of 8 years, 2 months, the behavioral treatment group showed larger increases in IQ and adaptive functioning than did the eclectic group. The behavioral treatment group also displayed fewer aberrant behaviors and social problems at follow-up. Results suggest that behavioral treatment was effective for children with autism in the study.

ABA based treatment has additionally been shown to help older children and has repeatedly been shown to improve skills for a wide variety of learners, in the areas of:

  • Communication
  • Social interactions
  • Play
  • Adaptive daily living
  • Compliance
  • Behavior management

Research suggest that for best outcomes, treatment should be:

  • Started Early
  • Comprehensive
  • Intensive
  • Significant Duration

Treatment can still be effective for older individuals as well. Non-intensive treatment programs focusing on critical skills can still be effective.

While ABA has been proven to be the most effective treatment, it is not an immediate fix. Progress is the result of many hours of therapy using systematic teaching methods. An effective ABA program is customized for each individual learner based on current skills, needs, interests, preferences, and family situation. ABA is not a One-Size-Fits-All approach.

A Look at the ABA Team

Who does the ABA treatment team consist of?

  • A qualified and trained BCBA (Board Certified Behavior Analyst) who develops and directly oversees the treatment program and is responsible for service delivery oversight.
  • Therapists/RBT’s (Registered Behavior Technician) who is responsible for implementing treatment plans designed by their BCBAs
  • Parents/Caregivers a critical component to any child’s life and ABA program!
  • Other Professionals: And this can include speech therapists, occupational therapists, etc.

Role of the RBT

The therapist works under the direct supervision of the BCBA

Responsibilities may include but are not limited to:

  • Direct implementation of skill acquisition and behavior reduction plans developed by the BCBA
  • Data collection for both skill acquisition and behavior management
  • Conduct certain types of assessments (e.g., preference assessments)
  • The therapist is NOT responsible for designing the intervention or assessment plans.

Ultimately, the BCBA is responsible for the work performed by the RBT

RBT Responsibilities: Provide Direct Therapy Sessions

  • Therapists provide the direct treatment services
  • Each ABA treatment program will be unique and individualized
  • While sessions will vary, most therapy will include the following activities:
    • Preparation and clean-up: The therapist spends the majority of the session directly with the learner, with the exception of preparation and clean up. During set up and clean-up, the learner may or may not be present with the therapist in the designated therapy room.
      • Preparation activities generally include:
        • reviewing past data and BCBA notes, this is REALLY important for a successful therapy session. This allows each therapist working with the learner to review relevant data input by other therapists and the BCBA since their last session with the leaner, and being up to speed on that learner is critical to their success.
        • Selecting and gathering data sheets
        • Collecting and setting up therapy materials (stimuli)
        • Organizing and setting up toys, activities, and rewards (i.e., reinforcers)
      • Clean up activities generally include:
        • Putting away any materials used during therapy, including stimuli, toys, activities and reinforcers
        • Finishing documenting and graphing data
        • Leaving notes for the next team member
        • Filling out any other required documents (e.g., timesheet, or documents within the treatment log book
    • Rapport building: Especially at the beginning of a learner’s ABA program, therapist’s should be “paired” with fun, reinforcing experiences and given adequate time to bond with their students. This is also done when a new therapist starts on a team.
      • Interactions in rapport building are focused primarily on preferred activities, things that the learner really likes to do, social interactions that allow the learner to “warm up to” the therapist.
      • Few demands are placed during this time
      • Rapport building is a valuable and vital component to the long term success of a treatment program
      • In addition every therapy session should involve a little rapport building, we want to make sure that the learner continues to associate the therapist with fun and enjoyment
    • Skill acquisition tasks: Learning activities are typically performed within two types of formats:
      • Discrete Trial Training (DTT): More formal instruction, repetition of instructions, often conducted sitting down with specific materials being presented
      • Natural Environment Training (NET): Less formal instruction, variety of instructions, centered on naturally occurring activities, moving around in the natural environment. Activities here may be a little bit more play based and happening around the child’s house. Lesson’s are taught within the moment.
      • Most leaners will have both types of therapy formats within their ABA program, some will utilize more of one than the other.
      • Learning activities will be interspersed with play and social activities throughout each session.
      • Initially, learning activities may be brief, allowing the learner to gain rewards and breaks for small amount of task, and then will gradually be increased.
        • Demand fading
      • Positive reinforcement will be used throughout the entire session to keep the learner motivated and reward all desired behaviors
      • The BCBA and therapy staff will help determine what type of reinforcers should be used during therapy sessions to promote motivation
    • Behavior Management: Each learner should have a Behavioral Intervention Plan (BIP) designed by the BCBA.
      • Therapists are responsible for consistently implementing the BIP across the entire therapy session
      • Accurate Data is recorded and graphed
    • Data Collection: Is an essential component to ABA therapy. Data helps the BCBA and therapists identify what a learner knows, the learners rate of acquisition, what teaching procedures work and do not work, and what needs to be modified to increase the success of the program
      • Data collection occurs continuously throughout every session and is generally collected on both skill acquisition targets and behavior reduction targets within the BIP
      • Data is then graphed allowing the BCBA to visually inspect the collected data which helps them to know if the treatment is effective or needs to be modified
      • Typically, therapists will record data during each acquisition task and play activity, or if necessary, during breaks following more NET activities
      • In addition, therapists may be asked to generate objective session notes, describing what occurred within the session -a general overview of the day and should include any variables that effected the students performance during the session (positive and negative both!) and could effect performance during subsequent sessions such as illness, changes to environment, change in medication, a new highly preferred reinforcer, etc.
  • Therapy Sessions Across Locations
    • Depending on the treatment goals of the learner therapy sessions may be delivered across the home, school, community, or a combination of these settings.
    • The BCBA will determine the appropriate setting for each learner and identify therapy targets.
    • Regardless of the setting, data will still be recorded. Though the setting may determine how the data is recorded or when.
    • Home: For many learners services are delivered in-home. Often a particular area of the home will be designated for therapy sessions during initial learning. That being said, as the learner progresses, when generalizing therapy will move throughout the home. Additionally, siblings and parents will be incorporated into sessions to target specific skills and generalization.
    • School: Many learners also attend school placements, whether preschool, typical education or special education placement. Depending on the learner, a therapist may be sent to school with the learner to facilitate learning and generalization. A therapist supporting a learner in the school setting may be referred to as a school shadow.
    • Community: Often learners will also have goals that require sessions to be conducted in the community setting. It could be an extra curricular activity such as an art class or sporting practice, or a shopping trip to the grocery store or clothing store, or a restaurant. There will likely be goals involving safety awareness goals, behavior reduction (especially patience), functional adaptive behavior (such as purchasing items with money, ordering and eating in restaurants, and following social rules in the community) and of course generalization. As well as social facilitation (e.g. support during group activities)
    • Combination: Many learners will have a combination of these locations incorporated into their treatment plans.

