There are many factors that a family should consider when they are comparing the services of different ABA providers for children. However, families are often comparing providers with little information, under time pressure, and with waitlists closing, insurance authorizations expiring, and clinic marketing that never reveals important differences between clinics. Clinicians and case managers can be very helpful in translating the program design questions of families into questions that parents can ask of and receive useful information from providers about to sign a service agreement with.
Testing whether a program is genuinely individualized
In terms of individualized programming (all programs claim to have it) there can be considerable variation in terms of the information gathered during the initial assessment. The thorough program conducts an intake assessment by direct observation of the child in various settings, preference assessments (structured), uses a range of standardized tools to assess various aspects of the child’s behavior repertoire, and conducts interviews with caregivers and relevant school staff members. The outcome of the assessment should be a written program that reads as if it were written for that child alone.
A few red flags that we’ve come across are a) the same number of hours is promised to every single child, b) goals are written in very generic curriculum terms and c) programs can’t explain why they chose one teaching procedure over another. These are huge warning signs.
Questions that reveal the difference
- What specific assessment results led to the recommended number of hours?
- Which skill domains were ruled out as priorities, and on what basis?
- How will the plan change if progress stalls for six weeks?
- What does discharge or reduced intensity look like for this child?
Verifying clinical qualifications and supervision density
Board Certified Behavior Analysts (BCBAs) can design programs, but they cannot implement them. It is the Registered Behavior Technicians (RBTs) and the teaching staff in a child’s classroom who will implement the largest portion of the ABA programs. Therefore, a more important question for parents is how much time a child will spend with the BCBA who designs his or her program. Will that time be spent observing the RBTs implement the program, or completing paperwork?
Be sure to ask about the BCBA’s caseload size. Typically a BCBA cannot provide proper oversight to more than 5-8 clients. Ask how often the supervising analyst is physically present during sessions and how technician performance is monitored. Find out the turnover rate for the RBTs and how that will affect your child’s progress.
Comparing common service models
| Model | Typical intensity | Best suited to | Main trade-off |
| Center-based | 20 to 40 hours weekly | Early learners needing dense trial opportunities and peer contact | Skills may not transfer to home without planned generalization |
| In-home | 10 to 25 hours weekly | Targeting routines, self-care, and family interaction directly | Fewer natural peers, higher demand on household schedules |
| School-based consultation | 2 to 10 hours weekly | Learners whose main barriers are classroom-specific | Depends heavily on teacher buy-in and district cooperation |
| Hybrid | Varies | Children transitioning between settings or age brackets | Coordination burden across two teams |
Judging communication before it becomes a problem
Communication also has the potential to affect families negatively more than any other area. Families should look for applied behavior analysis programs that set up and follow through with a schedule of meetings with parents as well as communicate information from sessions in a clear format (i.e. Graphs, charts, etc.). Be wary of programs that do not assign a certain individual to deal with parents’ concerns or questions.
Ask how a provider would handle a parent’s disagreement with a goal or a specific program component such as a procedure. If the parent objects to a goal or procedure, ask the provider how such input from the caregiver and family would be documented and how the program would change as a result of such feedback. Families can determine within the first phone call if they can trust a particular program or not based on tone.
Goals that mean something outside the therapy room
Look for specific goals that outline an observable behavior, define a mastery criterion, and scope for generalization. Even more important is that the goals you agree to can be connected to the outcomes that matter most to family members. That means that a goal to participate in a family meal, to communicate a need in the community or at a doctor’s appointment, or other community based outcomes are far more relevant than just “compliance” or “reduction” of problem behaviors and can support the child’s emergence of stable and useful new skills in the absence of therapy.
Families should ask to review actual goals written for past or current clients (with identifying information removed). It is far better to read a written goal than to hear a provider explain the goal verbally, and established teams such as those offering ABA therapy in Rhode Island are usually willing to share sample goals so parents can see exactly how progress is defined before committing.
Making family involvement workable
- Agree on a realistic caregiver training schedule rather than an aspirational one.
- Identify two or three routines where parents will implement procedures, and start there.
- Build in coaching with feedback, not just instruction.
- Review what is working every quarter and adjust the load.
Practical constraints worth resolving upfront
Additional factors to consider in regards to sustainability of the program are insurance authorization limits, the family’s copay structures, transport time to and from sessions as well as any sibling care needs. A program that recommends 30 hours per week for a child is not sustainable for a family able to consistently send their child to 18 hours of programming. The provider that is honest with families in regards to their ability to authorize for the maximum amount of hours and subsequently has poor attendance is typically not providing quality services and therefore not yielding quality outcomes for children and their families.
