What is the best location for ABA? Well, that depends

With numerous ABA companies claiming to be the best or the most innovative, it can be quite challenging to identify a provider that aligns with your family's needs. Once you have selected a suitable provider, an important consideration will be the location of the sessions.

Each setting—whether it be in-home, center-based, community-based (such as schools, daycare, or afterschool programs), or via telehealth—has distinct advantages and disadvantages. This article will examine some of the most common benefits and challenges associated with these various locations. As with any service, it is essential to approach this process with due diligence; while a company may present information in a favorable light, it is crucial for you to conduct thorough research and engage as an informed participant.

In-Home

Benefits of In-Home ABA

• Children often feel most comfortable in their home environment, where they spend the majority of their time.

  • Conducting sessions at home allows them to naturally engage in skill development activities, such as cleaning up their toys, practicing hand-washing at the sink they use frequently, and playing with siblings.

• You can monitor your child’s interest in session and respond appropriately if they show signs of discomfort, potentially reducing the occurrence of tantrums that may arise when transitioning to a clinic or office. Furthermore, there is convenient access to preferred snacks, which can enhance the overall experience.

This approach is particularly beneficial for school-aged children who face the challenge of balancing a full school day with after-school activities or additional center visits. In-home sessions also provide greater control over the environment, allowing for easier breaks, quiet time, and tailored activities that suit the child's needs without the constraints often found in community locations or center-based sessions.

Behavior Technicians (BTs) can incorporate additional toys or activities during sessions, which can be helpful if a child struggles with sharing or shows disinterest in their usual toys. Moreover, parents can actively participate in the sessions. Even when working from home, it is generally manageable to set aside 15-30 minutes to engage with the BT and practice targeted skills or join in on activities.

This involvement not only enables parents to observe how sessions are conducted but also provides an opportunity for them to give feedback to the Board Certified Behavior Analyst (BCBA), interact positively with their child, and ensure that all parties are aligned in their objectives.

**In-Home Limitations**

**Challenges**

Staffing qualified ABA professionals for in-home services can present significant challenges, including long hours, extensive travel, and the demanding nature of the work. Many of these staff members are college students or recent graduates who are still determining if this is the right career path for them. Additionally, there are financial constraints in cases of session cancellations, particularly if replacements are not available.

It is important to note that there are limited opportunities for children to access insurance-based ABA services in the morning; most services are only available after school. These factors contribute to the difficulty of sustaining a position as a Behavior Technician (BT), especially in high-demand regions such as the Bay Area.

While it is essential for your child to receive the recommended services, it is equally important to have BTs who are genuinely invested in their work. The difference in session quality is evident when a BT is enthusiastic versus one who may not fully engage.

**Policies**

We recommend familiarizing yourself with the company's policies regarding substitutes, scheduling, cancellations, and make-up sessions. This is particularly important for in-home settings, as each provider may have different regulations that should be outlined in the agreement you sign. Please review the contract carefully and don’t hesitate to ask questions for clarification.

**Social Opportunities**

For children who are only children, there may be limited social opportunities. Initially, targeted skills will be practiced with the BT; however, it is beneficial for these skills to be reinforced with peers to foster communication, play skills, turn-taking, and other social interactions.

A responsible adult must be present during in-home sessions with the BT. Situations such as having other children enrolled in afterschool programs or neighbors supervising can necessitate adjustments to your routine or the location of the session. This measure is vital for ensuring your child's safety, as the BT is responsible for their well-being during the session.

**Session Cancellations**

When a session is canceled, options may be limited. It is crucial to clarify that in-home ABA services are not intended to serve as childcare or to supervise your child while you work from home. Existing routines may be deeply ingrained, making it challenging to implement changes without provoking difficult behaviors.

There may be established routines related to play or daily living skills—such as difficulties with sharing or specific ways of engaging with toys—that could be better addressed in different environments. Conducting sessions in neutral locations can be advantageous, especially if certain challenges are observed at home or school. The goal is to create a setting conducive to the child’s overall benefit.

**Environment Considerations**

Without passing judgment on any family's circumstances, it is important to recognize that the home environment may not always be conducive to effective sessions. Factors such as the presence of a crying baby or general distractions can hinder the learning process. Given that our sessions typically involve active engagement—such as singing, playing, and cheering for younger children—noise limitations may impact the quality of the session.

