By Ashleigh Evans, MS, BCBA

In the early 2000s, advocacy efforts pushed forward a medical model of ABA. This model gained momentum as states began passing autism insurance mandates. In 2014, the Centers for Medicare & Medicaid Services (CMS) published a bulletin clarifying that Medicaid programs must provide autism services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. This set in motion plans across all 50 states for Medicaid programs to provide ABA and other services to Medicaid recipients. As of today, every US state also has insurance mandates requiring ABA therapy coverage, fully integrating ABA into the healthcare system.

The shift to a medical model of Applied Behavior Analysis (ABA) has brought benefits to the field, including increased access to care. However, with it also came increased treatment plan scrutiny from payors. Most payors now require BCBAs to demonstrate that a client meets medical necessity to authorize services. Let’s explore the concept of medical necessity and consider how clinicians can advocate for their learners.

What is Medical Necessity in ABA?

Medical necessity is a concept used within the healthcare field. It refers to treatment that is necessary to diagnose, treat, cure, or alleviate symptoms of a particular condition. When we look at medical necessity in ABA, we have to consider whether the therapy modality and specific individualized goals will realistically help relieve the symptoms of autism that are interfering with the learner’s quality of life.

Each payor has different medical necessity criteria. Generally speaking, to determine medical necessity, funders consider the type of care, frequency and duration, location where care will be provided, whether the treatment is research-backed, and whether it would be considered effective for the individual patient.

How to Demonstrate Medical Necessity

Behavior analysts are responsible for advocating for their clients–this includes advocating for medical necessity to enable their learners to receive medically necessary care. Here are some recommendations for navigating this requirement.

1.    Understand the payor’s medical necessity criterion.
First, make sure you understand each payor’s criteria for medical necessity. Most major insurance providers publish medical necessity guidelines online under their Behavioral Health or Medical Policies. You can also access medical necessity criteria in your provider manual. If you can’t locate medical necessity criteria, reach out to your provider rep for guidance.

2. Ensure up-to-date diagnostic assessments.
   
   One component of medical necessity is typically a recent autism diagnosis. Most payors require comprehensive diagnostic evaluations every 3-5 years to verify the individual’s diagnosis. Keep an eye on the dates of diagnostic assessments and inform your clients when they’ll need a reassessment soon. Many providers have lengthy waitlists, so try to be proactive in urging families to get these scheduled.
   
   Tip: If your client is due for a reauthorization but is overdue for a diagnostic re-evaluation, encourage the family to at least get it scheduled before you submit the authorization request. Many funders will recognize that diagnosticians have schedules that book out for months or even years, so the client may not be able to access a re-evaluation by the required date, but they at least want to see that it’s scheduled.
   
   
3. Conduct insurance-approved assessments at least every 6 months.
   
   Make sure you have an updated and accurate assessment on file. Certain payors only accept specific assessment tools, so be sure to verify which assessments are accepted by the funder.

4. Add a rationale for each goal.
   
   In your treatment plan, add a justification for each treatment goal. This justification should tie back to the diagnostic criteria of autism spectrum disorder (ASD). In other words, specifically, how will targeting the goal alleviate the symptoms of ASD? Per the DSM-5, diagnostic criteria for autism include:
   

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
   
   
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
   
   
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
   
   
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).
   
   
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).
   
   
4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

Here’s an example of a justification statement for an ABA treatment goal:

Goal: Client will independently mand for preferred items in 80% of opportunities, across 10 consecutive sessions, by 10/09/2025.

Rationale: To remediate the deficits in social communication that limit the client’s ability to get their needs and wants met.

5. Make sure the hours you’re requesting match the learner’s needs.

Lastly, ensure the hours of ABA you are requesting match the learner’s needs. If the individual has minimal needs or if you aren’t effective in communicating the full scale of their needs within the treatment plan, the funder may deem that services at the requested level are not medically necessary. Consider the whole picture of the learner’s abilities, needs, other services, and school supports to determine clinical need.

Main Takeaways

Behavior analysts are responsible for advocating for their clients’ best interests. While navigating the complexities of insurance and Medicaid can be challenging, it can be done effectively. Take time to understand each payor’s criteria and create a comprehensive treatment plan that directly addresses the funder’s requirements for demonstrating medical necessity.

About the Author

Ashleigh Evans, MS, BCBA, is a Board Certified Behavior Analyst. She has been practicing in the behavior analysis field for over 13 years and opened her own independent practice in early 2022. Her experience has been vast across different age groups, diagnoses, and needs. She is passionate about improving the field through education, reformative action, and better supervisory practices, leading her to create content and resources for families and ABA professionals which can be found on her website, www.abaresourcecenter.com

By Patrick Faga, MS, Creator of the FirstWork App

Tablets have become common tools in education, but their impact in special education, especially within the framework of Applied Behavior Analysis (ABA), deserves special attention. For many students—particularly those with autism—tablets can offer lightning-fast feedback that is both immediate and consistent. When someone taps a tablet, it registers the input in as little as 1 to 10 milliseconds, faster than the human eye can detect. That kind of speed, paired with the tablet’s reliable response, can make a world of difference for learners who depend on quick reinforcement to build new skills.

A Brief Recap of DTT/DTI

Discrete Trial Training (DTT), also known as Discrete Trial Instruction (DTI), is a highly structured teaching method often used in ABA therapy. It typically involves three main steps: a clear, concise instruction or question (the “discriminative stimulus”), the learner’s response, and an immediate consequence—either positive reinforcement for correct answers or gentle correction for errors. Because it focuses on repeated practice and immediate feedback, DTT has been particularly effective for children with autism and other developmental disabilities. However, the success of DTT hinges on providing quick and predictable responses to each learner action.

Why Faster, More Consistent Feedback Matters

Research published in the Journal of Applied Behavior Analysis highlights the importance of minimizing the delay between a learner’s action and the educator’s response. The less time between response and consequence, the more robust the learning connection becomes. Yet in busy classrooms or therapy sessions, even well-trained professionals can experience natural variations in how quickly or consistently they deliver feedback. Human factors—like fatigue, changes in tone of voice, or distractions—can cause slight delays that might interrupt the smooth flow of reinforcement.

Tablets bypass many of these challenges. The moment a learner taps the screen, an on-screen prompt or sound can tell them right away if they’re correct or if they should try again. That instantaneous feedback helps learners form stronger associations between their response and the outcome, reinforcing correct behavior and guiding error correction more effectively.

Benefits for Learners with Autism

Many individuals with autism thrive on consistency and predictability. Knowing exactly what will happen when they touch the screen can reduce anxiety, encourage engagement, and help them persist with challenging tasks. A tablet’s consistent, automated feedback is less likely to vary because of human mood or environment, making it an invaluable tool for reinforcing positive behaviors or prompting self-correction. Over time, learners often show increased independence and confidence when they can anticipate the same quick response every time.

Generalization Through Digital Presentation

Another major advantage of digital DTT/DTI is the built-in capacity to present multiple examples or “exemplars” of a single concept. Generalization—being able to apply a skill across different settings, stimuli, or people—is a critical goal in ABA and special education. When using a tablet, it’s easy to display various images or sounds in rapid succession, exposing learners to different contexts without having to gather real-life objects or shuffle through physical flashcards. This variety helps learners transfer what they’ve mastered to the broader world, ensuring the skill doesn’t remain “locked” in a single context.

Keeping it Simple for Teachers and Therapists

Of course, the human element remains essential. Educators and therapists are still the guiding force, shaping each learner’s progress and providing the warmth, understanding, and personal connection no device can replicate. However, certain digital platforms strive to make it easier for professionals to leverage tablets in DTT/DTI. One such example is FirstWork, which offers a wide range of images and straightforward data-tracking features, streamlining session prep and progress monitoring. By automating some of the rote tasks—like collecting response times and instantly providing feedback—tools like FirstWork allow educators to focus on what really matters: helping learners succeed.

In short, tablets represent a powerful ally in delivering more immediate, consistent feedback in DTT/DTI programs. Their speed, reliability, and versatility in presenting varied content help learners, including those with autism, stay engaged and acquire skills that transfer smoothly into everyday life. When paired with thoughtful strategies and a caring educator, tablet-based DTT can turn each tap of the screen into a stepping stone toward independence and growth.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).

Criterion B2 for Autism Spectrum Disorder lists “insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or non-verbal behavior”—underscoring a clinical preference for predictable, consistent environments.

