Choosing a Behavior Analyst: Not All Clinicians are Created Equal

Christopher D. George, M.Ed., BCBA, LBA

The diagnosis of a child with autism is a life-changing event. In addition to dealing with the emotions of the diagnosis, your family needs to seek quick answers to questions and determine the most effective treatment for your child. With 1 in 88 children currently being diagnosed with autism (CDC statistics) and there being no known cause, you have a plethora of possible treatments or combinations of treatments to research and decide what you think will work best for your child. Within the field of applied behavior analysis, there are different procedures, techniques, and styles instead of a ‘one size fits all’ treatment package. I wish that I could give you a matrix that would easily match you up to the best BCBA for your family, but unfortunately this is a decision making process. Hopefully the points below will help to focus your thoughts and streamline the process.

1) Know your family. Every family has their own lifestyle and this will impact the type of ABA service delivery and BCBA that you choose. Many families see the success of a 40 hour a week ABA therapy treatment plan and want that for their child, but in reality, their priorities and the demands on their time do not make this a viable option. It is very important to know how your family functions best and be able to clearly explain this to potential clinicians. Just because your work schedule only allows you a few hours a night two days a week to work 1:1 with your child and the BCBA is not something to be ashamed of. Do not try to rate yourself against the other families in your support group, and make statements about what you can or are willing to do that just sound good. Be honest and know that as BCBAs we will not judge you, but we need that information to know if our style will be a good fit for you or if we need to shape our strategies and techniques to provide you with the best possible service. Failure to address these characteristics up front can lead to frustration, disappointment, and lost treatment time. Some questions to answer about yourself and to share with potential clinicians,

• What does your schedule and/or your spouse’s schedule look like?
• When can you schedule time to meet with the BCBA and to work with your child? How many days a week for what length of time?
• Would you prefer to work in your home or to work in a ‘clinic’ location?
• Would you like a BCBA who provides direct matter of fact instructions (i.e. ‘Just tell me what to do and I’ll do it’) or would you prefer someone to take more time explaining why they want you to do something (i.e. ‘I need to understand it before I will do what you are asking me to do.’)?
• What is your current discipline style? Are you a permissive parent that takes the path of least resistance or are you an authoritative parent who expects your children will do what you say when you say it?
• How often are you willing/able to collect data of target behaviors and skill building strategies?
• Other critical family dynamics that the BCBA should be aware of? (i.e. blended family, joint custody, involvement of grandparents, siblings with or without diagnosed disabilities, strong support network or no support network, limited financial resources, etc).

2) Know your child. While 1 in 88 children are currently being diagnosed with autism, my experience has taught me that everyone is unique. The combination of their strengths, weakness, challenging behaviors, and health issue will impact the type of treatment necessary and the necessary skills/experience of the BCBA. Knowing these factors and attempting to match them with the BCBAs skills/experience will be important. It is equally important to have a basic understanding of goals and outcomes that you have for your child, and what you want the BCBA to focus and work on. When searching for a BCBA to work with your child, you will need to quickly give a brief overview of who your child is, what skills they currently have, what you are concerned about, and what you hope to achieve. This will allow the BCBA to talk about their experience with the challenges you have listed as well as briefly explain how they hope to help you accomplish your goals. This dialogue should help you to know if the clinician will be a good fit for your child.

• What are your child’s diagnoses?
• What are some things that your child does well? Favorite activities?
• What missing skills are you concerned about?
• Does your child engage in challenging behaviors? What are they?
• What do you hope your child learns in the next 6 months? A year? 5 years?
• If you could name just one thing that is most important for you to see your child accomplish, what is it?

3) Know your funding source. There are many different funding streams that can help to pay for behavior analytic services including: private insurance, Medicaid waiver, private pay, etc. Each of these different funding streams has different regulations/requirements, limits on units of service, and qualifications to provide the service. It will be necessary for you to know exactly what these are so that you understand the limitations of how the BCBA will realistically be able to provide the service. (i.e. if you want a BCBA to work with your child 20 hours a week but your funding source will only pay 3 hours of service, you need to talk to the clinician about what they can do with the 3 hours a week and not why they won’t provide 20 hours a week of service). Collect the following information about your funding source:

• What are the minimum qualifications for the clinicians to provide behavioral services within this funding stream? (In KY, private insurance companies must use a Licensed Behavior Analyst, however Medicaid waivers allow other disciplines to also provide behavior support.)
• How many hours a week will your funding source pay for?
• What does the funding source require for documentation?
• What type of service delivery model will the funding stream pay for? Will they allow direct 1:1 work with your child or only consultation?
• Are there any limitations on where the funding stream will pay for the service? At home? in school? In a clinic?
• Are there annual caps on how many hours of service or total dollar amount of service your funding stream will pay for?
• Are you able to use more than one funding stream to pay for similar services?

