Choosing an intervention or therapy to address your child’s behavioral challenges may take some time, collaboration, and trial and error. While Applied Behavior Analysis (ABA), for example, is commonly recommended for kids with autism, it doesn’t work for everybody. Other techniques may suit your child’s needs and individual goals. But how do you know which is best? And how, as a parent, can you tell what is working?
As Rose Griffin, speech language pathologist, Board Certified Behavior Analyst, and founder of ABA Speech, tells us, being able to observe and go into the session and see exactly what's taking place is one of the most important aspects when choosing the best therapy for your child. ABA, for example, will typically have a parent coaching or parent training piece, which can help make sure that parents are comfortable with the intervention that's taking place. But this is key for all therapies, ABA and beyond. Any behavior intervention program needs to be uniquely suited to meet your family’s and your child’s needs.
Here are some common interventions, and maybe a few you may not have heard of:
Whether or not you’ve attended ABA sessions with your child, chances are that you’ve heard of ABA therapy — the good and the bad. ABA uses a functional-based approach to behavior that seeks to improve or teach specific behaviors in areas such as social skills, communication, self-care, and academics. ABA aims to teach, maintain, or reduce behavior based on a system of reinforcements, and is often considered the gold standard for supporting children with autism. There are multiple service options for ABA, such as Discrete Trial Training (DTT) and Early Start Denver Model (ESDM), and individual therapists may use a single system or multiple systems in combination.
As a parent, the most important question is whether ABA will benefit your child. Of course, the answer will depend on your family and child’s individual needs. But ABA is not without criticism. Critics worry about behavior control, whether ABA is used ethically, as well as who gets to decide what a “problematic behavior” is. Other critics say that ABA only aims to make a neurodivergent child more acceptable to others.
Dr. Scott Akins, chief of developmental behavioral pediatrics at the UC Davis Department of Pediatrics and medical director at the UC Davis MIND Institute, explains that early forms of ABA therapy were harmful and not neurodiversity-affirming, and often placed all of the burden for acceptance and communication on the individual who was already struggling in those areas. He says, “I think that's part of the frustration that my friends that are adult self-advocates, or adults with autism, express when we talk about that kind of early form of ABA, and just how uncomfortable it was for many individuals.”
According to Dr. Douglas Vanderbilt, director of Developmental-Behavioral Pediatrics at Children’s Hospital Los Angeles and professor of clinical pediatrics at Keck School of Medicine and Occupational Science/Therapy at the University of Southern California, ABA is engineered to promote data collection, which has led to large amounts of research in support of this intervention. However, “the key is, ABA doesn’t work for everybody. It doesn’t work for every family.” Other techniques may suit your child’s needs and individual goals.
Dr. Susan L. Hyman, a Professor of Pediatrics and Division Chief of Developmental and Behavioral Pediatrics at the Golisano Children’s Hospital of the University of Rochester, explains, “There is an incredible amount of variation in the needs and presentation of autism at various ages; there’s no singular treatment.” However, she points out that the practice of ABA has grown enormously and is very different than when it was first developed. (Learn more about types of ABA therapy here.)
Dr. Sally Burton-Hoyle, professor, ASD Area, and faculty advisor in the Department of Special Education College Supports Program at Eastern Michigan University, tells us that sometimes parents have no choice when it comes to choosing an alternative to ABA: “Sometimes families are limited. They're in a system that says you can have ABA, you can have pivotal response training, etc. And the one thing I say to parents is that you need to vet whoever is working with your child. And number one, look for their ability to have a relationship with your child. Personally, am I a fan of ABA? No, I'm not because I've seen what it can do and I've had the benefit of hearing adults with autism speak about it, who are the real experts. I know it can be hurtful and harmful to families because if they tell you, ‘This is what it's gonna take, this is the answer, this is the answer,’ and then it's not the answer, where does that leave families?”
ABA is not one-size-fits all
While ABA does have some criticisms, it may be a great fit for your child. Dr. Akins goes on to tell us that certain types of ABA can be very helpful for individuals: “I just think it's really important that we don't throw the baby out with the bathwater and that we do recognize that those skills, I keep talking about — basic communication skills, a communication system that works for you, being able to transition and wait . It's really hard to engage in meaningful activities in any setting if we don't develop those skills.”