Goris, J., Brass, M., Cambier, C., Delplanque, J., Wiersema, J. R., & Braem, S. (2020). The relation between preference for predictability and autistic traits. Autism Research, 13(7), 1144-1154.PubMed

This empirical study found that higher autistic-trait scores correlate with stronger preferences for predictable music, images, and reward schedules, providing experimental evidence for a drive toward predictability.

About the Author

Patrick Faga, MS, is a behavior scientist and technologist. Patrick obtained his masters in Behavior and Decision science from the University of Pennsylvania. He has experience as an ABA technician, working directly with learners on the spectrum. Patrick’s passion is applying science based principles into technology systems to create new avenues for learning and skill development. 

By Nahoma Presberg, MS BCBA NYS-LBA

Behavior analysis can support the improvement of an individual’s quality of life in a wide variety of ways. We can teach language and functional skills as well as help clients find replacements and alternatives for unsafe behaviors. We can also help clients develop a wider repertoire of leisure skills that can support the enjoyment of free time and broader access to the world around them.

There’s no better feeling than when you can see someone getting more comfortable and curious to explore and try new things. Introducing new interests really has the power to change someone’s life in a meaningful way. However, this task can be extremely complex and requires a lot of intentionality from the therapists.

So, what are some things to keep in mind when you’re working with a client on developing new interests?

1. Be patient. Familiarity often leads to enjoyment. When we’re more comfortable with an activity, it’s easier to relax into it and have it be a true leisure skill. One of the characteristics of autism is preferring to stay within routines and familiarity. This means that it can be difficult to try new things. It may evoke feelings of anxiety or nervousness in our clients (and probably ourselves too!) Take your time, it will be worth it.
2. Abandon expectations. There are endless things that people find interesting in this world. Some are more popular, while others might be more niche. While we know that shared interests can help facilitate social skills and make developing friendships easier, it’s important that we listen to our clients about what is genuinely interesting. From there, we can help them tap into various social communities that share these interests. The same can’t be said in reverse order.
3. Get creative. You never know what’s going to click. Get comfortable exploring the process with your client and have fun with it!
4. Respect autonomy. New interests is a great opportunity to let your learner take the lead more than they might get to otherwise. This is an opportunity to understand how they approach things and what gets them excited.
5. Get curious. You never know what might work!
6. Be careful about what you’re reinforcing: When you’re introducing new activities, materials, etc. towards the intent of supporting the development of new interests, it can be easy to want to reinforce compliance behaviors or task completion behaviors. However, finding new interests is often about the process and we want to make sure that we’re reinforcing willingness to try, flexibility, curiosity and other behaviors that support the client’s ability to engage with you. Remember, it’s about the process and the process should be fun!

About the Author

Nahoma Presberg, MS BCBA NYS-LBA, is a Board Certified Behavior Analyst. Nahoma obtained their master’s degree at the University of Rochester in Human Development. They have been working with clients in their homes for the past 6 years but has over a decade of experience supporting children with developmental disabilities. Nahoma is passionate about neurodiversity affirming care and thoughtful programming that helps every client thrive.

For more information about Nahoma, you can visit their website at https://www.nahomapresberg.com/.

By Dana Reinecke, BCBA-D, LBA. Originally posted by Different Roads on January 25, 2018

Many people set goals for themselves throughout the year, and parents often think about their goals for their children.  In setting goals for a child with a disability, there are a few important considerations that will improve the likelihood of the child’s success, as well as the parent’s satisfaction.

It’s usually a good idea to start with big picture goals, and then narrow them down.  You might start by asking yourself what your ultimate goal for your child is, and then where you would like to see him or her in 5 years.  Then, what would you like to be accomplished in this coming year? 

Let’s say your big picture goal is for your son to have a happy social life.  Your 5-year goal might then be for him to have at least 3 friends that he sees on a regular basis.  Your goal might be to get him involved in an after-school club on a regular basis. 

To take another example, your big picture goal might be for your daughter to communicate effectively with other people.  Your 5-year goal might be for her to have conversational exchanges with other people in the absence of prompts or augmentative communication.  And your goal for this year might be for her to ask for what she wants when she wants it (to “mand” for desired objects).

Starting with the big picture goal and thinking about the 5-year goal can help parents to maintain their focus.  If you start with small goals and build up, you might find yourself building in the wrong direction.  Most importantly, keeping the big picture and 5-year goals in mind help to keep your more immediate goals functional and meaningful.  When time and resources are precious, you want to make sure that you use them only to address goals that are going to help your child to attain his or her best, most important possible outcomes.

A second consideration in setting year-long goals is how realistic they are.  No one knows your child better than you, as his or her parent, but even parents can have difficulty gauging just where their child may wind up after a year.  Many factors can impact the success of any goal, including the interventions available and other, unexpected barriers or supports that may arise.  It can be helpful to break year-long goals down even further into smaller steps, which will be easier to predict and monitor. 

So, for the son who you want to see be more social, consider breaking the goal of joining an afterschool club down into its parts, each of which will be easier and faster for him to accomplish than the whole:  investigate the clubs that are available, discuss his top two choices with a guidance counselor, attend the first meeting, etc.  Each of these smaller goals can be measured and celebrated, helping to keep momentum and motivation towards the bigger year-long and further aspirations.  Similarly, the daughter who is working on communication can achieve smaller goals by learning to mand using prompts as earlier goals, and then continuing to mand independently as prompts are faded. 

Finally, each of the smaller goals set for the year should be measured so that progress can be tracked.  Seeing progress is not only motivating and exciting, but can help to guide when to advance to the next set of goals.  Measurement is also important for identifying when progress is not happening as quickly as desired, so that the supports and strategies in place can be updated for better success.

About The Author

Dana Reinecke is a doctoral level Board-Certified Behavior Analyst (BCBA-D) and a New York State Licensed Behavior Analyst (LBA).   Dana is an Assistant Professor and Department Chair of the Department of Special Education and Literacy at Long Island University Post.  Dana provides training and consultation to school districts, private schools, agencies, and families for individuals with disabilities.  She has presented original research and workshops on the treatment of autism and applications of ABA at regional, national, and international conferences.  She has published her research in peer-reviewed journals, written chapters in published books, and co-edited books on ABA and autism.  Current areas of research include use of technology to support students with and without disabilities, self-management training of college students with disabilities, and online teaching strategies for effective college and graduate education.  Dana is actively involved in the New York State Association for Behavior Analysis (NYSABA), and served as President from 2017-2018.

This week’s article comes to us from Executive Director David Celiberti, PhD, BCBA-D, Association for Science in Autism Treatment. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

April is Autism Awareness and Acceptance Month. Infinity symbols, puzzle pieces, and calls to light it up blue will appear on thousands of social media pages and billboards, and the media will give greater attention to autism. Further awareness is wonderful, as detection and diagnosis are necessary first steps to accessing critical help in the forms of treatment, information, and support. With well over 500 treatments from which to choose, parents and caregivers of children with autism need guidance, tools, and accurate information to empower them to make the best possible choices for their children as these choices will undoubtedly have a profound impact on both their current quality of life and their children’s future and potential.

When I first entered the field over 35 years ago, autism was considered a rare condition and a low incidence disability. When people asked what I did for a living, they often misheard me and thought I said that I worked with “artistic” children. I received that response a lot. Clearly, autism spectrum disorder (ASD) is no longer the rare diagnosis that it once was. With the incidence of one in 36 children, so many of our own families, neighbors, and co-workers are touched by autism. In fact, the sheer numbers have heightened awareness of autism in and of themselves. This broader awareness is essential: it promotes early detection, and with early detection, we hope for a relatively clearer course toward effective intervention and ultimately better outcomes.

Sadly, however, early detection of autism alone does not provide a seamless path to intervention. Furthermore, families whose children are diagnosed with autism are still not able to access the most effective science-based treatments available expeditiously. Instead, families are often distracted by scores of pseudoscientific treatments until they arrive at the most effective interventions supported by peer-reviewed research to address the complexities of autism. Furthermore, other barriers such as lack of providers in their area and long waiting lists may lead families to consider a pseudoscientific treatment if accessing it is quicker or easier.

We must do better! “Autism Awareness” should involve more than just detection and diagnosis. “Autism Acceptance” should involve more than just tolerance or simply advocating for inclusion in the absence of any investment or commitment. At the Association for Science in Autism Treatment (ASAT), it has always been our hope that the conversation around autism awareness and acceptance would be broadened to focus on directly addressing the obstacles that separate individuals with autism from receiving effective, science-based intervention, to receiving the supports that are needed (across the lifespan), to ensuring that they are just not invited but truly welcomed at the table, and on combatting the misinformation that distracts individuals with autism, families, caregivers, and teachers from accessing accurate information. And this important work is needed year-round, not just during the month of April when it is popular and easy to signal support for the autism community.