If the child displays anxiety or discomfort due to environmental distractions, such as a sibling’s cries, it may be more effective to hold sessions in alternative locations to focus on skill development rather than merely accommodating the situation.

When sessions occur in smaller or distracting spaces—such as a studio apartment or during home renovations—it is essential to take proactive measures to minimize disruptions. Steps might include turning off the television, designating a specific area for sessions, limiting the number of individuals present, and integrating outdoor activities or community outings whenever possible.

Construction noise, both inside and outside the home, can pose additional distractions and potential hazards. If a child has a history of elopement or is unaware of their surroundings, care should be taken to ensure their safety while attending sessions, especially with frequent transitions due to school or extracurricular activities for siblings.

**Community Location: Preschool, Daycare, After-School Program**

**Benefits:**

For Applied Behavioral Analysis (ABA) specifically, a community setting can be advantageous for children who have begun to develop some communication, daily living, and social skills but are seeking opportunities to practice these skills with peers or in new environments.

Challenges may arise in building connections and making progress toward initial goals within these settings. Children who lack certain skills might feel uncomfortable in these environments, highlighting the importance of tailoring experiences to the child and program.

In the event of a Behavioral Technician's (BT) absence due to illness or emergencies, it is beneficial for the child to still participate in activities. The child should be placed in a setting where they can reasonably succeed without the support of a BT. It is the role of the BT to provide additional assistance to facilitate participation and engagement.

The expected level of participation, both with and without the BT, should be discussed collaboratively with the provider. Some parents and children may be comfortable with independent reading during after-school programs in the absence of the BT. Therefore, it may not be realistic to anticipate full engagement in every activity solely due to the presence of the BT.

Focusing on the child's interests and ensuring access to preferred activities is crucial. If the program lacks motivating options, it may be unreasonable to expect the BT to gain the child's attention and encourage participation.

Additionally, community settings often provide ample opportunities for children to practice social skills with their peers. Adequate time should be set aside for engaging in preferred activities and interacting with peers if this serves as motivation for the child.

When children are motivated to participate in activities, their willingness to engage will naturally increase. It is essential to find a balance between providing structure through routines and expectations while allowing flexibility to explore the child's interests with the BT.

Introducing different toys and activities that are not typically found at home can aid in generalizing skills. After spending significant time at home, a child may lose interest in familiar toys or activities. Utilizing new or varied toys can support the development of sharing, turn-taking, and negotiation skills.

Group skills, such as lining up, transitioning, and waiting, can be practiced in a natural environment, where the routine may facilitate learning these skills more effectively than at home. Observing peers model appropriate behaviors can further ease this process.

In certain settings, there may be well-suited peer models available. Children often begin with observational play rather than parallel play, meaning they observe others before actively participating. If your child is at this stage or engaged in parallel play, having peers available can be beneficial.

For a clearer understanding of the environment and peer interactions, consider taking a tour of the setting before enrollment. While every child may experience challenging days, aspects such as routine, structure, and age-appropriate expectations can positively influence their experience.

It is important to recognize that adhering strictly to rules or expectations is not necessary for a structured environment. Adults in the program should be prepared to respond appropriately if a child is reluctant to participate, fostering an atmosphere of respect and predictable transitions.

Some programs may require children to be entirely still and focused on the teacher before transitioning, an expectation that may not be realistic for most children. For instance, expecting young children to sit attentively for extended periods during circle time in Kindergarten can be unreasonable. It is vital for caregivers to understand realistic expectations based on the developmental stage of the children involved.

**Limits**

The Behavior Technician (BT) is not intended to serve as a 1:1 support. If your child requires an adult to accompany them in order to participate in activities, please communicate this to the Board Certified Behavior Analyst (BCBA) in advance. This proactive approach will help prevent miscommunication later on. Many Applied Behavior Analysis (ABA) companies are not equipped to accommodate same-day substitutions; therefore, if the BT is unavailable due to illness, another staff member may not be available to fill that role. In such situations, your child may need to be sent home from the program due to a lack of appropriate supervision. If the school mandates a dedicated person for your child, this indicates the need for a 1:1 aide, rather than a BT.

Additionally, the BT should not provide support in personal care activities such as bathroom assistance, diaper changes, or emergency situations, similar to home sessions. Parents must communicate this expectation to the community location before services commence.

