Program Design

The BHC Mission

The mission of Behavioral Health Consultants [a.k.a. BHC,] is to provide specific, high quality ABA treatment services to children diagnosed with Autism Spectrum Disorders. 

BHC Services

ABA Treatment Services are provided Monday through Saturday between the hours of 8am-7pm to children diagnosed with an Autism Spectrum Disorder. Children served are approximately one year of age to seven years of age. ABA Treatment services are provided to children living in and/or going to school in Glendale, Pasadena, Burbank, Hollywood, Mid-Wilshire Los Angeles and West Los Angeles areas. When Assessment services are authorized, a trained and experienced Board Certified Behavior Analyst i.e. a ‘BCBA’ will conduct a ABA Assessment & Functional Analysis. The assessment, when completed is then submitted to Regional Center and/or the school district for their approvial and funding. 

      BHC provides the following services:

Intensive ABA Therapy

Parent Training

Functional Assessments

Direct Supervision

Varied Treatment Settings

Intensive ABA Therapy

BHC therapists receive intense training in a wide spectrum of ABA models including but not limited to Discrete Trial Therapy (DTT), Natural Environment Teaching (NET), Pivotal Response Therapy, Picture Exchange Communication Systems (PECS), Incidental Teaching, Peer Integration, Generalization, Positive Behavior Support, Visual Support Systems, Reinforcement Strategies, Behavior Management, etc. In brief, treatment is based on the use of positive reinforcement. Rewards are selected based on the needs of each child. Typical ‘positive-type’ reinforcement includes but are not limited to favorite drinks, snacks, toys and verbal praise. As intervention progresses with older age children, more age-appropriate rewards are provided when the older child can demonstrate that they have mastered problem-solving skills, and have demonstrated age appropriate socialization skills. Older children must demonstrate that they can cope with and problem-solve in a wide spectrum of community activities. 

Parent Training

Parents receive training in behavior management during weekly parent training sessions. This training includes parent and staff discuss of reinforcement…i.e. when to use it….when not to use it, and which reinforcement strategies are most useful, and appropriate etc. When parents successfully learn intervention skills, they are reportedly, “better equipped to more successfully manage their children‘s maladaptive behaviors.” ABA research validated this hypothesis i.e. “children with autism have better therapeutic outcomes when their parents or caregivers are involved in their treatment. “

ABA Functional Assessments

The ABA Supervisor, with their special skills in Applied Behavior Analysis, will conduct an ABA Functional Analysis, write up their observations of the child and present their findings and their recommendation to Regional Center. Included in the ABA Functional Assessment will be the ABA Supervisor’s recommendation regarding the treatment design, the methodology to be used to implement the treatment plan and an evaluation of the instructional and environmental modifications that may be necessary to produce socially significant improvements in the child’s behavior. Through the vehicle of this ABA Assessment, Regional Center and/or the school district will be able to view behavioral measurements in the following areas: Cognition, language and communication skills (verbal and non-verbal,) adaptive skills, social skills, basic living skills, compliance etc. If Regional Center and/or the school district is in agreement with the recommendation of the ABA Supervisor, ABA treatment services will be authorized. A specific treatment plan will then be implemented.

Direct Supervision

When ABA treatment services are implemented, the BHC Case Manager will meet with parents on a weekly basis. The ABA Supervisor will oversee by “hands on” observations that the treatment plan is being implemented as designed. In addition, the ABA Supervisor will oversee that Case Managers are providing parents and therapists with on-going training on ABA techniques specific to the treatment plan.

Varied Treatment Settings

The settings where ABA services are delivered is varied and based on the clinical needs of the child. Services are conducted within the child’s primary home environment and locations within the community (e.g., grocery stores, parks, community walks).  Services may be generalized to include community integration and recreational programs (e.g., basketball camp, soccer practice).   

The ‘ABA’ Model

BHC utilizes an ABA Model for each child’s treatment plan.  Research suggests that treatment should typically start while the child is under three years old. ABA is based on the concept of breaking skills down into smaller more manageable tasks and goals until the child learns the skill.  This integrated approach teaches skills that build upon and complement each other.  