Effective Communication with BCBA

RBTs are expected to be in close communication with their BCBA at all times pharmaciepourhomme.fr.

  • In addition to data collection and session notes, it is important to relay information important information to the BCBA in a timely manner. The more critical the information the more critical that the information is provided to the BCBA as soon as possible. Of particular importance because BCBAs are not typically in daily contact with the client.
  • Examples of when an RBT may want to call the BCBA:
    • Client is sick and sessions are being cancelled (call)
    • Behaviors have unexpectedly increased (depends)
    • Parent/Caregiver expresses concerns or has questions (call)
    • Learner is having difficulty with a particular lesson/task (email)
    • Changes in environment effecting therapy sessions (email)

Communication with Other Professionals

Often clients also receive services from several other professionals (e.g., speech therapist, occupational therapist, etc.). There may be times when another professional sits in on a therapy session to observe treatment in efforts to collaborate. During these observations, the therapist may be asked to demonstrate certain lessons or activities. If the BCBA is not present during these observation sessions, the therapist should clarify how questions from the observer should be handled (i.e., refer all questions to the BCBA or Only respond to questions directly related to lesson implementation, refer all other questions to BCBA). Remember, nothing about the learner can be discussed without the written consent from the parent.

Communication with Parents

Therapist will be in regular communication with the client’s parents or caregivers typically both before and after a therapy session. Parents will often want an update on the completed therapy session. Must remember to remain professional.

  • Only discuss what occurred within the therapy session at hand, direct all overall questions or prognosis queries to the BCBA.
  • Be honest. But be careful with what you say. Use common sense and courtesy. Try to balance positive and negative feedback.
  • NO DUAL RELATIONSHIPS> See ETHICS for more detail <

Parent Training

Parent involvement is a crucial component to a successful ABA treatment program. The more parents are involved, the more successful the program. So typically, there is some degree of parent training incorporated into the program. Whether the parent training is provided by the BCBA or the therapist is dependent upon outside variables however the BCBA will determine this. “Parent” training could also include other family member, nannies or other individuals who come into regular contact with the learner. Additionally, the BCBA will outline the goals and structure for any parent training and if requested by the BCBA the RBT may be asked to implement some of this training.

  • During parent training, target skills are modeled and then parents are given hands on support as they learn to implement new procedures with their child.
  • Goals will include teaching the parents how to teach new skills and manage challenging behaviors.
  • Parents may also be trained on data collection procedures

Team Meetings, Planning Meetings, etc.

Meetings to discuss the learner’s progress. This meeting could include the therapists for a learner’s team, BCBA, Agency direct staff, Parents, and Other Professionals. Things like what is working, what isn’t? What new issues?

  • The BCBA leads the meeting and reviews the learner’s skills acquisition and behavior reduction data and makes updates.
  • Parents present any new information and ask questions
  • Therapists ask questions and demonstrate lessons with client
  • Some ABA providers may not hold regular team meetings where the whole team is present and in these instances there should be other methods in place for frequent and open communication between therapists/BCBA and parents. The BCBA should be regularly observing the therapist/ learner interactions as well as the learner.
  • The RBT would take lots of notes during the meeting: Any new information provided. Actively participate. Help keep the learner engaged if present at the meeting.
  • Responding to feedback:
    • Team meeting provide an opportunity for the BCBA to observe therapist behavior and technique and provide feedback
    • BCBA may offer praise/constructive feedback regarding:
      • Therapy technique
      • Behavior management
      • Data collection
      • Professional behavior

In addition to team meeting, direct observation/overlaps of the therapists during therapy sessions may also provide opportunity for feedback. And they are an opportunity for ongoing training and support.

Learn More…

Ethical Guidelines for Therapists Implementing ABA Treatment

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