What Does ABA Even Look Like?
So your child’s physician has recommended ABA therapy after an autism diagnosis, or maybe you just know someone getting ABA. You're probably curious about what the therapy sessions actually look like. While most people have a pretty clear idea in their heads about what speech-language therapy, physical therapy, or even equine therapy might look like for their children, ABA is typically a little bit more mysterious. And unfortunately this usually isn’t something that will get an easy answer from Google, since you will get several different opinions that might make you even more confused than when you started.
Center or In-Home?
The biggest factor that affects what an ABA session will look like is the setting of therapy. There are already entire research studies and books that compare the pros and cons of center-based and home-based ABA, but for the purpose of this article here are some ways they will look different from each other:
Because our company provides strictly in-home services, the rest of this post will use home-based language. If your child happens to be getting center-based services instead, the scheduling and types of programs will be very similar, and for activities involving a sibling you can just substitute a peer.
2-5 Hours Long
The vast majority of ABA sessions are around 2-3 hours long. The duration can sometimes go up to 5 hours long if it’s during the weekend (e.g. Saturday from 10am-3pm) and/or if the child is an early learner and not enrolled in school already (e.g. 3-year-old still a year away from pre-school and in need of early intervention). If your child is school-aged, most likely your session will be something like 3-6pm or 4-7pm. The more flexible that you can be with your schedule availability, the better chance you have of getting a therapist quickly.
Sample schedule of a 3-year-old getting a clinical recommendation of 40 hours/week in a comprehensive program (no school attendance):
Sample schedule of a 14-year-old getting a clinical recommendation of 20 hours/week in a focused program (in addition to school):
In reality, when it comes to scheduling we are balancing more than just school schedules. Most likely the child above also has something like soccer practice on Tuesdays right after school and karate on Wednesday evenings, so the final schedule for a 14-year-old clinically recommended 20 hours/week, who also participates in extracurricular activities, might look something like this:
If you are hoping after the last section that we are done discussing scheduling, I have some bad news. In addition to the therapy schedules that parents and therapists manage, your child will also have a schedule to follow during each session. Nearly all ABA providers try to keep sessions structured. Knowing what is ahead of them will help increase motivation, decrease non-compliant behaviors, and ensure that all of the programming for your child is hit.
Of course the type of schedule will depend on the age and functioning level of your child. After an initial period of 10-15 minutes at the beginning of session when the therapist will check in with a parent about how the day is going so far for your child, get the work area prepared for therapy, and engage with your child, they will typically start with schedules like these:
What the schedule will probably look like for the 3-year-old:
If the session is from 8-11am, the overall breakdown of the session would look something like this most likely:
For the 14-year-old, the schedule would be a lot more advanced for the session, and most likely he would be able to make some choices himself. Typically it’s either written out on notebook paper or typed out on an iPad.
If it was written on notebook paper, it might look something like this:
If Bobby knew how to tell time, the numbers might be replaced with times. At this age it usually comes down to choices made in the moment by “Bobby” and the therapist. The reason that what Bobby does for break isn’t already written at the beginning of session is because his preferences/motivations might change over time. For example, if the session above was from 4-7pm, right after an after-school snack, something like snack time during break wouldn’t be motivated if he isn’t hungry yet. But as time goes on he will most likely get hungry again.
Activities that involve other family members, like playing with his sister or having dinner, are usually based on a preset time so that the family can plan ahead (e.g. not have his sister start homework two minutes before she appears on Bobby’s schedule). And the reason that the therapist’s choice activities, which make up the bulk of the programming, aren’t always written in advance is because it can often lead to non-compliant behaviors. For example, if Bobby hates brushing his teeth, and the therapist puts that as #8, Bobby might get frustrated, have decreased motivation, etc. as he perseverates on the non-preferred activity on his schedule.
What Do the Programs Themselves Look Like?