Dr. David Stein, PsyD, pediatric psychologist, agrees, sharing that we have to be careful that we don't say ABA isn’t a fit for everyone because one form of ABA was not a fit for one person: “Everybody's different. Everybody's going to need a different approach. [And] different providers are doing the same thing in a different way. So maybe one person is doing discrete trials with love and care and compassion and it's really helping somebody. And maybe someone else has a different approach where they're not as loving and caring and maybe it felt painful or harmful. That doesn't mean that we should say, generally speaking, ABA is bad… For some kids with intellectual disabilities and Down syndrome, it might be the only way they can learn. So again, we have to be really careful about not making broad generalizations when we can be talking about a range of different things that can be more effective or less effective for different people.”
Dr. Burton-Hoyle’s advice to families who are exploring ABA, or any other therapy, is to find the right fit: a therapist and therapy system your child likes: “So if we start with first, who would my child perk up and go, ‘Oh, this looks like fun!’? So whether it's ABA, or whether it's another therapy: do they like the therapist? There are some ABA people who are fabulous and the kids love them, so that's kind of what counts.”
A neurodiversity-affirming approach to behavior embraces and respects a child’s neurodivergent identity and recognizes that behaviors are a unique way of expressing distress and needs, and it recognizes that all behavior is communication. But is there such a thing as neurodiversity-affirmative ABA, for example? Many of the early behavioral treatments, such as ABA, are rooted in the medical model and don’t consider “issues of neurodiversity, social validity, and person-centered approaches to care.”
But more recently, the idea of neurodiversity-affirming assessments and behavioral therapy is growing in popularity, which is person-centered, strength-based, and focused on the strengths, preferences, goals, and values of the individual. It’s also a collaborative process between the child, IEP team, parents, and providers. The Therapist Neurodiversity Collective, for example, has created a list of 10 neurodiversity-affirming therapy principles to live by, including writing therapy goals that are self-determined, targeting self-advocacy, and teaching individuals authentic, robust communication. They also tackle what it means to be neurodiversity-affirming vs. ableist in practice.
Getting neurodiversity-affirming support
Dr. Burton-Hoyle tells us that more models are emerging that are looking at neurodiversity across special education, and looking at people as people, including their strengths. “Every child has strengths; they're an individual, they have their strengths, they have their interests — that is what should be capitalized. And there are wonderful parents who have just gotten sick and tired of the whole negative approach.” Strengths lead!
This may be tricky when it comes to securing services through Medi-Cal, Regional Center, or the school, since the process is often based on need and deficit. Dr. Akins tells us that it’s important that families feel empowered from the very beginning, that they understand neurodiversity, and that they understand in a strength-based model all that their child has to give. “But how do you do that? How do you operationalize that within the context of a healthcare system, in a school system, where you have to have a diagnosis and you have to have certain deficits to be able to have the therapies that you need? I think the big thing is to just help parents understand exactly what I just said — that that's the system. We'll go and get the assessments done and qualify, but then we're going to talk about strengths, the things that your child already does so well.”
Dr. Burton-Hoyle adds, “When we teach and approach using the the neurodiversity model, which is, ‘Let's focus on strengths,’ we're going to do things completely differently: we're going to focus on what they want and what what they're good at, and telling people that they are in charge of their lives. And I feel like the earlier we can tell people that, the more they can get the bad voices out of their head about how they are flawed.”
One example that may be a marriage between the two worlds — ABA and the neurodiversity-affirming movement — is a person-centered Naturalistic Developmental Behavioral Intervention, or NDBI. NDBI therapies were developed to combat the rigidity of ABA, and these interventions “share core characteristics that are less medicalized, stigmatizing, and depersonalizing, and approach skill acquisition in a more accepting, compassionate, and empathetic manner. NDBIs enhance the components of traditionally practiced ABA by creating a more motivational, naturalistic, comprehensive, and person-centered intervention.” Research has shown that NDBI may help in supporting the development of early social communication, language, and play skills, and offer interventions that highlight strengths and prioritizes individual preferences.
As Dr. Vanderbilt explains, naturalistic development interventions “blend both ABA principles and developmental relationship principles,” and emphasize parent training. “If you want generalization of learning, you have to put it in naturalistic settings and have parent involvement.”
Dr. Hyman says that in both modern ABA therapies (like Pivotal Response Training) and developmental behavior interventions, you will be playing, identifying communication and social goals, and responding to children where they're at. “This idea of neurodevelopmental behavioral interventions is the pinnacle of what we’re aspiring to right now,” Dr. Hyman adds.