The BT and ABA team will follow the activity's routine, which may not be suitable if the structure is not developmentally appropriate or engaging for the child. If the child struggles with neutral activities or if the environment consistently places undue demands on them, the ABA team’s effectiveness will be limited. It is important to recognize that we cannot compel a child to participate in activities that are excessively lengthy for their age group.

Parental participation is limited in many of these settings. There may be specific events, such as open houses or a Halloween Party, that would allow parents to participate, but this varies by company. Consequently, you may not have insight into what takes place during sessions. For parents who prefer to be fully informed about the team’s activities, the limitations may not be as significant if there are no concerns at home.

It is essential to ensure that the chosen location is beneficial, incorporating age-appropriate expectations aligned with your preferences. Your child’s willingness to attend is also crucial. Some difficulty in transitioning during the initial sessions, or after a period of time, is to be expected. However, if your child continues to struggle with transitions after consistent attendance for several weeks, we recommend consulting with the team to explore potential strategies.

There should be sufficient opportunities to address goals and areas of need, as outlined in your child's assessment. The BCBA will recommend a specific set of goals tailored to the needs of your child within the setting to maximize their benefit.

During sessions, the BT should be actively facilitating engagement. It is not uncommon for there to be times during academic tasks where the child may work independently while still requiring support during social activities. Collaborating with the setting and the ABA provider will help ensure that the BT is present during critical moments of support.

Center-Based Services

- Typically involves small groups of peers throughout each session.

- Participants can engage in both small group activities and individual tasks with the behavior technician (BT).

- Many centers incorporate circle time or calendar time, providing additional practice for children who may be facing challenges at home.

- Sessions may still be conducted if another child is absent.

- Since the BT does not need to travel between locations, there may be opportunities for sessions with a different BT who has likely interacted with your child at the center previously.

- Board Certified Behavior Analysts (BCBAs) are located nearby to provide support and guidance to the BTs.

- Having all staff working from the same office allows for increased direct and indirect oversight by a BCBA.

- The center may offer activities or strategies that are not available at home or in community settings.

- All children attending the center have sensory needs and may require support with transitions and social skills. The environment is designed to be more accommodating than typical community locations, with additional support and sensory-friendly activities compared to afterschool programs.

**Recommendations and Considerations for ABA Services**

When considering center-based therapy options, exercise caution regarding firms that suggest a standard recommendation of 40 hours per week without prior assessment or interaction with your child. There have been instances where ABA service providers advise parents that their child requires 40 hours of therapy weekly without ever meeting them or conducting a proper evaluation. It is important to note that a recommendation for 40 hours a week may imply that the child is not attending school, which raises concerns as ABA therapy should not substitute educational environments.

While there may be cases where a child could benefit from a structured setting similar to a school environment within a center, these scenarios are exceptions rather than the norm. If your child is of school age, they may be eligible for an Individualized Education Program (IEP), which can offer tailored small-group instruction and help with academic skills development.

**Transparency in Service Delivery**

Please be aware that due to confidentiality regulations concerning other clients, many center-based sessions operate on a drop-off basis. If you prefer to remain informed about your child's activities during sessions, this arrangement may not be suitable for your family.

**Consistency of Service Providers**

One of the advantages of center-based ABA services is the potential for consistent session delivery. However, there is a possibility that your child could be assigned different behavior technicians (BTs) with each session, which may not always be communicated to you. In contrast, with in-home services, any changes in staff are typically more visible.

**Parent Training / Telehealth Overview**

**Benefits:**

- Provides effective strategies and feedback in situations where the child may exhibit reactive behaviors.

- Utilizes technology to observe the child in their natural environment, minimizing any potential influence on their behavior that assessment might cause.

- Allows Board Certified Behavior Analysts (BCBAs) to offer enhanced support, as travel time between locations is reduced.

- Research indicates that telehealth supervision can be as effective as in-person sessions.

- Offers flexibility in scheduling, enabling meetings at times convenient for you without the need for extended home sessions.

- Facilitates ongoing communication even during travel, ensuring continuous support.

- Allows for easy scheduling of additional support sessions, should the need arise.

**“Train the Trainer” Approach:**

- In a parent-focused treatment model, BCBAs can collaborate with you to implement effective strategies in real-time as you interact with your child.