Early Learners

Early research suggests that 1:1 behavioral therapy be administered initially in the home setting, and then generalized to other settings such as school (Lovaas, 1993). At BHC, treatment begins in the home setting. Transition to school placements occurs once the child reaches school age.  

ABA treatment focus is on the reduction of maladaptive behaviors such as tantrums, aggression and self-injurious behaviors. For children under three years of age, the child’s natural environment is the ‘learning classroom.” Therapists will apply Incidental Teaching and Natural Environmental Training models to build rapport and teach age-appropriate skills. Goals for young children include: reducing maladaptive behaviors, increasing language skills, developing play skills, and increasing imitation and gross motor skills.  

Older Children

More structured teaching is incorporated during sessions around this time.  Older children are usually required to sit for periods up to 30 minutes in length, typical to a school environment. Skills are taught through a variety of teaching strategies such as Discrete Trial Teaching, Natural Environment Teaching, Incidental Teaching, and Peer Integration. Goals for older children include: following instructions, increasing socialization, advancing observational learning, building complex language, and generalizing learned skills. These are pre-requisite skills that a child must learn in order to progress to more complex behaviors.

Features of Our Model

Individualized treatment customized to the child’s individual needs.

Comprehensive treatment: i.e. all skills are addressed: language, adaptive, social, etc. 

Principles of Applied Behavior Analysis are used to teach functional skills and to reduce maladaptive behaviors

Supervision is conducted on a weekly basis

Parent training is on going: Parents receive training throughout the course of their child’s treatment.

Latest research findings are incorporated into our treatment planning.

Learning objectives are age-appropriate.

Treatment is intensive.

BHC Goals

Therapists use incremental learning coupled with positive rewards (i.e. reinforcement) to move a child toward their respective goals. When a child demonstrates age-appropriate and/or functional communication and/or behavior i.e. has mastered certain tasks, the child is then transitioned to learning more complex behaviors and goals.

Development of Adaptive and Socially Significant Behaviors

Learning basic living skills is the foundation for learning more complex adaptive skills. When the child demonstrates age appropriate skills and behaviors, he/she moves on to more complex coping, problem solving and socialization skills. “Going to school” requires the incorporation and implementation of a wide spectrum of abilities, if the child is to be successful in the school environment. Schools challenge children to solve problems, cope with adversity, learn how to play with others, how to communicate one’s needs, how to focus, comply and express oneself appropriately. The ABA treatment plan is designed to target these and other issues with each child.

Reduction of Maladaptive Behavior

Children are taught more socially appropriate behaviors that eventually serve as ‘replacement’ behaviors for maladaptive behaviors such as self-injury and tantrum behavior.

Generalization 

Each target skill builds upon each other.  Generalization is targeted immediately to ensure skills are transferred from one situation to another (e.g., from communicating with caregivers at home, to interacting with classmates at school).  Emphasis is placed on generalizing skills across people (e.g., parents, nanny, extended family, and school staff); the way instructions are presented, and across learning environments (e.g., home, community, school).

Parental Involvement 

Parents are incorporated within the child’s ABA program immediately.  Emphasis is placed on training parents to follow the ABA Treatment Plan, learning to ‘reward’ their child for appropriate behavior, conducting a functional analysis of their child’s behavior (i.e., Why does their child engage in a specific behavior?), data collection, and learning to maintain their child’s acquired skills.   

Transition and School Inclusion 

Community Outings are incorporated so that skills can be taught and generalized in the setting in which they are meant to be used. Treatment gains are often generalized to school through the use of 1:1 aide…and/or, the treatment itself may even be carried out at the school itself. Steps are carefully taken to ensure consistency across the child’s comprehensive treatment plan.  Consultations with school staff and other providers (e.g., Speech, OT) are provided when requested by parents, regional center service coordinators and/or teacher specialists.

Transition to Independence

BHC addresses transition to independence and/or less restrictive treatment settings through the following methods.