As Dr. Akins mentions, these can include interventions such as the Early Start Denver Model (ESDM), as well as Pivotal Response Treatment (PRT) and Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) — naturalistic models that were derived from ABA, which is what he recommends for families. “Finding an ideally naturalistic treatment that helps you develop joint attention skills and imitation skills so then you can participate in things like speech therapy, feeding therapy, and inclusion in an educational setting, where you can learn extemporaneously because you can imitate and because you are able to increase your engagement with the environment and sharing with your peers. Building those skills is really important, and the best way that we can get that paid for through insurance and covered is under what we call ABA broadly still. And most of us hope it ends up being an Early Start Denver Model, or TEACCH, or another naturalistic form.”
JASPER was developed by Dr. Connie Kasari at the University of California, Los Angeles (UCLA) and emphasizes social communication skills while teaching and modeling:
JASPER is typically conducted one-on-one between a child and their therapist using developmentally appropriate toys and activities. Children can receive JASPER in conjunction with other therapies in various settings, such as their home or classroom.
According to Kasari Lab, children taking part in a JASPER program showed improvements in “joint engagement, social communication, and emotion regulation with decreasing negativity over time, as well as increasing parental co-regulation strategies.” JASPER was also recognized by the National Institute of Health and Care Excellence (NICE) as being evidence-based in 2013 and was one of just two social communication interventions they recommended.
Kasari Lab, in Los Angeles, California, offers JASPER treatment and can be contacted by email or by phone at 310-206-1268. For more on using this method to help kids with autism learn how to play and interact with others, see our article here.
### Early Start Denver Model (ESDM)ESDM is a hybrid therapy that combines aspects of ABA therapy with relationship development. It is typically used for infants and toddlers with autism between the ages of twelve and forty-eight months. ESDM primarily focuses on developing social-emotional, language, and cognitive skills.
Dr. Hyman explains that there is a difference of opinion as to whether ESDM is a type of ABA or a closely related alternative. Unlike other ABA models, therapists may have multiple goals per activity (if a child is presented with blue and red triangles, for example, and asked to point to the blue ones to teach them to differentiate between colors, in ESDM they may be simultaneously learning about color, what a triangle is, and to repeat the words “triangle” or “blue”).
To find a provider near you, refer to the directory on ESDM’s website. To learn more about how to practice ESDM at home, visit helpisinyourhands.org to access a series of video modules featuring intervention practices you can add to your daily routines.
Dr. Vanderbilt tells us that relational development approaches focus on the interactions between a child and their caregiver, which families may find attractive. However, these therapies are less structured than traditional ABA therapy. He recommends relationship-based therapies for younger children in cases where the relationship between the parent and child needs to be strengthened.
They are based in developmental psychology and heavily rely on the relationship between parents and children to move children along their developmental pathways. With this model, the key is to develop a relationship with your child — so parents are very much involved in all aspects of the therapy. Parents have to learn about how their child responds to behavior intervention and what the best approaches are. However, these therapies are less structured than traditional ABA therapy (find out more here).
Developed by Dr. Stanley Greenspan, The Developmental, Individual Differences, and Relationship-Based (DIRFloortime) model is a play-based therapy that seeks to help your child progress through creativity and connection. It is a child-led but still targeted approach where all or most of the child’s senses will be engaged while using their emotional and motor skills.
In a 2011 study, researchers “found that after the parents added home-based DIRFloortime intervention at an average of 15.2 hours/week for three months, the intervention group made significantly greater gains in all three measures employed in the study.”
Professionals such as child psychologists and special education teachers can become certified to provide Floortime. The Interdisciplinary Council on Development and Learning (ICDL) created a searchable directory where you can find qualified practitioners.
Parents can also implement Floortime at home. ICDL offers free virtual consultations for parents who are new to Floortime, during which they can review videos of you and your child interacting to learn how a Floortime provider can help. You can also sign up for paid courses or take advantage of free resources on stanleygreenspan.com.
According to RDIconnect, “RDI programs teach parents how to guide their child to seek out and succeed in truly reciprocal relationships while addressing key core issues.” RDI providers will concentrate on critical skills like creative problem solving, communication, and self-awareness.
RDI programs focus on the family’s role in supporting a child’s growth. Sessions are conducted in the home with all family members because “every family member is critical to success.”
One 2009 study states, “Preliminary research suggests that parents, through the RDI curriculum and consultation process, have the potential to exert a powerful impact on their children's experience-sharing communication, social interaction, and adaptive functioning.” Read a more detailed rundown of how RDI works here.
You can find a consultant near you by visiting RDIconnect’s website.
