Which Is Best for My Child – ABA Therapy in the Home or Clinical Setting?
When not fully understood, applied behavior analysis (ABA) may seem like an overwhelming treatment option for children diagnosed with autism.
Many people are unsure what ABA is, what it can do and why it is used. Simply put, ABA is a science that uses reinforcement strategies to increase or decrease socially significant behavior. Based on empirically validated learning principles ABA is widely used; not only for adults and children diagnosed with autism or intellectual disabilities, but also with parent training for neuro-typical developing children, substance abuse, dementia care management, traumatic brain injury, business management, and a host of other things.
The rise of autism has become a prevalent health crisis in this country. ABA has become one of the most scientifically studied treatment approaches for children and adults with autism. It has developed into such an important treatment option that 48 states have taken government action to cover ABA therapeutic costs (Health Insurance Coverage, 2018).
Now that ABA funding is being covered by most insurance plans, parents have treatment options. These options can include ABA home servicing programs delivered within the home or approaches delivered outside the home within a clinical setting.
But which is better? Should a child be receiving services in a clinic or should they be receiving services at home?
Honestly, this question comes down to the quality of programming. Does your child’s programming offer the “BATCAGE” of services? Meaning does it hold all seven core dimensions of ABA (Baer, Wolf, Risley, 1968) which is Behavioral, Analytical, Technological, Conceptually Systematic, Applicable, Generalizable, and Effective (BATCAGE).
Let’s take a closer look at these dimensions and see if the home or clinical approach is the right fit for you, your child and the whole family.
ABA focuses on the behaviors that we need to do. Meaning, the programming is based on behavioral learning concepts.
Is the teaching of ‘skill acquisition’ based on decreasing behaviors and increasing skills? Home programming and clinical setting approaches should both be behavioral in nature. Each should have a focus on increasing socially appropriate skills and decreasing maladaptive behaviors. Home programming may offer a larger option in developing household skills that a child may not have an opportunity to practice meaningfully in a clinical setting.
A clinical approach may allow for the practice and learning opportunities but may not produce an increase in skills in the natural environment. Quality programming should offer an opportunity to practice these new behavioral skills across settings and across people.
A quality ABA program is data-driven. Data should be what is guiding the decision making for your child’s programming. Good questions to ask when evaluating the right program for your child are:
- How is data taken, graphed and analyzed?
- Is data being taken every day?
- Is data being analyzed regularly for program changes and interventions?
- Who is the person analyzing this data and making program decisions?
It is highly recommended that ABA programming should be overseen by a Board Certified Behavior Analysis (BCBA). Not sure what a Board Certified Behavior Analyst is? A great resource is to look into the Behavior Analyst Certification Board at the www.bacb.com.
What are the contact hours between the supervising BCBA and client? Home and clinical programming should have a supervising BCBA who regularly visits, analyzes, assesses, and makes programming decisions with the family and in some cases the client. Clinical programming may have more opportunities for BCBA supervision on site. Home programming may lack fidelity in supervision depending on the approval hours given. This should be a consideration when looking at programming.
These are the directions or instructions for delivering programming and precise instructions for implementation. A good way to understand this concept is to think of it as the “lesson plan” for skill targets. These instructions should be clear and concise that anyone reading them will understand them and be confident with delivering the instruction.
Home and clinical programs should have these instructions for all skill acquisition targets and should be open to the family. Home programming may offer a data book that stays in the home and is the property of the family that can be looked at whenever they choose. Clinical programming should offer the same concept so families can understand the delivery of the programming and its reinforcement strategies.
Does your home or clinical program use these terms when describing procedures and programs? Interventions should be consistent with the principles seen in empirically validated research. Anything done in an ABA program should be from research related behavior analytic concepts. Programming should be thoroughly enriched and guided with concepts such as positive reinforcement, shaping, prompting and even error-less instruction.
Can they tell you why they are doing what they are doing and have the research to back it up? ABA therapy is an empirically supported treatment that has close to 50 years of research.
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What will my child be learning and how will it apply to his/her life? Goals and interventions are chosen based on its social significance to the client and the family.
Clinical settings demonstrate an ability to practice these situations in mock and contrived environments. These contrived settings are a great starting point for many early learners. However, if the skill is not generalize in other environments, the effectiveness of a clinical setting diminishes.
Home programming may be a larger help for the application of many daily living skills. The learner has the opportunity to practice these skills in a “real life” setting or the “natural environment.”
When behavior occurs outside its learning environment that is generalization and it is one of the most important parts of ABA therapy.
Will a home or clinical program generalize across settings, people, and time? A good program, whether in the home or in the clinic, should always be programming for generalization. Generalization teaches the learner how to access reinforcement within his/her environment. Home programming should encompass all aspects of instruction including access to the community. Clinical programming should overlap within the home and community for generalization purposes.
How will I know if programming is working? The effectiveness of ABA programs are measurable (data, data, data!) Honestly, for a program to be effective behaviors that are being targeted for increase or decrease should show behavior change.
Behaviors that learners engage in should show improvement to an “effective” degree. Home programming may address the most needful behaviors that occur in the home and affect family life. Clinical settings may only be able to address behaviors that are seen in that setting.
ABA: Home or Clinical setting? What is the right choice for me? Whichever setting you choose, it is important to make sure that is the “BATCAGE” of programming. Both settings can heed great behavioral change. It is up to us, the consumer, to continue to push, research, and evaluate the effectiveness of our children’s programming using the “BATCAGE” as our starting point.
Baer, D.M., Wolf, M.M., Risley, T.R. (1968). Some Current Dimensions of Applied Behavior Analysis. Journal of Applied Behavior Analysis, 1, 91-97. https://doi.org/10.1901/jaba.1968.1-91
Health Insurance Coverage for Autism (2018, August) Retrieved from https://www.autismspeaks.org/health-insurance-coverage-autism,
This article was featured in Issue 87 – Building ASD Awareness and Communication