Fading to success 

Careful consideration of prompt compliance is reviewed and discussed on a weekly basis.  Care is taken to ensure that assistance provided to the child  is systematically faded based on success. Therapists and parents are trained to utilize the least intrusive prompt necessary when providing assistance to the child.  

Behavior Management 

Parents receive intense training throughout the course of their child’s ABA Program.  A heavy emphasis is placed on conducting a functional analysis of their child’s behaviors. Specifically, parents are provided with the tools necessary to: (a) Recognize when a behavior requires intervention, (b) Keep accurate data on that specific behavior, (c) Analyze the data to determine why the child is engaging in the behavior, and (d) Implement the correct intervention to reduce that behavior.  In accomplishing this, control of the child’s behavior is transitioned to parents.  

Naturally Occurring Reinforcement Schedule 

At some point in the ABA treatment program, transitioning the child to a naturally occurring reinforcement schedule is prioritized. What this translates into is that the child is given fewer and fewer rewards for the same behavior. [In ABA jargon, this process is called “thinning.”] Theoretically, when the child ‘internalizes’ a reward (positive or negative,) the internalization of that reward, will, over time, define the communication. That is, the behavior begins to “occur in a natural state.” An example of this is found in the simple act of greeting another person. When a “smile” is added to the greeting, as for example, saying “Hi” and smiling concurrently, the ‘smile’ becomes part and parcel of the “greeting.” The ‘smile’ is the non-verbal or meta-communication. The ‘smile’ reinforces and validates the greeting, “Hi.” It is the non-verbal communication that is what is most powerful and, what really suggests to the recipient if the “Hi” is warm and sincere.  One other example that occurs frequently, is saying, “I love you.” The words, “I love you,” in and of themselves are meaningless unless validated and reinforced by other, more powerful, non verbal behavior. The same is true in reverse, simply ‘going through the motions of loving or caring,’ but not validating it by verbally communicating the expression “I love you,” may compromise or confuse what the “behavior” actually means. Over time, if the verbal communication or the non-verbal communication is “left out of the communication equation,” the result may compromise, twist or misconstrue what the message was intending to convey. This is a difficult problem to overcome with persons who do not have an autistic spectrum disorder. It is even more difficult of a problem with those children who are experiencing an autism spectrum disorder. For this reason, the clearer that the message can be delivered, with the concomitant meta communication validating it, the clearer will be the interpretation of the message. 

Transition to Independence 

Goals for older children will include the acquisition and the practice of problem-solving, coping and age-appropriate living and play skills. Of particular importance to transitioning to independence is the development and practice of impulse control and postponing satisfaction. All of this translates into “learning a discipline to live by.” Bottom Line: To improve the child’s quality of life, certain areas of functioning need to be prioritized.  Without having a firm grasp of the building blocks that are fundamental to learning more complex behaviors, the child will have problems learning skills that will provide him/her with a high quality of life.  The Supervisor of ABA Services will be responsible for determining which priority skills the child needs to learn. The ABA Supervisor, in turn, will monitor the progress of each child in learning these skills.  When the skills are mastered, the child can then progress to more complex skills and behaviors. 

From Home to More Independent Living

Our goal at BHC is for the children to ‘generalize’ and implement their ABA learned skills and behaviors to living more independently. To expedite this process, the ABA Program is individualized so that children will progress ‘at their own speed,’ and, in incremental steps. Success is measured by the children’s ability to generalize skills and behaviors by applying them appropriately in a wide spectrum of community-based settings. 

Process

Skills acquired at home are generalized across environments, people, stimuli, and instructions.  Once a child adapts to the structure of Discrete Trials, for example the next goal is to make the instructional setting as natural as possible. Natural Environment Teaching (NET) and Pivotal Response Training (PRT) are usually implemented to transition the child away from a structured setting, and, to a more natural setting (e.g., to the outdoors or the community). 