Below I offer you 12 perspectives about what “Autism Awareness and Acceptance” should be about, along with several ways ASAT can assist families and providers alike in navigating the complex maze of autism treatment options. Please know that there are many voices in the autism community, comprising providers, family members, and autistic individuals. While my points are meant to foster discussion and understanding, these priorities may not resonate with everyone and are certainly not exhaustive. I encourage others to share their priorities as well. It is important to acknowledge and respect the diverse perspectives within the neurodiversity community.

1. “Autism Awareness and Acceptance” must recognize that the spectrum of autism is wide and that if you know one person with autism, you only know one person with autism.

In recent years, the autism community has witnessed and benefited from the rising voices of individuals who identify as autistic and who have expressed an array of views on their lived experiences. Although some have been diagnosed later in life and did not receive autism intervention or special education services and accommodations, many have shared both positive and negative accounts of what it was like to access services when they were younger. Among the many lessons to be learned is the importance of fully including the person with autism in goal selection and intervention choices and any and all decisions in between (as well as to carefully consider how we are empowering autistic individuals to have agency and an authentic voice when communicating their wants and needs in the first place). These important conversations have been insightful, transformational, and, at times, unsettling as we own our missteps and generate a path forward. Many professionals have shared shifts in preconceived notions, priorities, and perspectives. We do better when we truly listen.

Respect for divergent views is the soil in which the autism community can grow so that every person with autism can obtain the experiences and help needed to live their best lives. Some light it up red, some light it up blue, some say a person with autism, some say autistic person and it is all OK. While considering and respecting these preferences is important, there is also other important work to be done. All this work will be more achievable if there is more compassion and less judgement.

Another important lesson is that given the tremendous diversity we see in individuals with autism, with respect to strengths, challenges, and needs, no one individual has the experience and authority to speak for all, particularly when we are considering individuals with ASD who require 24/7 support and supervision. Many parents have shared views that their children with more significant needs are being overlooked (e.g., Ursitti, 2022 and as reflected in my interview with Eileen Lamb). We must do all we can to meet the needs of the members of the autism community with the most intensive and enduring needs. While every voice is important, we have to be mindful that one voice should not eclipse another.

2. “Autism Awareness and Acceptance” must include a differentiation of effective treatments that are scientifically validated from the plethora of “therapies” and “cures” lacking scientific support. Such distinction is critical.

Autism treatment is a billion-dollar industry. For the majority of the 500+ available interventions, science is overlooked in favor of pseudoscience, marketed using heart-wrenching testimonials, anecdotes, and video montages. These interventions are often bolstered with poorly crafted and misleading surveys that masquerade as legitimate scientific research. Many interventions boast inaccurate and even outrageous claims that are touted as evidence of effectiveness. Marketing of these so-called “therapies” and “cures” is unambiguously aggressive in nature and can be so overwhelming that it drowns out accurate information for those parents desperate to help their children access the very best treatment. We are in a time when the word for any experience can be placed before the word “therapy” and pushed forth as a “bona fide treatment” (e.g., Legos, llamas, bleach, sand, magnets, lavender oil, surfing, and even Shakespeare, to name but a few examples). Think about how confusing that may be for many consumers.

For most other medical conditions, a medical provider who disregards a proven intervention in favor of using a “fringe” treatment may be sued for malpractice! Sadly, such safeguards are not well established for autism treatment. We do no favors for children with autism, their families, and those responsible for providing needed services when we not only ignore junk science but allow it to proliferate by failing to counter baseless claims. Families deserve better. Individuals with autism deserve better.

Visit our website to learn more about the scientific support behind various autism treatments, the relevance of peer-reviewed research, the pitfalls of testimonials, as well as many other articles related to becoming a savvy consumer.

3. “Autism Awareness and Acceptance” must recognize our collective responsibility to make sound choices.

As adults, voters, consumers, providers, and parents, choice underlies all our decisions. We have a right to make these decisions, even poorly; however, when we hold the futures of individuals with autism in our hands, decision-making power comes with tremendous responsibility – a responsibility that should never be taken lightly. There are numerous “decision-makers” whose choices have profound implications for children and adults with autism – not just autistic individuals but their parents, siblings, teachers, treatment providers, administrators, program coordinators, and taxpayers.

• Individuals and their family members must exercise caution to make the best possible choice when sorting through autism treatment options, particularly since many providers do not make the path to effective treatment clear and simple. ASAT has offered many articles that speak to this challenge including this one on how to explain choices that are being made to other family members and how to stand for science on social media.
• Scientists need to take responsibility in making their findings about an intervention’s effectiveness clear, unambiguous, and devoid of exaggeration. Efforts should be made to promote replication, clarify which segment of the autism population would benefit from the intervention, articulate directions for needed future research, and to participate in peer review to the fullest extent (rather than bypass it altogether). Lastly, they should take steps to include those on the spectrum with the highest needs as well as from marginalized communities who are often excluded from research.
• Administrators and program leaders need to take responsibility for identifying internal and external training opportunities that further their staff’s competence with evidence-based practice. Additionally, they should make sure their staff receives the support needed to sustain these efforts and to continually engage in data-based decision-making when both selecting and monitoring. Decision makers must be savvy and selective in their choice of training for their staff and not fall prey to gimmicks, splashy sales pitches, or fads.
• Providers must select procedures that are based on published research, adhere to their discipline’s code of ethics about evidence-based practices, and maintain a commitment to ensure that parents and to the extent possible autistic individuals have truly been given the opportunity to provide informed consent. In short, if there is no scientific evidence to support an intervention that one is using, the professional is ethically obligated to inform consumers of this lack of evidence. In addition, providers should aspire to hire the right kind of people. Those employees must have integrity, compassion, a strong work ethic, the right attitude, and a thirst to always improve their repertoire of skills.

There are far too many individuals with autism who do not have access to effective treatment, receive ineffective treatment, or are subjected to treatments that are, in fact, dangerous. Every minute of ineffective intervention is one less minute spent accessing effective intervention. Every dollar spent on an intervention that does not work, takes a dollar away from an intervention that does work. Choices made have profound implications; therefore, the importance of choosing wisely cannot be overstated. Such choices should be informed by science and guided by data.

Please see our webpage for parents and a special section on becoming a savvy consumer which includes over a dozen articles in our “Is There Science Behind That” series. In this special section, you will also find an article on questions to ask marketers/providers so you can make sure that the individual with autism in your life is receiving science-based treatment, as well as questions that you can ask yourself.

You can also read more about the three phases of inquiry about particular interventions and their associated questions and considerations in the Road Less Traveled: Charting a Clear Course for Autism Treatment.

Phase I: Exploring the viability and merit of a particular treatment approach.

Phase II: Assessing the appropriateness of an intervention under the supervision and guidance of a specific service provider for a specific individual with autism.

Phase III: Monitoring the implementation of the treatment and evaluating effectiveness.

The questions listed for each phase not only can guide decision making but may occasion conversations that can lead to stronger collaborations and better outcomes.

4. “Autism Awareness and Acceptance” efforts must alert and remind the community that available information on the internet (and actual information from providers) varies greatly in accuracy, and, in fact, may be completely wrong. This point cannot be overstated.

As we know, not all information on the Internet is reliable and accurate and this is worrisome when you are looking to that information to make important decisions that can impact you and a loved one. You have probably heard the term, caveat emptor (“Let the buyer beware”). Consumers must also practice caveat lector (“Let the reader beware”). Often, internet information is deemed equivalent in relevance, importance, and validity to research published in peer-reviewed scientific journals, but it is not. Testimonials and uncontrolled studies from so-called researchers can lead parents astray and be a tremendous source of distraction.

Parents of newly diagnosed children may be particularly vulnerable. They need to know the red flags to avoid and learn how to evaluate research. Our library of articles highlights scientific concepts and methods as they relate to potential autism interventions, with the goal of providing families, educators, and clinicians with the information they need in order to be savvy consumers of marketed treatment products and therapies. We also published an article that showcases position statements about specific treatments such as Facilitated Communication and cannabis to name a few.

5. “Autism Awareness and Acceptance” must include solid reporting by journalists and other members of the media community who embrace their role as “public educators” and who are committed to spreading accurate information.