This approach, which focuses on kids understanding social expectations, often comes with critiques. Are we teaching children to understand social expectations, or are we teaching them to mask their differences? Listening Larry, for example, taught children “Whole Body Listening!” such as keeping your hands quiet in your lap or by your side, making sure your feet are quiet on the floor, and turning your body so you’re facing the speaker. But these things may not come easily to our children, and it doesn’t acknowledge that everyone communicates differently.
The Social Thinking Methodology is one such social model, and it focuses on building a child’s social competence so that they can better navigate interactions with their peers and understand others’ perspectives while learning other crucial skills. Social Thinking is suitable for children over age four “with social emotional learning differences and/or challenges, whether neurotypical or neurodivergent (ADHD, social communication learning differences, social anxiety, twice exceptional, autism levels 1 and 2).”
This method can be provided by a wide range of professionals including speech-language pathologists (SLPs), teachers, and therapists. Social Thinking created a directory of professionals who have attended a training course and received an attendance certificate. However, it is important to note that the company cannot attest to the skills or knowledge of the individuals listed, and remind parents to use due diligence in determining whether a provider will meet their needs.
While it’s a non-ABA approach, Social Thinking is criticized often for not being neurodiversity affirming. For example, does teaching children to understand social expectations contribute to them being taught to mask their differences? The creators of Social Thinking state that it’s not trying to fix or cure an individual, but “supporting their learning by teaching how the social world works to help them advance toward developing further competencies to meet their social goal(s).” As parents, we want our kids to navigate the world with as much independence and self-determination as possible, so it may feel tricky trying to find the balance between helping them develop the needed skills to interact with the world and supporting them to be themselves and make their own choices.
In IPGs, a supervising adult, or “play guide,” supports group interactions between children with autism and their neurotypical peers. There are typically between three and five children in a group. An IPG intervention is designed to teach children social and communication skills while they develop relationships with their peers.
Recent research showed that children with autism between the ages of three and eleven who participate in IPG programs show progress in “social interaction, communication, language, representational play, and related symbolic activity (writing and drawing).” Other benefits may include increased self-esteem, empathy, and social communication skills.
Professionals who complete the Autism Institute’s training courses through their host organization (such as their school, clinic, or non-profit) are qualified to deliver services.
PEERs was developed at UCLA for children from preschool age to young adulthood. PEERs offers several programs separated by age group where individuals will learn skills like maintaining body boundaries, making friends, and handling disagreements.
In a 2021 study, researchers found that “young children with autism in PEERs for Preschoolers demonstrated long-term improvements in socialization skills, with areas targeted in the curriculum showing maintenance 1–5 years after program completion.” The PEERs website offers a list of relevant research for further reading.
Use their directory, organized by age, state, and county, to find a service provider in your area.
### Learning social skillsStephen Hinkle, MEd, disability rights advocate, tells us that while kids with disabilities such as autism do things differently, and it's very important for people to adapt, “learning social skills is not necessarily useless either. And the reason I say that is because there are some settings where one has to know what to do…I do think neurotypical [people] need to adapt. But I also will say that there are times where one can be what I call a beginner at something, like not knowing what to do in a setting, and it's more of a ‘knowledge of how to’ issue. And I'm not saying to force compliance here, but sometimes a basic knowledge of what's going on or how to do an activity is useful.”
With these social skills, most typical kids learn and understand more easily how to maneuver social settings and rules, especially in adolescence. But it’s not as easy for kids with disabilities, who often have a hard time learning and keeping up with the elaborate and often “hidden” rules of friendships, relationships, and social hierarchies. Neurodiverse kids may need very explicit instruction. Hinkle tells us that this instruction needs to occur in real settings, and in many different settings, not just from a book or a lecture in a classroom, and especially not in segregated classrooms. He tells us a few settings this can happen in — recreation, leisure, great outdoors, visual and performing arts, amusement, gaming, hospitality, school spirit, and sport — and how each of these settings require different manners and etiquette and rules to be follow. For example, when you're in a party, expected behavior is going to be different than when you're in a classroom, or a stadium, or a bunch of other settings.
When talking about social skills and training neurodiverse children “out of behaviors,” Griffin tells us that there is a gray area between wanting to be neurodiversity-affirming and also helping kids thrive in their lives, now and in the future. She says that some adults with autism she’s spoken to use the term “code switching” instead of masking, which can be more of a skill to have and not necessarily something to do to fit inside social expectations. “If we don't teach social skills, that could potentially cause an [an adult with autism] to not be able to have a job that they want or to have those connections socially that they want and enjoy… So it does get into a gray area because ethically, we need to provide instruction in that area if it's important to that person because we would be really remiss if that was a barrier to them accessing employment, which we know can open up your world and give you more financial independence. And that's an individualized situation.”