Natural Environment Teaching (NET) involves generalizing learned skills to natural occurring situations. For example, through the vehicle of play activities,  an ABA therapist may teach the child to ‘request’ by using a process called “Manding”  Operationally, as an example, if the child reaches for a toy truck, the therapist may use the act ‘of reaching’ as an opportunity to teach the child ‘how to request.’ To do this, the therapist might say, “Oh you want the truck,…. say truck.”  When the child responds and says, “Truck” the child immediately receives access to the truck, In this example, the child received natural reinforcement. Natural Reinforcement refers to the child now having access to the truck. Similar principles are applied in other situations that also occur naturally in the child’s milieu. 

Pivotal Response Training (PRT), on the other hand, is based on the concept that there are two ‘pivotal’ behaviors that affect a wide range of behaviors. With children experiencing autism spectrum disorders, motivation and responsiveness to multiple cues are key variables in PRT.  Operationally, it is suggested that in PRT, motivation and responsiveness are key factors that influence a wide range of functioning. It is suggested by some researchers that positive changes in one area i.e. motivation or responsiveness, will in turn, create or trigger a positive change in the other area. Theoretically, PRT is able to increase the generalization of new skills while increasing the motivation of children to demonstrate the behaviors being taught to them. Components such as child choice, turn taking, and making reinforcement contingent upon behaviors are also central to PRT. 

Maintenance 

Once it is determined that a specific skill has been acquired, or ‘learned’, generalization continues, however, the frequency in which the skill is practiced gradually decreases.  For example, a skill may go from being practiced daily, to 3x/week, to 1x/week, to 2x/month. Maintenance is conducted so that the child does not ‘lose’ the acquired skill.  Rather, the child is ‘tested’ occasionally to determine if the skill is being maintained.  

Skill Building 

Every skill taught within our ABA Program builds upon each other.  In order for advanced skills to be introduced, there has to be certain pre-requisite skills that must first be met.  In this sense, each skill that is taught will be later used to teach the child another skill, possibly a more advanced skill.  Therefore, a skill that has been previously acquired will never stop being practiced.  Since each skill is used to build the next skill, this ensures that maintenance of previously acquired skills continues throughout the child’s program.

Data Collection 

In order to determine if a skill has been successfully learned, consistent and accurate data collection must be kept. To start off, we must first establish a method of measuring the specific target or behavior.  Each target and behavior must have a clear operational definition. This definition will ensure consistency across therapists and care providers. Once a method of measurement is clearly defined, data collection and measurement of generalization can then proceed.  

Measurement 

The operational definition will clearly define the response that is expected and in what teaching environment generalization will take place. A skill is not considered mastered until the child is able to demonstrate the skill across individuals, settings, instructions, and stimuli with 80% accuracy. Behavioral data is collected using rates of behavior.

Rates of Behavior: Data collection consists of: ABC’s (Antecedent, Behavior, Consequence) frequency, and duration.  Each behavior is calculated as a frequency per hour figure (e.g., .70 per hour).

Progress: Frequencies are calculated every two weeks for both therapy and non-therapy hours.  Progress is measured in terms of frequency reduction (i.e., from .70 per hour to .50 per hour).

Generalized Learning 

Exemplars are introduced until a child demonstrates ‘Generalized Learning.’  Generalized Learning is the ability of a child to demonstrate mastery of a skill without prior training.  For example, a child is taught to catch and throw a ball back and forth to his mother while at home.  While at school, the child is able to independently engage in a game of kickball with his peers.  In this example, the child was never taught to play a game of kickball. Rather, the child ‘generalized’ his ball playing skills to a game of kickball at school. 

Parent Training Objectives

Parents play an integral part of their child’s ABA program.  Parents must participate daily during all ABA sessions.  Through parent training, parents learn the tools necessary to ‘carry on’ their child’s treatment after therapy sessions are over (during non-therapy hours).  Parents are trained to be the child’s “best instructor.”