There are scores of “miracle cures” and “breakthroughs” for autism that receive widespread media attention (e.g., print and online news outlets, radio and television programs), even if these treatments have not been shown to be beneficial through peer-reviewed, published research. Unfortunately, effective treatments may receive less media coverage because their providers often focus more on outcomes than on garnering media attention. Things are not likely to improve in terms of access to effective treatment for the autism community without more accurate and abundant representations of autism treatment in the media.

The media has a responsibility to scrutinize sensational claims related to a proposed treatment and to be knowledgeable enough to report on those treatments with healthy skepticism and objectivity. Such scrutiny can be accomplished by members of the media asking important questions such as:

• Who am I interviewing for this story, and what are their qualifications? What do they stand to gain from this interview?
• Are there any published research articles documenting the efficacy of the intervention method featured in my article? If not, should I proceed with this story?
• What are the benefits touted by those who provide this intervention? What does this look like? How does it improve the quality of life for the person with autism? Their family?
• Is there any evidence of harm associated with this intervention? What are the risks?
• What are the costs? How is this paid for?
• What kind of education, training, and supervision do treatment providers need to have before implementing the intervention?
• Would my final article encourage false hope or suggest unrealistic benefits?

If you are interested in other questions to be considered when approaching a potential story, please review this article.

To support accuracy in the media, ASAT has developed a webpage for journalists. For examples of accurate and inaccurate reporting, please learn more about our Media Corner campaign, review resources about science journalism, read about the relationship between journalism ethics and autism treatment, and peruse our bank of archived letters. You will find that some of these letters showcase and celebrate accurate media representations whereas others highlight concerns about inaccurate representations.

6. “Autism Awareness and Acceptance” must recognize the critical need for newly diagnosed children to access effective treatment as soon as possible. We know that early intervention makes a huge difference.

For many conditions, such as Lyme disease and breast cancer, awareness is essential because awareness promotes detection, and with detection comes relatively clear paths toward well-established and evidence-based treatments. Optimal prognoses are often associated with early detection. Within a few short weeks of proper diagnosis, individuals have the opportunity to receive the best treatment that science has to offer. If their conditions are not detected early, access to such treatments is delayed and their conditions may worsen.

With autism, the story is very different as detection is not the “be all and end all.” There may be long delays between initial detection and diagnosis. Unfortunately, even at the time of diagnosis, many children with autism are not accessing the best that science has to offer, and their families are bombarded with solicitations to partake in any number of the 500+ autism treatments, most of which do not have an iota of scientific support.

While individuals with autism learn and progress across their lifespan, it is widely understood that the earlier intervention begins, the greater the potential for an optimal outcome. Learning more about the research basis for early intervention is crucial. It is also important to remember the limited window of time there is to prepare children for the “least restrictive setting” once they enter the school system.

The fact that resources allocated early can save a tremendous number of resources over an individual’s lifespan does not always enter the conversation when evaluating costs and benefits. These conversations must change. These long-term savings should become an integral part of the discussion about the appropriateness of intensive early intervention. Children’s futures hang in the balance and providing them with an effective early intervention experience can lead them towards better outcomes. Please see the following articles on the ASAT website:

• Early detection and intervention
• Teaching an 18 month old
• Parent participation in home-based intervention
• What to expect from a quality ABA program
• Empowering caregivers for successful collaboration
• Expanding interests
• Explaining decisions to use science-based treatment
• Discussing concerns with family members
• What is involved in an early intensive ABA program for autism
• Some language considerations when working with bilingual families
• A review of Promoting Functional Communication within the Home
• A review of Responsible and Responsive Parenting in Autism: Between Now and Dreams

We also recently published an annotated list of ASAT articles that might be of interest to parents of newly diagnosed children, as well as an annotated list of other websites.

7. “Autism Awareness and Acceptance” should also instill hope for a better tomorrow for those individuals who are not part of the “best outcome” group.

With the right treatment and preparation for adolescence and adulthood, all individuals with autism demonstrate improvement, and many go on to lead happy and fulfilling lives. Much of the conversation about treatment, however, focuses on “best outcomes” and this is often defined as entering “mainstreamed” education settings or losing the diagnosis of autism altogether. This point may delegitimize the significant progress made by most individuals with autism, whose outcomes may be different, but are no less important and meaningful. I am very grateful for the advocacy of parents and professionals (e.g., Profound Autism Alliance and the National Council on Severe Autism) who are advancing the visibility of those with profound autism, a term that is sorely needed.

We know, for example, with intensive intervention based on applied behavior analysis (ABA), individuals with autism learn to live and work in the community, access faith communities, fully participate in routine healthcare, enjoy a range of recreational pursuits including a commitment to fitness and water safety, become independent in their self-care needs, have meaningful relationships, and are active, contributing members of their communities. The relevance of such gains must be recognized as a significant benefit of effective treatment and are important conversations to have, particularly at a time when some vocal bloggers are viciously maligning any and all treatment efforts as abusive, immoral, or otherwise unethical. This maligning includes the denigration of parents who only want to help their children realize their fullest potential with an joyful quality of life.

Autism awareness should also include a celebration of a broad array of outcomes as was touched upon in our recent interviews with Eileen Lamb and Catherine Maurice, author of Let Me Hear Your Voice, as well as editor of a number of other titles. Please also visit our Perspectives page which shares the views of some parents such as Judith Ursitti and highlights success stories of young people with autism, who are not necessarily in the best outcome group, carving out sustainable vocational experiences.

8. “Autism Awareness and Acceptance” must mandate accountability from all treatment providers regardless of discipline.

Accountability involves a shared commitment to objectively defined targets, data collection, and respect for the scientific method. It is every provider’s responsibility to objectively measure outcomes. No one should get a pass on accountability. No one is excused from defining their target and objectively measuring progress. No one should get away with implementing their intervention carelessly, without accountability, and in a non-transparent manner. No one should be permitted to boast claims that they cannot demonstrate through data. Yet, many providers, not just those who provide pseudoscientific interventions, but those who provide evidence-based treatment of poor quality, are capable of boasting unsupported claims.

Providers using interventions that lack scientific support have an ethical obligation to share this fact with consumers, and to exercise caution in making claims about outcomes. Far too often, applications of interventions that lack any scientific support are carried out in a manner devoid of transparency and objective measures to substantiate claims of the treatment’s success. This lack of transparency must also not be tolerated. Providers must make sound, scientifically-validated decisions, and recommendations. Please visit our website for more information about ethics and evidence-based practice (including this book review of Practical Ethics for Effective Treatment of Autism Spectrum Disorders). Please see Principles # 1 and # 2 of the Ethical Code for Occupational Therapists, Principle of Ethics I, Rule M and Principle of Ethics II, Rule A of the ASHA Code of Ethics, Section 2.04 of the Ethical Principles of Psychologists and Code of Conduct, and Section 2 of the Professional and Ethical Compliance Code for Behavior Analysts. We also published this paper exploring the nexus of journalism ethics and autism treatment.

9. “Autism Awareness and Acceptance” must involve recognition that an abundance of clinical research already exists, and this body of research matters.

In the world of autism intervention, peer-reviewed research, which should guide and inform treatment efforts, is too often disregarded or ignored altogether. Imagine a world in which it was deemed acceptable for mainstream cancer providers to treat childhood leukemia with methods they preferred without any consideration of already published research as if did not even exist. Sadly, that is the reality of autism treatment, as many providers use their personally preferred methods, what comes easy for them, often divorced from scientific support and then often carried out without any objective means to assess benefit (e.g., objective data collection).

If treatment providers and consumers are interested in published research on diverse topics such as improving conversation skills, promoting academic skills, eliminating self-injurious behavior, increasing food repertoires, or developing a tolerance for healthcare procedures, they can find it (see this helpful article for strategies on conducting a literature review and accessing article databases). Sadly, these peer-reviewed studies are often not accessed by treatment providers and caregivers. Thousands of researchers and experts in their fields have published their findings in peer-reviewed journals that can guide autism treatment, yet their findings are often overshadowed by media representations and clever and splashy marketing that put sensationalism about the “next big thing” in autism treatment over objective scientific research. Please visit our website often to read our ever-increasing number of research synopses, a vast library of treatment summaries, and our growing library of Science Corner articles.

10. “Autism Awareness and Acceptance” should help us identify and overcome the barriers that families and individuals with autism face even within their own communities.