However, Griffin adds that this doesn’t mean we send the message to kids that what they’re doing or who they are is wrong. We can tell them, “[Your disability] is a part of who you are, and your brain works a certain way, and every brain is beautiful and all those really positive things,” but it should be a team decision, especially for kids who are conversational and have insight into their goals and what they're working on in therapy. They should be involved and know that they can work on those social goals if they wanted to.
Helping our kids build skills
One way Griffin approaches the social aspect of behavior is by focusing on what she calls “modified leisure skills.” She says, “I know that I want my students to be happy, to be independent, and to be able to communicate with everybody in the world. And so the way that I work on that is through these socially engaging activities. For a young child, that may mean spending time with their family reading a book, doing a song, or playing modified Simon Says musical chairs. For older students, that might be doing yoga so they can generalize it to a gym class and have more peers and access to social engagement… And so I try to frame it that way: working on leisure skills so that we can work on that social engagement piece, but that it's very nuanced and that we are teaching students lifelong social engagement skills that will serve them over their entire lifespan. So that's really how I frame it.” Dr. Sarah Pelangka, BCBA-D and education advocate, tells us, “Some may argue that ABA and social skills training try to rid individuals of their autism — of who they are — but I believe people with autism want to be social. We know, through research, that individuals on the spectrum are at much higher risk for depression, and their suicidal rates are also much higher (often due to social isolation and not wanting to be different). We need to do better at providing individuals with autism the tools to have positive social experiences, and equally as important is the need to simultaneously educate neurotypical peers on how to support said social interactions: how to understand autism and be good friends.” Hinkle emphasizes that parents can focus on knowledge gaps, skill building, and their children’s wants and needs when it comes to teaching social skills in real-life settings:
Collaborative & Proactive Solutions (CPS) was founded by Dr. Ross Greene, clinical psychologist and the author of The Explosive Child, Lost at School, Lost and Found, and Raising Human Beings (outlined step by step on his Lives in the Balance website). CPS emphasizes empathy, collaboration, and problem-solving rather than traditional motivation-based approaches we often see in functional-based therapy, like ABA. This approach centers on working collaboratively with a child to solve the underlying problem that is creating the external behavior. This means that challenging behaviors are a result of lagging skills, such as flexibility, adaptability, frustration, tolerance, problem solving, and emotion regulation rather than lack of motivation to be good.
According to a 2017 study, “lagging skills contribute to challenging behaviors in children with autism spectrum disorder without intellectual disability,” indicating that CPS therapy can help children with autism progress by supporting them in developing those skills. However, researchers state that more study is necessary.
Dr. Greene points us to the unmet expectation when trying to figure out why a child is having a behavior instead of the actual behavior.
Dr. Greene’s approach moves away from the ways we are all familiar with, which he calls Plan A — adults come up with the solution and impose it on the child, which might be done by offering incentives, or threatening consequences, or simply physically intervening — into Plan B, where adults work with the child to understand their perspective, identify the specific unsolved problems contributing to the behavior, and come up with mutually agreeable solutions. This approach focuses on teaching lagging skills, building empathy, and fostering a positive relationship between adults and children. Greene also has Plan C, which involves setting aside certain unsolved problems temporarily, especially those that are not immediately critical or urgent, in order to reduce stress and conflict in the short term. Sometimes, we need to recognize that the expectations you or someone else are putting on your child are not developmentally appropriate, which can help reduce everyone’s frustrations.
The hard part? For most parents, changing our mindset from Plan A to Plan B is possibly the most difficult part of CPS, especially when so many of us have been trained, as parents of children with disabilities, to approach behavior through a functional-, motivation-based approach. Even the best-intentioned behaviorists are going to focus on the challenging behavior and provide motivation to perform a replacement behavior, even if the functional assessment identifies skill deficits as the function of the behavior. By shifting the focus from discipline and control to collaboration and problem-solving, Greene's evidence-based approach has helped many parents, educators, and clinicians better understand and support children with behavioral challenges.
CPS offers a list of providers in California.
TEACCH is a classroom-based model that was developed at the University of North Carolina and emphasizes a structured environment, visual aids, and student engagement. Activities are laid out predictably, often with a visual schedule, focusing on students’ interests to promote self-initiated communication and independent learning.