Now that we are (finally) past schedules, you’re probably still wondering what actual ABA programs look like. The answer to that is largely dependent on the age, deficits, goals, functioning level, and behaviors of the child. Here is a comparison of different types of programs that our two sample kiddos might run:
As you can see, the programs vary widely between the two children. Typically the focus areas for early learners are functional communication, expanding vocabulary, social skills, learning to play, school readiness skills, etc. For older children, who already have solidified their mode of communication, the focus often changes to social skills, relationship-building, replacement behaviors, and daily living skills.
The number of programs will also vary quite a bit between the two clients. The sample programs listed above would only make up a portion of the entire programming. The number of programs is based on age, functioning level, skill deficits, and whether or not the treatment plan is comprehensive or focused. Comprehensive would mean that it extends across several domains (e.g. communication, socialization, play, motor skills, daily living skills, etc.) while focused programming would just be a couple (e.g. the 14-year-old might just have deficits in social skills but communicates appropriately and has no daily living skill deficits). There’s no exact formula for the number of programs run at a time, since it depends on the type of program (labeling the color Red would take up a lot less time than running through an entire shoe-tying routine), but a lot of providers stay around a rough 1:1 ratio where the number of therapy hours=number of programs. In this case the 3-year-old might have around 40 programs, and the 14-year-old might have around 20 programs. Typically insurance companies like to see something close to this ratio as well.
That being said, there are typically several “targets” within each program. For example, in the sample programs above, the first one listed for the 3-year-old is labeling colors. The program itself, which the therapist will run and collect data on, is actually broken into probably a dozen different colors. If data were only collected on something as broad as “colors”, the graph would be all over the place, and it would be impossible to know which colors are mastered or unknown. If you were to walk by your child’s session you might overhear something like “give me the RED truck” or “point to the BLUE cup”. So out of the 40 programs run at any given time, 6 of them might be different colors that are currently being taught, 8 might be different animals they are learning, 4 are different sounds they are learning to vocalize, and so on.
Another way the programs will differ between the two clients is the location where they are run. Several parents picture their child sitting at a desk or table when they think of ABA, and while a large portion of the session does take place there, good luck keeping a 3-year-old seated for an entire session. Instead, for an early learner it might be 5 minutes at the desk to practice colors, 5 minutes on the floor of their bedroom to practice sharing with his favorite train, 5 more minutes back at the desk to label different types of clothes, and so on. For the 14-year-old it might be 10 minutes to practice maintaining conversations on different topics, 5 minutes to take a break and watch YouTube, 15 minutes to practice taking turns in a new board game with a sibling at the kitchen table, then 10 minutes to practice role-playing asking a classmate about their interests. The 14-year-old might also go into the bathroom to practice washing his face, the laundry room to practice putting clothes in a dryer, the garage to practice tolerating sitting in a seat of the car that isn’t the “usual” spot, etc. During the assessment period with your BCBA is a great time to state if there are some areas of the house you aren’t comfortable having the therapist run programs in, and also a good time to state if there are specific times you’d prefer that we stay away from a certain area of the house (e.g. your sister gets piano lessons in the living room from 4-5pm, so we wouldn’t want to distract that with programs in the area).
Besides checking in with the therapist at the beginning and end of sessions, there isn’t anything that you’re needed for during therapy unless your child’s BCBA has already mentioned something to you. In my experience parents typically watch or hover around the first couple sessions to see what ABA is all about and then do whatever they would normally be doing. Some parents work from home, others might use this time to give more attention to their other children, and several use the time to take care of chores like laundry or cleaning.
If a parent is involved in the session, it’s either because of a scheduled meeting with the BCBA or to assist with a program. Meetings with the BCBA occur every 1-4 weeks, typically for 1-2 hours, and often occur near the beginning or end of session (so that the BCBA can supervise therapy before/after the meeting if they’re already there anyway). Programs that require parental involvement might include activities involving a sibling (if the parent has to assist with the transition for the sibling), more invasive daily living skills like learning to shower independently (some parents are simply more comfortable being present for things like that, even if the therapist is running the program), or play programs that require a third person (e.g. practicing taking turns during Uno with 3 people is a lot more effective than 2).
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