Not every child with autism is invited to birthday parties. Not every faith community welcomes families of children with autism. Not every school provides meaningful contact between students with autism and their typically developing peers. Not every community provides recreational and other important social opportunities for individuals with autism. Not every child has access to timely evaluation and intervention, particularly children of color, those who live in rural or economically disenfranchised communities, and those who live in countries where access is not adequately supported by legislation, mandates, provider pools, and resources necessary for proper care. It is crucial that our efforts in raising autism awareness and acceptance not only highlight these disparities but also advocate for the changes needed to create a more inclusive and supportive world for all individuals with autism, no matter where they fall on the spectrum.

Like all families, those with children with autism want to be able to live comfortably and fully within their communities. Living comfortably and fully may mean simply going to the park, enjoying play dates, attending religious services, accessing routine medical care, going to the movies with friends, or eating at a restaurant with their family. Unfortunately, many families are not able to access these activities because the community is not sufficiently informed or prepared to include individuals with autism within these settings. In some cases, the children are not taught how to manage these situations well due to ineffective treatments. As a result, families of individuals with autism are often isolated, particularly as children age. This lack of opportunity is both a function of misinformation about autism and the lack of awareness about the successful efforts of those who have overcome such barriers. With one in 36 children being diagnosed, every facet of society should become aware of the support necessary for individuals with autism to succeed within their communities. Increasing awareness could involve accessing information about success stories, receiving education and training, and open dialogue with individuals and families about what could be helpful. It would be prudent if every facet of society evaluated what they are doing to support individuals with autism, what they are not doing, and what they could be doing differently, particularly to address the ethnic and racial disparities that are sadly so prevalent.

The autism community will be better served if we all made a commitment to the following notion: We want to be more accepting today than we were yesterday, but not as much as we will be tomorrow.

11. “Autism Awareness and Acceptance” is needed worldwide. In many countries, families of individuals with autism face incredible challenges and barriers.

As a US-based organization, we recognize the many benefits that exist here in our country. These include, although are not limited to, well-established special education laws, the lion’s share of Board-Certified Behavior Analysts (BCBAs), providers from other disciplines who are committed to science-based practice, and a long history of the conversation about best practices. This is in contrast to the experience of families of children with autism residing in many other countries. These families are often offered outdated therapies such as psychoanalysis, have very limited resources, face stigma and rejection within their communities, may encounter a professional community that has low expectations about what may be possible and lack the support of laws mandating even adequate treatment and education. Providers eager to learn and use best practices will face limited education and training opportunities, a dearth of accessible supervisors, and struggle to access supporting professional networks. In some countries, the social and economic conditions may be so poor that autism treatment is relegated to being a lower priority which in many cases means receiving no services at all. We recently published this article about how our resources can support the efforts of international behavior analysts and are heartened with the growth and development of international credentialling bodies (e.g., International Behavior Analysis Organization® and Qualified Applied Behavior Analysis Credentialing Board).

We believe that knowledge is power and that a global community of savvy and informed consumers can help shape the landscape of effective intervention. Please note that we have flyers about our website and our monthly publication, Science in Autism Treatment, in 24 languages including Arabic, Armenian, Bangla, Bulgarian, Brazilian Portuguese, French, French Canadian, German, Hebrew, Hindi, Italian, Japanese, Malay, Mandarin, Polish, Russian, Serbian, Spanish, Swahili, Swedish, Tagalog, Telugu, Turkish, Urdu, and Vietnamese. If you are interested in distributing our translated materials, please write to us at info@asatonline.org.

At the bottom of every page on our website, we make it easy to disseminate our content through a variety of social media platforms. Please also note the Google language translation option in the upper right-hand corner of our webpage.

12. “Autism Awareness and Acceptance” should be about the reality that the hundreds of thousands of children with autism will become hundreds of thousands of young adults with autism; unfortunately, we remain woefully ill-prepared to meet their needs.

When children with autism become adults (at the age of twenty-one in the U.S.), funding for services drastically changes. As a result, there are very few quality programs for adults with autism. We are facing a crisis in the field, with a scarcity of services for adults with autism and the absence of a clear strategy for closing the gap between the ever-increasing need, and an unprepared body of available resources. Quality evidence-based services for individuals with autism must continue into the adult years. Research indicates that interventions such as applied behavior analysis (ABA) can effectively help adolescents and adults with autism continue to work toward their fullest potential. The conversation about “cure” often delegitimizes and derails important conversations about how we can help individuals with autism live and work independently, develop meaningful relationships, reduce challenging behaviors that may limit opportunities, access faith communities, and enjoy the array of recreational pursuits that are available locally. Those are crucial conversations to have so that all members of the autism community can have lives which bring joy, independence, and purpose. A huge part of this conversation must be to plan for and engage in all of the smaller conversations about how we are truly preparing young people with autism for decades of life as an adult by harnessing strengths, considering cultural, linguistic, and community factors, and maximizing assent.

At ASAT, we have broadened our scope so that we can be a part of this important and essential dialogue and have written extensively about that commitment. In response to the needs of families of older children and adults, we are also continuing to add to our webpage that addresses lifespan topics, Here, one can learn about maximizing employment opportunities, strategies to support older learners, and transitioning to adulthood.

We are expanding our collection of clinical corner articles on lifespan topics and research synopses that include adolescent and adult participants with autism. Finally, we have written about this topic extensively within Media Watch. Please see the following examples of some of our letters related to lifespan topics:

• ASAT Responds to abc.news.go.com’s “How A Child With Autism Became ‘His Own Man’ After Treatment”
• ASAT Responds to Psychologytoday.com’s “Making Severe Autism Visible”
• ASAT Responds to NBC News Dateline’s “On the Brink”
• ASAT Responds to ABC.net.au’s “Hope for autistic teens: How Applied Behaviour Analysis helped Ian Rogerson’s son Jack overturn bleak prognosis”
• ASAT Responds to FoxPhilly.com’s “Parents Of Autistic Children Worry What Life Will Bring When They’re Adults”
• ASAT Responds to Portland Press-Herald’s “Graduating to an Uncertain Fate”
• ASAT Responds to MSNBC’s “1 in 3 autistic young adults lack jobs education”

I hope these 12 calls to action have furthered your appreciation of the complexities and nuances surrounding autism awareness. We all play a role in advancing science, bettering the lives of individuals with autism, and helping their families and supporters become skilled and savvy consumers. Embrace that role with an eye toward identifying what additional steps you can take to become a contributor to important discussions and an even bigger part of the solution. There is much more important work to be done to promote access to science-based treatment, to improve outcomes, to promote access, to ensure data-based decision-making, and to essentially keep science at the forefront of every conversation about autism treatment.

For more information on how to join ASAT and be part of the solution, please subscribe to Science in Autism Treatment, visit our website, and follow us on Facebook. Learn more about how to become a sponsor, volunteer, or extern. Or you can support our work by making a donation. Join us in making a difference in our global autism community!

Reference for this article:

Celiberti, D. (2025). What autism awareness should be about. Science in Autism Treatment, 22(4).

About the Author

David Celiberti, PhD, BCBA-D, is the Executive Director of ASAT and Past-President, a role he served from 2006 to 2012. He is the Editor of ASAT’s monthly publication, Science in Autism Treatment. He received his PhD in clinical psychology from Rutgers University in 1993 and his certification in behavior analysis in 2000. Dr. Celiberti has served on a number of advisory boards and special interest groups in the field of autism, applied behavior analysis (ABA), and early childhood education. He works in private practice and provides consultation to public and private schools and agencies in underserved areas. He has authored several articles in professional journals and presents frequently at regional, national, and international conferences. In prior positions, Dr. Celiberti taught courses related to ABA at both undergraduate and graduate levels, supervised individuals pursuing BCBA certifications, and conducted research in the areas of ABA, family intervention, and autism.

This month’s ASAT feature comes to us from Juliana Oliveira, PhD, BCBA-D, Munroe-Meyer Institute, University of Nebraska Medical Center. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

Question: I’m a BCBA working in a home-based program for school-aged children. I know caregiver involvement is integral to a program’s success; however, I’m having a difficult time not only getting caregiver buy-in but also learning how to best support and coach the caregivers I work with. Any guidance would be helpful.

You raise an important question, and you are most certainly not the only provider to go through situations related to caregiver buy-in and support. Families play a central role in creating their children’s social world and have the most intimate knowledge of both their children and the environments in which they will thrive and grow. Therefore, considering how to effectively support and empower families through the intervention process is key to a successful collaboration.