According to a 2013 study, “TEACCH had small effects on perceptual, motor, verbal, and cognitive skills.” Researchers also reported gains in social behavior.
As Dr. Hyman tells us, “we know that children with autism perceive sensory input differently. Sensory interventions are really behavioral interventions that reflect these differences.”
Sensory therapies are provided by trained clinicians, like occupational therapists, and require active engagement with the child in play to build skills and desensitization. Parental involvement is key, and clinicians should help families develop techniques and accommodations that fit a child’s needs, so they can learn coping skills when faced with sensory triggers in their environment.
There are many commonly used strategies, like weighted vests or therapy balls, but they are not yet supported by research. In addition, as a 2014 study notes, more research into the effectiveness of sensory therapies in general is needed.
According to Soundly Speaking Therapy Services, “trained Speech-Language Pathologists (SLP) and their SLP-Assistants teach clients to advocate for themselves through functional communication, thereby ensuring that they retain the inherent human-right [sic] of self-determination.” The program operates on the core belief that all behaviors are communicating something or result from an inability to communicate wants, needs, and feelings. An SLP will work with you and your child to teach them the communication skills they need.
According to a study completed in 2012, speech and language therapy was “perceived by parents and teachers as effective at improving some functional pragmatic and social communication skills at home, and classroom learning skills for these children.”
Though not technically a type of therapy, the Respond but Don’t React method was developed by Dr. David Stein, a psychologist and co-director of the Down Syndrome Program at Boston Children's Hospital. The method is detailed in his book, Supporting Positive Behavior in Children and Teens with Down Syndrome: The Respond but Don't React Method.
This approach encourages parents to be proactive and consistent, create visual schedules, use a token economy to reward wanted behavior, and teach siblings to ignore unwanted behavior.
We can’t talk about behavior without talking about Social Stories™. Social Stories and scripts are commonly used to help children understand events taking place in their lives as well as social norms and how to interact with the world around them. A typical Social Story describes a social situation and helps kids learn ways of behaving in these situations. Studies indicate that the benefits of using Social Stories include helping children cope with changes and life transitions, understanding their behavior as well as others’, and understanding emotions they may be experiencing — such as anger, sadness, and anxiety — and how to deal with them. Social Stories are often used as a behavior management tool, but they are actually about understanding what the child misses about social context.
Here are a few ways to use Social Stories:
Carol Gray, the creator of Social Stories™, tells us that Social Stories help to eliminate some of the common mistakes adults make when we communicate with children with autism or other disabilities and helps us make space for their individual responses to life and social situations.
She says, “The theory behind Social Stories is that we're sharing social information as accurately and safely as possible, without bias. And what the research has shown and what our experiences show is that very often, the person reads the story and comes up with their own response. It might not be our own, but it is consistent with their personality and consistent with how they perceive the situation, and it works. And that's what we want. That's the goal of Social Stories. By sharing accurate information, over time and through several stories, helping kids to identify the relevant factors in a situation, to read them and interpret a situation more effectively, and to respond in their own way. Because that's what it means to be social.”
With all these approaches and interventions, it’s easy to feel overwhelmed, confused, and completely lost. Which method is best for your child? Where does one even begin? First, take a breath; remember that while there are many behavioral interventions to explore, there is no one right answer. Deciding which approach is best for your child is going to be very individualized and based on their assessment, the goals of your child’s therapy, and your own values and goals as a family. You can decide on one approach and stick to that, or you can take pieces you like from two or three approaches. For example, maybe you’d like to use a relationship-based behavior intervention while also sprinkling in some social-based rewards. When your child is evaluated either in early intervention or by their school district, the results can help you narrow down your options based on the areas where your child needs the most support.
Dr. Hyman suggests focusing first on the goals of your child’s therapy, how to include the child’s family and natural environment, and how your child can learn both functional and spontaneous skills. She explains that this is so they “learn how to apply these skills across [their] day.” When your child is evaluated either in early intervention or by their school district, the results can help you narrow down your options based on the areas where your child needs the most support. As Dr. Hyman explains, it’s essential for parents, schools, and other providers to match “an individual child and their profile (what their needs are) with what’s available” when making a decision.
One tip Dr. Akins gives parents is to find a match that works for them, and to stay engaged as much as they can. Often, parents agree to therapies or interventions that they may not fully be on board with, but it’s important that therapies and goals, whether at home or at school, are aligned with your values.