Parent’s Role

Parents are required to participate on a daily basis during their child’s ABA program. Parents receive weekly training on ABA techniques utilized within our agency.  On-going training is also provided daily during parent participation.  During the initial functional analysis assessment, parents are instructed that participation in their child’s treatment program is mandatory. Parents are thoroughly debriefed on BHC’s expectations regarding their involvement.  Parents agree to and sign BHC’s Parent Agreement before their child receives any ABA services.  The Parent Agreement outlines in detail the role parents must take during their child’s ABA sessions.       

Learning Objectives

BHC provides parent training on the following topics.  Parents are expected to learn and implement all of the following ABA techniques.  Parents are provided with materials outlining each of the below mentioned ABA techniques. In addition, handouts are given to parents at the end of parent training sessions.                                                              

Reinforcement: Training begins with teaching parents on how to successfully reward their children for appropriate behavior. Parents are expected to demonstrate appropriate reinforcement within one month of treatment. 

Behavioral Deficits: Parents are provided with training on the four behavioral deficits observed in children with autism: Social Integration, Language, Play Skills, and Self-Help Skills.  

Behavioral Excesses: Parents are also expected to learn the four behavioral excesses observed in children with autism: Tantrums, Aggression, Non-Compliance, and Self-Stimulatory Behavior.

Function: Parents are taught that each behavior a child engages in has a certain function (i.e., children and adults engage in behaviors for four separate reasons).  Parents are then taught that interventions for behaviors depend on the function of the child’s behavior (i.e., you cannot implement an intervention unless you know the function of the behavior). Training on the function of behaviors occurs immediately.

ABC’s of Behavior: Once parents understand the function of behaviors, they are then taught how to determine the function.  Parents are trained on how to conduct a functional analysis on their child’s behavior (i.e., Antecedent, Behavior, Consequence).  This will allow the parents to implement their own interventions, without assistance from a therapist/Case Manager.

Behavior Reduction Procedures: Training continues on how to successfully implement behavioral interventions.  Parents are expected to learn the following techniques: Redirection, Extinction, Over-Correction, Response Cost, and Differential Reinforcement.

ABA Basics: Training is provided on the following ABA techniques utilized at BHC: Discrete Trial (DTT), Natural Environment Teaching (NET), Pivotal Response Training (PRT), Picture Exchange Communication System (PECS), Incidental Teaching, and Peer Integration Programs.

Generalization and Maintenance: Additional learning objectives for parents include generalization and maintenance.  Parents are trained on how to correctly generalize and maintain their child’s learned skills.

Method

Parent training includes lecture and direct 1:1 demonstration with their child.  Techniques are first modeled for the parent.  After demonstrations, parents are expected to ‘apply’ the learned technique in the presence of the instructor.  Additional demonstrations are provided when necessary.

Since parents receive ‘hands-on’ training during their child’s ABA session, parents are given verbal feedback immediately by therapists.  ABA therapists coach parents during all parent participation sessions.  Therapists do not wait for the parent to ‘finish implementing the procedure incorrectly’ before feedback is provided.  Rather, therapists interrupt parents immediately to provide them with feedback.  In addition, parents are provided with in-vivo demonstrations on all ABA techniques. 

As mentioned above, parents are provided with direct 1:1 instruction and demonstrations.  In addition, parents are asked to keep data on their child’s behaviors during non-therapy hours.  Data consists of what behaviors are occurring, why the behavior occurred, what consequence was provided, whether or not the consequence was effective in reducing the behavior, and how long the behavior lasted.  Data is collected weekly during parent meetings.  Although parents are instructed to keep data weekly on their child’s behavior, some parents do not follow through with data collection.  When this occurs, parents are instructed of the importance of data collection and how it is vital that they provide this information.  If parents fail to follow through with data collection during non-therapy hours for three consecutive weeks, service coordinators are contacted and this information is reported in the upcoming progress report.

Role of Parents in Treatment Implementation

Parents play a vital role in the implementation and planning of their child’s comprehensive treatment program.

Treatment planning 

Meetings between parents and Case Managers are conducted weekly.  During parent meetings, Case Managers review the child’s progress with programming and behaviors.  Parents also use this time to notify Case Managers of any concerns or issues with programming and/or behaviors during non-therapy hours.  Case Managers collaborate with parents on how to successfully problem solve behaviors and/or program concerns.