Building a Strong Caregiver-Provider Rapport

One of the definitions of “buy-in” is the “agreement to support a decision” (Merriam-Webster, 2013). Supporting a decision, or engaging in behaviors aligned with a decision, implies that engaging in those behaviors might lead to short-, medium- or long-term reinforcement. If caregivers do not support a decision, the first thing to reflect on is “Do they believe their family will gain something from this treatment in the near- or long-term future?” This reflection may arise when you are starting a new relationship with a family or when a current relationship with a caregiver is not going as expected. In the first few meetings with caregivers, providers tend to focus on the client’s current skill level and the challenges the client might be facing. However, it is also important to consider skills, challenges, goals, and barriers related to the family (Taylor & Fisher, 2010). A strong relationship between a caregiver and a provider can be achieved through demonstrations of genuine interest in and empathy for the caregiver, respect for each family’s ethnic and cultural background, knowledge about the family’s strengths, routines and preferences, and effective communication (McGrath, 2005). Here are a few questions that can be asked when getting to know a family or when trying to reestablish rapport with a family that has been already receiving services:

• “What do you hope to gain from our time together?”
• “What went well in your relationship with prior providers? Can you share anything that could have made it better?”
• “What skills would you like to see your child develop over the next 6 months? What is your top priority or concern?”
• “What are the activities that you enjoy doing the most with your child? The least?”
• “What are some fun aspects of daily life with your child? The most frustrating?”
• “What worries do you have about beginning our work together?”
• “How much time do you usually spend with your child every day?”

The questions above and other questions related to the treatment plan, goals, or strategies being taught should be part of a continuous assessment of caregivers’ engagement throughout treatment (see Walkup, 2012) for a further discussion on encouraging parent participation in home-based services. Additionally, the caregiver should be encouraged to speak openly and honestly about issues and/or past experiences that are important to them. The service provider can facilitate an open dialogue on these topics by asking open-ended questions, listening attentively without interruption (making eye contact, nodding), reflecting on key aspects of what the caregiver says (e.g., “It sounds like you are worried that Maria can’t express herself”), and building on their responses (e.g., “It must feel hard. It seems like you are looking for alternatives on how to best help her”). See Rohrer et al. (2021) for a more comprehensive discussion on compassionate interactions.

Modify Your Role as an Authority Figure

As behavior analysts, we receive intensive training on selecting meaningful goals, designing procedures, and solving potential teaching procedure barriers. However, we receive less training on how to establish a collaborative relationship with caregivers and how to recognize the caregiver’s expertise in their family (LeBlanc et al., 2020). Barnett et al. (2014) conducted a study on types of therapist coaching and found that therapists’ responsive coaching (e.g., praise to parents) was a partial mediator of change in parenting behavior; whereas directive coaching (e.g., commands) did not relate to change. These results indicate that using a collaborative, rather than directive approach, may help facilitate meaningful caregiver behavior change.

Thus, instead of behaving as the authority figure with all the answers, or as the “provider-as-expert,” research suggests that it may be important to move towards a “shared-expertise” model, in which behavior analysts serve as collaboration partners. In other words, we are the “experts” in the intervention, but the caregiver is the “expert” on their child. See some differences between the authority figure and the collaboration partner in Table 1.

Table 1. Examples of an authority figure versus a collaboration partner

Authority figure/expert	Collaboration partner
Identify the child’s needs as you have defined them based on your assessment. Example: “One of the skills we will work on is imitation, as Maria did not demonstrate this skill during the initial assessment.”	Identify the family’s goals for their child and their assessment of their child’s strengths and needs, as well as strengths and recommended areas of intervention focused on in the individualized family assessment process. Example: “Based on the initial assessment and based on what we observed together while playing with Maria, it seems like imitation is an important skill for Maria to work on. Let’s work together on establishing imitation goals to work on at home.”
Direct caregivers on what do to at home and when to do it. Example: “Here are the imitation targets you will work on: clap hands, wave, and blow a kiss. You can work on these targets during bath time and when singing songs together.”	Discuss with the family what they could do at home, how the therapist can better support them, and what routines would work best for the targeted skills. Example: “What routines do you think you could use imitation in? Let’s discuss targets that would make sense at home. Let’s also discuss what materials we have available at home that we could use to work on this goal.”

As you can already probably tell based on the previous examples, integrating shared decision-making into your practice might help you move away from an authority figure role and better establish rapport with the family you are serving. Shared decision-making encourages the caregiver to play an active role in decisions about assessment and treatment.

Examples:

• The caregiver takes an active role in gathering information on the child’s current skills and selecting meaningful goals.
• The caregiver and service provider brainstorm on available activities and materials that will be part of the teaching set.
• The service provider and caregiver discuss how to break down long-term goals into short-term achievements.

By employing these strategies – aligning with the family’s values, treatment goals, and procedures – the service provider is setting the stage for successful treatment.

Supporting and Coaching Caregivers

At the beginning of each coaching session, the service provider should schedule a time to check in or conduct a brief reflection with the caregiver (Rogers et al., 2021). Check-ins can be relatively brief (e.g., 5 minutes). During this time, the provider should ask how the caregiver found the use of the strategies from the previous session. This check-in time is also a good opportunity to problem-solve potential challenges, such as limited time to implement the technique and potential difficulties in implementing the technique at home. An initial check-in is a good opportunity to recognize the caregiver’s and child’s strengths, efforts, and successes. Some examples of questions to ask caregivers during this time include:

• “How did you feel about using this strategy during these last few days?”
• “What do you think went well when trying to implement the strategy?”
• “Were there any barriers when trying to implement the strategy?”
• “I’m so impressed you were able to implement the strategy in this way [describe how they implemented it].”
• “I’m so glad to hear that Maria responded in this way [describe how Maria responded to it].”

Describe and Discuss the Technique

After the check-in, describe the technique the caregiver will be implementing, provide a rationale for using the technique, and describe examples of the technique, relating it to the family’s routine. It is important that the caregiver actively participates in this process and can ask questions and bring examples from their daily life.

Examples:

• “The technique we will be working on today is…”
• “The importance of this technique is that…”
• “Here are some ways we can implement this technique that align with your daily routine and resources…”
• “This technique will help Maria make progress on the following goals…”
• “Do you have any questions about it?”
• “Now it’s your turn to tell me what the technique is that we will be working on today. Would you be able to describe it?”
• “Can you tell me some examples of how we could use this technique with Maria?”
• “Does this technique align with your long-term goals for Maria and your family?”

Demonstrate or Model the Technique During Direct Work with the Child

The next step is to briefly demonstrate the technique with the child. While using the technique, narrate what you are doing and how the technique is affecting the child’s behavior in the moment. It is important to note that at this stage, the provider should not outshine the caregiver while modeling the technique with the child. The caregiver should feel empowered and motivated to employ the technique, instead of feeling frustrated or intimidated by the provider.

The provider works on mand training with Maria (i.e., teaching Maria to make requests). While creating mand opportunities, the provider provides an echoic prompt. Maria echoes, and the provider immediately delivers the preferred item to Maria. While modeling to the caregiver, the provider says, “It seems like Maria really wants to play with the puppy, so let me hold it for a few seconds out of her reach while she can still see it. Now she is looking at it and reaching for it. Let’s try this… ‘DOG.’ Wow! Did you see that? Maria repeated, ‘DOG!’” The provider immediately delivers the dog to her after that. “And that’s how we will practice requests together. She is a rock star!”

Live Coaching with Caregivers

When caregivers understand the technique by providing examples related to their child and identifying the technique when implemented by the provider, they can move on to practicing the techniques. If the caregiver seems initially hesitant to participate, you could conduct more role-plays or intersperse practice between you and the caregiver. It is important that the caregiver understands that their involvement and practice is an important part of each session’s routine.

• The caregiver says, “I still don’t think I’m ready. She responded so well to you. I’m not sure I can do it…” The provider says, “I understand the hesitation. I’ve been using this strategy with different kids, but please remember, you are the expert on your kid! I have a suggestion… What if we take turns? I will create one request opportunity, and you create another request opportunity. Does that sound good?”

Feedback

A crucial component of live coaching includes feedback. Several strategies for providing effective feedback are outlined in the literature (e.g., Ingersoll & Dvortcsak, 2010; Simonian & Brand, 2022). Parents are likely to require a higher level of direct feedback early in the implementation of treatment. However, it is important to remember that rapport plays an important role when receiving corrective feedback. Make sure to provide more positive feedback early in the treatment and wait to provide constructive comments until a rapport is established, so caregivers feel comfortable and safe during coaching sessions.

See Table 2 for examples of different types of feedback you could implement while live coaching the caregiver (Bruinsma et al. 2020).