Communicate with your care team
When it comes to school-based interventions, Griffin wants parents to know that it’s important to collaborate and communicate with the IEP team about what intervention they want or don’t want. And to always make sure it’s documented in the IEP.
It can, however, feel like an overwhelming process for families. When choosing a provider, Dr. Hyman wants to remind parents that even research-based therapies might not be implemented by some practitioners in the same way they were intended by the researchers, so they might not show the same results. In addition, some interventions, like Floortime, offer classes and consultations that allow parents to implement them at home. Dr. Hyman suggests working with a provider to learn the system and help ensure that the therapy is practiced the way it was intended. Dr. Vanderbilt suggests getting recommendations from parent support groups, your local autism society or Regional Center, or non-profit groups like Family Voices or the Autism Alliance SoCal.
Staying in communication with your provider or developmental-pediatrician, and asking for support can also help you as you work through which intervention is best suited for your child. As Dr. Akins tells us, “We would get a plan together and ask families what their priorities are, then in joint decision making, work on the things that are most important.”
He adds that these days, he offers families plain language, after-visit summaries that have a plan for the steps families should follow to secure the behavioral services they need. “If I just said, ‘We're recommending ABA, please reach out to your insurance company and book it,’ a family doesn't know that what that really means is they have to contact the behavioral health department of their insurance company, then they have to go through the list of providers that they're given — which might be 10 or 15 — to find someone. Then they have to go in for an evaluation. Then insurance has to approve the therapy. Then they have to get assigned a therapist. And so it's months and it's all the steps. So we now just give families, at the time of diagnosis, these after-visit summaries that in very plain language say, ‘I have contacted an ABA provider — check. I have scheduled the initial evaluation — check.’ So at least families have a roadmap of what to expect.” If this sounds like it would help you, try asking your provider for next steps!
Obtaining funding for ABA alternatives can be tricky and will change based on which option you choose for your child. According to California’s Department of Mental Health Care (DMHC), “California’s mental health parity law has the same coverage requirements for children. California law also requires all plans to cover behavioral health treatment for autism or pervasive development disorder, which is frequently identified during childhood.”
It’s important to note that many private insurers won’t cover ABA or alternatives if the child doesn’t have an autism or pervasive developmental disorder diagnosis. Medi-Cal and Regional Center will, but they require evidence-based treatments. And because ABA has a large evidence base, insurers are more likely to fund it than its alternatives.
Getting behavior supports and interventions, and securing funding for them, whether that’s ABA, or an alternative, can be expensive when paid out of pocket. When exploring or deciding on a specific intervention or provider, know that it’s most likely going to come through insurance or Medi-Cal (if private) and the school district.
Undivided Public Benefits Specialist Lisa Concoff Kronbeck tells us, “At this time, most people’s ABA is going to come through insurance or Medi-Cal. Regional Center will only handle it if [insurance] doesn’t. They will agree to fund an assessment first, and then the funding for the service itself is a separate funding request once they have the assessment and service recommendation. They will fund a couple of different types [of therapy] but not at the same time. I have heard of people getting Floortime instead of ABA, but it’s an either/or, not an and.”
If you already know which intervention you want your child to receive and are ready to dive in and begin, there are multiple avenues available to parents when searching for a specific provider, such as:
In 2012, Governor Jerry Brown signed Senate Bill 946 into law, requiring that private insurance in California cover behavioral health services for children with autism or “pervasive developmental disorders.” To receive coverage, your child will need a prescription from their doctor or psychologist who has determined that ABA is medically necessary. If you have insurance through your employer that is self-insured or self-funded, ABA services may not be covered. Contact your Human Resources Office or your plan’s member services department to see if your plan will cover behavioral health services and which services are covered under your policy. Your insurance provider must process your claim within thirty days. If you are denied coverage, you can submit an appeal through your member services department. You can also contact the treatment provider to find out if they accept your insurance.
According to California’s Department of Health Care Services (DHS), “Medi-Cal covers all medically necessary behavioral health treatment (BHT) for eligible beneficiaries under 21 years of age.” However, Medi-Cal requires evidence-based treatments, so you’ll need to check to see if the type of therapy you would like to pursue would be funded. Medi-Cal will cover behavioral health services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Medicaid benefit for beneficiaries under twenty-one years old. To receive coverage, your child will need a prescription from a doctor or psychologist who has determined that the intervention is medically necessary. The process will look different depending on the child’s Medi-Cal plan. According to California’s Department of Health Care Services, “Fee-for-Service (FFS) beneficiaries who are eligible for Regional Center services receive BHT services coordinated through their local Regional Center.” By January 1, 2023, most Medi-Cal clients will receive their medically necessary behavioral therapies via their managed care plans (or with managed care as secondary coverage if the family also has private insurance). See the DHS directory for your MCP’s contact information.