- This approach is particularly beneficial for enhancing communication skills, promoting independence in daily routines, and addressing tasks such as potty training. Since parents typically spend the most time with their children, consistent implementation of strategies can facilitate faster progression toward independence.

**Limitations and Considerations**

- Telehealth services may not always be a direct service option for your child.

- However, telehealth can provide valuable opportunities to discuss strategies and receive feedback for both you and the individual working with your child.

- It is important to analyze real-life scenarios through telehealth or recorded videos, supplemented by in-person meetings for additional support.

- Older children and teenagers might benefit from direct telehealth sessions with a Board Certified Behavior Analyst (BCBA) or participation in a social skills group.

- There are certain prerequisite skills that may be necessary for independence in these settings; thus, a behavior therapist (BT) or parent may need to provide in-person assistance.

- Please note that insurance coverage for telehealth services for children may be limited, though it is likely to cover Parent Training.

- Some larger Applied Behavior Analysis (ABA) organizations tend to prioritize cases requiring more extensive services and may not accept cases focusing solely on Parent Training or those that would benefit from 10 or fewer hours of ABA therapy with a BT each week. This approach allows them to allocate resources effectively.

- It is not uncommon for parents to encounter difficulties in obtaining support from ABA companies, especially while waiting for BT services to begin or while on a waitlist.

- In specific regions, such as the Bay Area, securing a BT for after-school services can take six months or longer.

- Parents nearing the conclusion of direct services may find that their children no longer require sessions with a BT, but still wish to maintain regular check-ins with a BCBA for questions and guidance during this transition.

- Many children may not require extensive ABA services; often, they just need periodic check-ins—potentially weekly or bi-weekly—especially prior to major transitions, vacations, or social engagements.

- Engaging with someone outside of their parents can facilitate discussions about making friends and navigating social situations.

- Using preferred activities, such as Minecraft or Roblox, can enhance social skills development.

- Some children find it easier to converse about sensitive topics, like friendship, through a digital medium.

The management practices and protocols within ABA agencies can change frequently. An agency that receives high praise now may face challenges in the future. You may begin the intake process with one agency and feel uncertain about your choice. A provider claiming a six-month waitlist may, in reality, have a shorter timeframe.

If you begin services and find they do not meet your or your child's needs, you have the option to discontinue at any time.

Should you determine that the behavior technician (BT) is not the right fit or that the services offered are not suitable, it is important to address this with the BCBA early on.

If you suspect that a particular agency may not align with your expectations, continue exploring other options that may better suit your needs. As long as you feel your child is in a safe environment, they can continue to receive sessions from the current ABA provider while you seek an alternative.

**Assent Should Be the Focus for You and Your Child**

Assent refers to the agreement of individuals who are not legally able to provide consent. It is essential to prioritize this aspect in our interactions with children. We should avoid using hand-over-hand prompting if a child is in distress or resisting.

New behavioral therapists (BTs) who lack experience in managing specific tasks, such as potty training or helping a child get fully dressed, should not be placed in these situations. It is acceptable for a child to opt out of an activity. Forcing participation in unnecessary activities can lead to trauma and increased stress for the child.

In certain situations, such as visits to a medical professional or dental care, it is important to focus on the child’s health and safety. These experiences can be approached using trauma-informed practices to minimize stress. When children are in potentially vulnerable situations, they should engage in these activities only with trusted adults.

When addressing potty training, a BT may gather prompting or task analysis data outside the bathroom, but it is crucial that a parent or teacher is the only adult present with the child inside the bathroom, especially during undressing. Collaboration with the parent during dressing routines can help integrate practices into natural morning and evening activities. Frequent or excessive focus on non-functional tasks may lead to undesired behaviors.

Exceptions may be made for tasks like putting on shoes, which can be seamlessly incorporated into outdoor activities during sessions.

It is vital to ensure that you and your provider are aligned in adopting neurodivergent-friendly approaches. Strategies such as enforcing eye contact, mandating complete sentences at all times, compelling social interactions, neglecting adequate downtime, overlooking sensory needs or interests, and implementing certain punishment methods have been documented to cause harm to neurodivergent individuals.

We encourage you to listen to the experiences of adults who have undergone ABA therapy or those who identify as neurodivergent. Life can be challenging, and it is important to avoid practices that may exacerbate difficulties. Advocate for what is in the best interest of your child, rather than conforming to societal expectations.