Table 2. Types of feedback

Type of feedback	Definition	Example
Give behavior-specific feedback.	Feedback should be specific, clear, and related to the caregiver and child during that moment.	“When you held the duck, waited for the reaching response from Maria, and said ‘DUCK’, Maria immediately said ‘DUCK’. This was a great way to create a request opportunity”.
Give behavior-focused feedback.	Focus each session on a single or a small number of techniques.	“When you held the duck, waited for the reaching response from Maria, and said ‘DUCK’, Maria immediately said ‘DUCK’. I love how you were able to quickly identify the indicating response and provided an immediate prompt.”
Use positive examples of the correct application of techniques.	Provide caregivers with positive examples of the correct uses of the technique.	“Good job following her reaching response!” “You are being very immediate in providing positive reinforcement!” “Awesome holding the duck in front of her to assess motivation!”
Use corrective feedback when needed.	The use of corrective feedback is important to ensure integrity.	“Maria seems to have lost interest in the duck. Rather than continuing to try to play with the duck, let’s see what she shows interest in next.”

Sometimes you will have to provide succinct feedback while the caregiver is implementing the technique. However, the caregiver might benefit from more elaborate or reflective feedback. If that’s the case, make sure to provide more in-depth feedback after the practice is done.

Final Thoughts

Caregiver coaching is a process that certainly requires technical skills but also a variety of soft social skills (Rohrer et al., 2021). Each family has different values, preferences, abilities, goals, and obstacles. Getting to know the family and establishing a strong, trusting relationship with the caregiver are critical to a successful collaboration. Shared decision-making and switching from the provider as the “expert figure” to a collaborative partner will provide a strong foundation from which to start successful coaching sessions.

References

Barnett, M. L., Niec, L. N., & Acevedo-Polakovich, I. D. (2014). Assessing the key to effective coaching in caregiver-child interaction therapy: The therapist caregiver-interaction coding system. Journal of Psychopathology and Behavioral Assessment, 36(2), 211-223.

Bruinsma, Y. E., Minjarez, M. B., Schreibman, L., & Stahmer, A. C. (2020). Naturalistic developmental behavioral interventions for autism spectrum disorder. Brookes Publishing Company.

LeBlanc, L. A., Taylor, B. A. & Marchese, N. V. (2020). The training experiences of behavior analysts: Compassionate care and therapeutic relationships with caregivers. Behavior Analysis in Practice, 13, 387–393.

McGrath, J. M. (2005). Partnerships with families: A foundation to support them in difficult times. The Journal of Perinatal and Neonatal Nursing, 19(2), 94-96.

Merriam-Webster. (2003). Litmus test. In Merriam-Webster’s collegiate dictionary (11th ed., p. 727).

Rohrer, J. L., Marshall, K. B., Suzio, C., & Weiss, M. J. (2021). Soft skills: The case for compassionate approaches or how behavior analysis keeps finding its heart. Behavior Analysis in Practice, 14(4), 1135–1143. 10.1007/s40617-021-00563-x

Rogers, S. J., Vismara, L. A., & Dawson, G. (2021). Coaching caregivers of young children with autism: Promoting connection, communication, and learning. Guilford Publications.

Simonian, M. J., & Brand, D. (2022). Assessing the efficacy of and preference for positive and corrective feedback. Journal of Applied Behavior Analysis, 55(3), 727-745.

Taylor, B. A., & Fisher, J. (2010). Three important things to consider when starting intervention for a child diagnosed with autism. Behavior Analysis in Practice, 3, 52-53.

Reference for this article:

Oliveira, J. (2025). Clinical Corner: How can ABA providers empower caregivers for successful collaboration? Science in Autism Treatment, 22(3).

About the Author

Juliana Oliveira, PhD, BCBA-D, is an assistant professor at the Integrated Center for autism spectrum disorders (iCASD), at the University of Nebraska Medical Center (UNMC) Munroe-Meyer Institute (MMI). She obtained her bachelor’s degree in psychology at the Federal University of Para (UFPA) in Brazil, and her M.S. degree in Experimental Behavior Analysis also at UFPA. Juliana conducted research on conditional discriminations with Cebus apella monkeys, stimulus-stimulus pairing procedures to induce vocalization with children diagnosed with autism, and caregiver training for toddlers and children diagnosed with autism. Later, she moved to Texas and obtained her doctorate at Texas Christian University (TCU). During that time, Juliana worked on a series of studies that evaluated the efficiency and other potential benefits of equivalence-based instruction, while remotely consulting families back in Brazil. In her current position, Juliana is providing ABA services to dyads and small groups of children diagnosed with autism. She is also interested in assessing different teaching procedures to teach verbal behavior and to assess the emergence of different verbal operants. She loves eating shrimp (any kind of shrimp!) and loves to go to the beach.

By Alicia Marshall, MAT, BCBA LBS

One of the most appealing aspects of entering the field of Applied Behavior Analysis (ABA) is that analysts and technicians have the opportunity to work in a variety of settings. It is common for these ABA practitioners to accept jobs with organizations that allow their employees to work in multiple settings such as clinic-based therapy, school-based therapy, and in-home therapy.  Furthermore, clinicians have the opportunity to implement strategies and build skills among various settings during their sessions. BCBAs and behavior technicians working in schools may have the ability to work with clinicians in multiple settings, such as the special education classroom, general education classroom, cafeteria, music class, and recess all in one day.  Additionally, BCBAs and other clinicians working in a traditional clinical setting are often responsible for generalizing skills and training all key stakeholders.  This variability and flexibility often comes with challenges and increased responsibilities.

Understanding Behavior Contrast

An important concept to consider when entering the field is the concept of behavior contrast.  Behavior contrast is a side effect of reinforcement of punishment procedures implemented in one setting that causes a behavior change in another setting where the same contingencies are not in place.  For example, if a reinforcement procedure is used in the school setting to increase functional communication, but the same procedures and strategies are not used at home, the clinicians and family are likely to see an increase in the functional communication in school and a possible contrast of decreased functional communication at home.  In order to avoid the effects of behavior contrast, it is important that clinicians properly and thoroughly train all key stakeholders and implement treatment with fidelity. 

Best practice would suggest that all key stakeholders undergo Behavior Skills Training (BST).

What is BST?

The basics of BST include having the lead clinician, most likely a BCBA, provide thorough verbal and written instructions followed by modeling the behavior in a role play or re life scenario.  The trainee, key stakeholder, would then reverse roles with the trainer and demonstrate the skill being taught in a role play or real life scenario.  The trainer would then provide timely and effective feedback to the trainee.  The implementation of BST is essential to ensure that treatment fidelity is high.  The higher the treatment fidelity, the more likely there is likely to be progress with the student or client.

Preparing for Generalization

Another key component to assure that expectations are met in a variety of settings is to include plans for generalization as soon as treatment begins.  A common misstep of some practitioners is only discussing behavior plans for the treatment setting and forgetting to consider other settings until mastery criteria is obtained in that initial setting .  BCBAs should account for generalization into other settings on the onset of treatment.  When a BCBA begins to create a behavior, he/she should consider types of reinforcement available in all settings.  The behavior plan will not be effective if potential motivators are available in one setting, but not another.  During initial planning, it is also important to plan for fading of reinforcement.  When starting to develop a behavior plan, it may be necessary for the stakeholders to offer a dense schedule of reinforcement.  However, over time a BCBA should plan to teach learners to retain skills without the need of continuous reinforcement.  This strategy can include providing access to preferred activities and items less frequently, or generalizing reinforcement to other intrinsic, or “natural”, motivators.

The field of Applied Behavior Analysis has many challenges.  Clinicians, families, and other key stakeholders have to collaborate effectively in order to generalize reinforcers, skill acquisition, and assist with behavior reduction in all of the settings the learner will be a part of.  Many Behavior Analysts and other clinicians must also start planning for effective collaboration and transition of services amongst settings from the onset of beginning services.  While these challenges can be stressful, having the opportunity to work with learners in many different environments and measuring progress leads to a rewarding career and success for all stakeholders involved.

About the Author

Alicia Marshall, MAT, BCBA LBS, started out as a Special Education teacher and made the switch over to full-time BCBA 5 years ago. Alicia received her BCBA coursework at Rutgers and currently works as a Director of Behavioral Health in the Greater Philadelphia area. Alicia is passionate about making learning fun for all stakeholders and to encourage educators to focus on socially significant goals and compassionate care. 

When Alicia is not disseminating the science of ABA, she can be found on the beaches of the Jersey Shore (and occasionally Hawaii) with her husband and two dogs.