Treatment Implementation 

Parents are aware and agree to follow all behavior interventions set forth in their child’s treatment plan.  Parents essentially ‘take over’ when therapists leave.

Analysis of treatment 

Data collected during therapy and non-therapy hours are reviewed weekly during parent meetings.  During this time, programs and interventions are reviewed with parents. In addition, parents inform Case Managers when interventions used during non-therapy hours are unsuccessful.  During this time, parents and Case Managers will collaborate and problem solve each of the program/behavior concerns.  

Parent Programs

All daily life skills (e.g., dressing, washing hands, toileting, bathing, brushing teeth, etc) must be implemented by the parent/caregiver. The parent or caregiver provides all instructions delivered during these programs. Therapists also use this time to coach parents/caregivers and to give constructive feedback.  

Parents are required to participate for a specific amount of time (as outlined in the treatment plan) during each ABA session. Case Managers then review the Parent Participation component weekly during their Supervisions. If it is observed that parent participation is not being conducted, a meeting with the parent will be scheduled to problem-solve issues compromising parent participation. The Case Manager and/or the ABA Supervisor will reinforce the importance of parental participation in the ABA treatment program.

Parents are also instructed to ‘track’ their child’s behaviors during non-therapy hours.  Data provided by parents are reviewed weekly during parent meetings.  Parents are also asked to implement these techniques in-vivo.  

Description of BHC Supervision Model

Assessments

All functional analysis assessments are conducted and written by the ABA Supervisor.

Parent Training

Therapists, case managers, and the ABA Supervisor provide parent training.

Supervision Standards

Supervision for ABA services is conducted on a weekly basis. Supervision during ABA sessions focuses on reviewing progress toward program/behavior goals and modifying program/behavior goals if necessary.  

Case Staffing  

Cases are staffed based on who would be the best fit for each child, based on relevant work experience, expertise in the treatment model etc.  BHC does not staff cases based on ‘personality’ traits and/or ethnicity/culture.  The ABA Supervisor has the “final say” on decisions regarding staffing. 

Frequency of Supervision

BHC provides one hour of clinical supervision for every 10 hours of ABA services that take place at the child’s residence. Additional Clinical Supervision also takes place during Clinic Meetings, when new therapists begin working, during individual consults, group training sessions and at any other time that supervision is requested or called for.  The ABA Supervisor is responsible for overseeing all supervision sessions.

Supervision of individual treatment plan

The ABA Supervisor conducts the initial Functional Analysis on every consumer referred to BHC.  Recommendations for hours needed for clinical services and the specific programs to be implemented are based on each consumer’s individual needs. The ABA Supervisor is solely responsible for conducting the Assessment and writing up the assessment. 

The ABA Supervisor meets with parents/caregivers to review the role of parents in their child’s ABA treatment plan.  Case Managers then meet with parents to introduce therapists and to conduct the initial parent training.  

Clinic meetings are held twice a month.  During clinic meetings, therapists, parents, Case Manager and ABA Supervisor review progress toward goals and new interventions that will be introduced.  Parents also meet with Case Managers once a week to discuss any concerns regarding treatment services.

Prior to report writing, the ABA Supervisor visits the home frequently to observe each consumer’s behaviors, and speaks with parents regarding issues and progress.  Changes to treatment plans are also discussed at this time.

Grievance Policy

BHC strives to provide the highest quality services to all our children.  The following steps are taken to ensure parental concerns are addressed immediately.

If a parent has a concern with respect to their child’s treatment plan, parents are asked to address this issue with their child’s Case Manager.  The Case Manager will meet with parents to address these and all other concerns.  

If parents are not satisfied with the outcome of the meeting, they have the option to speak with the ABA Supervisor. The ABA Supervisor will address their concerns and create a “plan of action” to resolve issues.

If parents remain unsatisfied after having met with the ABA Supervisor, they have the option to speak with the agency director and/or schedule an additional meeting(s) with other BHC managerial staff.