Prior to age three, children across California can receive early intervention services from Regional Centers if they have been diagnosed with, or are at risk for, developmental delays or developmental disabilities. Behavior supports should be in place if they are needed in order to meet an IFSP goal, regardless of whether there is a diagnosis of autism. Some Regional Centers, however, have things they want parents to try before they will fund direct 1:1 services.
Once a child turns three, the child’s school district of residence becomes responsible for providing special education services under IDEA, but Regional Center may still fund services. The scope of Regional Center services after age three is different from what is provided through early intervention — it’s provided under what is called the Lanterman Act.
Once a child has transitioned out of early intervention, depending on your child’s needs as outlined in the Individualized Program Plan (IPP), Regional Center may fund behavioral services. The Regional Center may refer parents to community resources, fund educational sessions or workshops to aid parents in addressing their children’s behaviors at home, or fund in-home consultation with a credentialed behaviorist, who helps parents set up an individualized behavior intervention program to be implemented by the parent. Some Regional Centers offer a toilet-training program as one of their behavioral services.
For children with higher behavioral needs, the Regional Center may fund in-home ABA services or other behavioral therapy programs, such as Floortime. The Regional Center may refer parents to community resources, fund educational sessions or workshops to aid parents in addressing their children’s behaviors at home, or fund in-home consultation with a credentialed behaviorist, who aids the parents in setting up an individualized behavior intervention program to be implemented by the parent. Regional Center is a payer of last resort but may fund behavioral services such as ABA if you receive a rejection from private insurance or Medi-Cal.
Regional Center may also fund social skills therapy, “structured programming in either an individual or group format that primarily addresses significant deficits” in engagement and awareness of other people, play skills, social communication skills, and social interaction skills. Some Regional Centers will provide social skills classes if they are necessary to aid the consumer in meeting social goals articulated in the IPP.
Your Regional Center can also coordinate services and provide evaluations and assessments at no cost to those who are eligible. A Regional Center may consider funding for behavioral supports when a child’s behaviors pose a health or safety threat to themselves or others, when they jeopardize a child’s ability to be live in the least restrictive setting (e.g., the behaviors put a child at risk of institutionalization or preclude them from participating in typical day programs), and when they interfere with the acquisition of developmentally appropriate adaptive or functional skills that are “fundamental to the attainment of social inclusion and increased independence.”
When Regional Center clients enroll in Self-Determination, they are given a yearly budget to use for services. Once a behavioral health treatment plan is chosen, it can be added to the spending plan. It’s important to note that the chosen therapy must meet a goal listed in their Individualized Program Plan. The chosen provider will also need to sign up with the client’s Financial Management Service (FMS). Learn more about Self-Determination here.
If you and the Individualized Education Program (IEP) team determine your child needs a particular therapy for them to receive a free, appropriate public education (FAPE), the district can cover the cost of service (note that this doesn’t mean you’ll necessarily get the service from a private provider, as the details will be worked out with the IEP team). Dr. Pelangka notes that school-based interventions will be evidence-based. “ABA isn’t ever written into an IEP,” she says, “evidence-based behavior strategies are. Most of which, of course, are done in ABA because ABA uses evidence-based strategies. For example, visual schedules are not ABA, but are often used within ABA sessions.”
Contact the treatment provider to learn more about the specific payment options they offer. If you qualify, you may be able to set up a payment plan or pay on a sliding scale.
Parents should be able to secure a wide variety of behavioral health treatment from qualified providers using insurance coverage. If for any reason your insurance provider denies the service, you have options: remember that your Regional Center is the payer of last resort. Having a denial letter from your insurance often opens up coverage directly from your Regional Center.
Disability Rights California has a useful guide to appealing the decision from your health insurance provider. If you are denied behavioral health treatment, such as DIRFloortime, through your health insurance plan, ask for the reason to be provided in writing. Keep digital copies of all assessments, treatment plans, goals, and letters from your child’s pediatrician, the school district, or Regional Center that provide support for the case that DIRFloortime is medically necessary. Keep detailed notes about who you talked to, the time and date of your call, and what was said.
Check out Undivided’s Guide to Funding Resources for more information.
Have you tried using a different behavioral therapy with your child? What therapy did you choose, and how is it going? Let us know!
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