By Ashleigh Evans, MS, BCBA

Have you ever been in an uncomfortable situation? Were you able to freely leave or voice your concerns and have them respected? Imagine being unable to communicate your discomfort or disagreement with the situation while being forced to stay. That is the reality many autistic children experience in school, therapy, and other areas of their lives. Gaining assent is critical to allow our learners to have a voice in their treatment. Let’s explore what assent is and consider some strategies to establish assent-based care.

Assent Versus Consent: What is the Difference?

First up–what distinguishes assent from consent? Consent is a term that refers to a client (if legally capable) or their parent or legal guardian agreeing to a treatment based on a comprehensive understanding of the intervention’s purpose, benefits, and risks. To provide consent, one must be legally capable of making these decisions. Children (and many adults with special needs) cannot legally provide consent.

Assent, on the other hand, is not a legal term. Assent refers to the client demonstrating signs of agreement or willingness to participate in treatment. Even if they cannot legally approve or deny therapies, every learner can express their preferences and willingness to engage in therapeutic activities.

What is the Significance of Assent?

Acknowledging and respecting assent and assent withdrawal demonstrates an upholding of client dignity, one of the four core principles outlined in the Ethics Code for Behavior Analysts. Gaining client assent in ABA is one component of what many refer to as “Today’s ABA,” a more compassionate approach to behavioral treatment. In the most recent update to the Ethics Code, assent is included as an ethical requirement, under section 2.11. Therefore, behavior analysts should not only understand what assent is but also actively empower their learners through assent-based practices. By doing so, they can create an environment where clients feel safe, valued, and motivated to learn.

What are the Signs of Assent and Assent Withdrawal?

Behavior Technicians and Behavior Analysts should watch for indications of assent and assent withdrawal. Signs of assent may be vocal, such as the learner making affirmative statements (e.g., “I’m having fun!”). They may also be non-vocal, such as eagerly approaching the therapist and actively engaging in activities.

Signs that your learner is providing assent include:

• Smiling and/or laughing
• Cooperating with learning activities
• Making approval statements, such as “I want to keep doing X” and “I love this!”
• Actively engaging in therapy activities
• Eagerly approaching the therapist
• Requesting to repeat activities
• Staying in the therapy space

Assent can be withheld or withdrawn at any time. Assent withdrawal refers to the indications that the learner does not approve of the treatment methods being utilized or goals being targeted. Signs of assent withdrawal may be both vocal, such as protesting (e.g., “no!”) and non-vocal, such as running away.

Signs of assent withdrawal include:

• Turning away or pulling away from learning activities
• Pushing away teaching stimuli
• Eloping from the therapist or therapy space
• Aggression, self-injurious behavior, property destruction, or other harmful behaviors
• Crying, screaming, or vocally protesting
• Dropping or flopping to the floor
• Avoiding the therapist
• Frowning

How Can You Implement Assent-Based Learning in ABA Therapy?

Gaining and maintaining assent is a complex, ongoing process that requires careful observation, flexibility, and respect for the client’s autonomy. Here are a few key strategies you can use to promote assent-based ABA therapy with your learners.

1. Prioritize Choices
   
   Empower your learners with choices to foster engagement and promote autonomy. Offer choices in activities, reinforcers, stimuli, location of sessions, and even the structure and order of programs or activities. While the client may not be able to make choices regarding every aspect of therapy, prioritize offering choices whenever possible.
   
   
2. Teach & Reinforce Self-Advocacy

Encourage your learners to communicate their needs, preferences, and boundaries. Regardless of their communication abilities or mode of communication, support them in developing critical self-advocacy skills, such as requesting a break and expressing discomfort.

3. Make Therapy Fun
    
   Therapy doesn’t have to feel like work. While there are bound to be goals that are challenging and tasks that aren’t the most preferred, there are countless ways to ensure therapy remains enjoyable and motivating. Regularly conduct preference assessments to ensure you are continuously enriching the environment with preferred items and activities.
   
   
4. Honor Assent Withdrawal
   
   

Respect your learner’s right to withdraw assent. This is essential for fostering trust.

5. Analyze & Address the Reasons for Assent Withdrawal
   
   When a client withdraws assent, that doesn’t mean the therapy session simply ends or the therapist allows them to do what they want for the remainder of the session. The therapist must analyze the situation to identify the reason(s) for assent withdrawal. They may need to modify various aspects of the learning environment, treatment modality, or goals to regain their learner’s assent. Here are a few things to consider:

• Has the therapist and client successfully paired? Does the therapist continuously focus on maintaining a positive rapport?
• Is the teaching style aversive to the client? (e.g., overly structured and repetitive when the learner may prefer a more naturalistic approach)
• Are the tasks too difficult? Are prerequisite skills missing? Is additional prompting necessary?
• Are the tasks too easy and monotonous?
• Is prompting aversive? (e.g., full physical when the learner does not like to be touched)
• Are there sensory sensitivities that may be making the learner uncomfortable?
• Are the learner’s preferences being accounted for and prioritized?

Beyond Compliance: The Power of Assent

While compliance has historically been a central focus of ABA therapy, the shift toward “today’s ABA” has redefined the field. True progress is about more than simply complying. It’s about trust, active engagement, and meaningful participation. By embracing assent-based practices, behavior analysts can empower their learners to play an active part in their therapeutic journey.

About the Author

Ashleigh Evans, MS, BCBA, is a Board Certified Behavior Analyst. She has been practicing in the behavior analysis field for over 13 years and opened her own independent practice in early 2022. Her experience has been vast across different age groups, diagnoses, and needs. She is passionate about improving the field through education, reformative action, and better supervisory practices, leading her to create content and resources for families and ABA professionals which can be found on her website, www.abaresourcecenter.com

By Nahoma Presberg, MS BCBA NYS-LBA

What do you do in ABA therapy, anyways? You might get this question a lot as a BCBA, and for good reason! ABA is a powerful technology that can be used to teach so many skills and reduce a wide variety of interfering behaviors. The possibilities are endless!

So how do we figure out what we should be teaching?

Assessment

The assessment process is (obviously) extremely important for putting together a curriculum. During the assessment process, we’re looking to get an understanding of:

• The learner’s skills
• The family’s concerns
• The reasons they’re seeking ABA services
• Perspectives from other providers

You may also want to take a look at my post about how to pick a social skills assessment.

Scheduling

Next we need to consider the schedule of services. Is the family looking for comprehensive services which may be as many as 20 or 30 hours a week? Or maybe they’re looking for therapy to focus on one specific concern.

Working with Insurance

Depending on your state, if you are providing ABA services covered by health insurance, there may be more specific rules about the kinds of goals that they will cover. Typically, these rules indicate that the goals must all be related to reducing the symptoms of autism. While this is a rather loaded statement, ultimately this means that goals must be related to the core deficits of autism, i.e. restricted and repetitive patterns of behavior or communication deficits.

Incorporating Family Preferences

One of the most important metrics of our therapy is social validity. Social validity addresses the extent to which the therapy makes a meaningful difference in our client’s and stakeholder’s lives. Families and clients have a lot of insight into what would make the biggest difference in their lives. For example, the family might have a tradition of going to the beach every summer but our client struggles with managing the different routines of a vacation schedule. We may choose to work on supporting the preparation and flexibilities skills required for our client to be able to successfully participate in vacation with the rest of the family. 

Our Role as Advocates

In our role as advocates, sometimes it is our job to help families understand more about autism or what is realistic to expect of their child at different points in their development. ABA therapy (particularly parent training) can be an important opportunity to teach families about autism in ways that might help them make their home more accommodating for their child or understand about what additional environmental supports might be needed.

Next Steps

Once you’ve compiled all this information, you’ll probably have a long list of skills you want to work on. You might need to prioritize and think about certain goals as “core” priorities, and other as supporting goals. There can often be a sense of urgency when looking at all of the things you want to teach but remember that slow and steady wins the race. It’s ok to prioritize just a few key goals that are really going to help your client the most and expand from there when they’re ready.

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About the Author

Nahoma Presberg, MS BCBA NYS-LBA, is a Board Certified Behavior Analyst. Nahoma obtained their master’s degree at the University of Rochester in Human Development. They have been working with clients in their homes for the past 6 years but has over a decade of experience supporting children with developmental disabilities. Nahoma is passionate about neurodiversity affirming care and thoughtful programming that helps every client thrive.

For more information about Nahoma, you can visit their website at https://www.nahomapresberg.com/.