4) Research potential agencies/BCBAs. Once you have determined how your family operates, what your child needs, and what your funding source will provide, it is time to start looking at specific agencies and clinicians. While much of this article has discussed getting matched up with a specific BCBA for your skill strength, many agencies have the ability to offer several choices of clinician and will work with you to find the best match within their agency for your family. Sometimes, the additional supports provided by the agency administration can be an added benefit for your child and family. This section will include a combination of questions both for agencies and clinicians

• Ask around. Often word of mouth reputation is the best indicator of good quality services. Talk to your case manager, support group, etc about who provides good quality services. But know that this is just someone’s opinion and not always factual. When asking others about agencies and clinicians be specific:
  • What exactly did you like about their services?
  • What exactly did you not like about their services?
  • What type of success did your child have when working with them?
• Research online. Many agencies and clinicians have a webpage that talks about their mission, values, services, etc. Get online and see what they say about themselves and see if this sounds like a good fit for your child and family.
• Call the agency. Once you have narrowed down your search, call and talk to them about the services they provide.
  • How many years have they been in business?
  • How many clinicians currently work for the agency?
  • How does the agency match up clients and clinicians?
  • Can the agency provide them with families they are currently serving that they can talk to about the services they have received? Do they have documented testimonials or satisfaction data on the services they provide?
  • How does the agency work with the family if the clinician is not a good fit for their family?
  • What types of supervision and supports are provided by the family to the clinician?
  • Ask to speak to potential clinicians within the agency as necessary.
• Talk to the clinician(s). These questions could be asked of a clinician prior to selecting them and/or during the first visit if you have chosen a particular agency to get services through.
  • What is their educational background? Are they Board Certified? Are they Licensed? Are they working on certification or licensure?
  • How many years have they been providing behavior analytic services?
  • What types of clients have they worked with in the past?
  • How many total clients are they currently serving?
  • How much time will they be able to work with your child each week?
  • Do they still have a supervisor or mentor that they can go to with clinical questions, etc? If so, how often to they seek their input? (note: I feel it is very important for clinicians to constantly be seeking supervision, regardless of how long they have been a BCBA).
  • What special skills or focus do they have in their clinical practice?
  • Ask about their style, approach, and what you as a parent can expect from them in teaching you to follow the recommended strategies.
  • What can you expect from them in regard to data collection, written strategies, other documentation.

5) Know you are the consumer. Just because you have chosen an agency and clinician, know that you continue to have rights to know about your child’s treatment, question strategies or services, and choose another provider as necessary. Ultimately you are responsible for decisions and permission regarding your child’s treatment, so be a strong (but fair) advocate!

• Always ask why a certain strategy should be implemented? Keep asking questions and for explanations until you understand. (If they can’t, this should be a red flag)
• Ask the clinician to ‘show you’ what you want them to do. (If they can’t, this should be a red flag)
• Ask the clinician to show you the graphs of your child’s behavior and to explain why there is or is not progress. (If they can’t, this should be a red flag)
• Ask for copies of all documentation. Functional Assessment, Behavior Support Plan, and Progress Notes (as necessary). These are the formal clinical documentation of your child’s treatment.
• After doing the above, if questions continue about the treatment you are receiving, ask the clinician to speak to their supervisor for a second opinion or call the agency administration (I know that often parents do not want to cause conflict, but it is critical to express any concerns as soon as possible.)
• If you are unhappy with the clinician providing you supports, you have the right to request a new clinician or agency. Talk to the administration of the agency as well as your case manager or service coordinator to determine the best avenue for switching services.

Ultimately, the right BCBA will be a blessing to your child and family! Often these relationships continue for many years and everyone shares in the ups, downs, frustrations, successes, fears, hopes, dreams, tears of sadness, and tears of joy that come from raising a child diagnosed with autism. Your preparation in selecting the right BCBA can set the foundation for success and help to minimize the stresses associated with being a parent! For more resources in your search for the right match, please follow the links below:

Consumer Guidelines for Identifying, Selecting, and Evaluating Behavior Analysts working with Individuals with Autism Spectrum Disorders:

http://www.behaviorcanchange.com/PDFs/ABAAutismSIG%20Gdlns%202007.pdf

Kentucky Association for Behavior Analysis: www.kentuckyaba.org

Association for Behavior Analysis International: https://www.abainternational.org

Behavior Analyst Certification Board: http://www.bacb.com

Kentucky Applied Behavior Analysis Licensing Board: http://aba.ky.gov/Pages/default.aspx

Christopher George graduated from the University of Florida in 1997 with a Master’s in Special Education. He taught high school special education for 4 years. During the same time he helped establish a non-profit Americorps program that taught GED courses and auto repair to high school drop-outs. The cars that were repaired were given away to individuals coming off of public assistance (350 in 4 years). Chris completed his ABA course work under Dr. Martinez-Diaz and became a Board Certified Behavior Analyst in 2001. He served as a behavior analyst for the Alachua County School District for 1 1/2 years before moving to Kentucky to work at an ICF/MR under Department of Justice Review. Since leaving the facility in January 2006, he has provided community based services throughout the state of Kentucky as well as serving as a behavior analyst/consultant for the Columbus Organization.

He started, Applied Behavioral Advancements, LLC in March 2007. In addition to providing services through the SCL Medicaid waiver, he has contracts for behavioral services and consultation with the state-run psychiatric hospital, an ICF/MR, Seven Counties Services (crisis and pre-crisis intervention), and Laurel County Public Schools. Chris’ experience includes working with individuals diagnosed with mental retardation, autism, and/or psychiatric disorders. He prefers to work with individuals who engage in high magnitude/frequency physical aggression or self-injury.