Behavioral Interventions Beyond ABA

While ABA therapy is considered the gold standard of behavior therapy, some adults with autism describe having negative experiences during sessions when they were younger. In addition, some parents question whether ABA is appropriate for children with other diagnoses.

According to Dr. Vanderbilt, 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. Hyman 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.)

What to think about when choosing a specific intervention or provider

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.

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.

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.

According to Dr. Hyman, “the research around relationship-focused interventions and Floortime is in its infancy and is more narrative than the literature regarding ABA.” Their effectiveness will become more clear with further research.

DIRFloortime/Floortime

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. (Find the answers to commonly asked questions in this brochure.)

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 from stanleygreenspan.com.

Relationship Development Intervention (RDIⓇ)

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.

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.

Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER)

JASPER was developed by Dr. Connie Kasari at the University of California, Los Angeles (UCLA) and emphasizes social communication skills while teaching and modeling:

• joint attention, which is the ability to focus on both objects and people,
• symbolic play, where children can use one object to represent another (for example, using a banana as a phone),
• engagement, and
• regulation of emotions and behavior.

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.

Social skills groups teach kids how to interact with their peers in social settings. Dr. Vanderbilt tells us that such groups are most beneficial for children who can gain from social problem-solving and modeling with peers.

Social Thinking

The Social Thinking Methodology focuses on building a child’s social competence so 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 and adults.

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.

Integrated Play Groups (IPG)

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.

Program for the Education and Enrichment of Relational Skills (PEERsⓇ)

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.

Treatment and Education of Autistic and related Communication-Handicapped Children (TEACCH)

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.

Sensory Therapies

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.

Communication-Based Behavior Management and Speech-Language Therapy

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.”

Collaborative & Proactive Solutions (CPS)

Developed by Dr. Ross Greene, CPS wasn’t designed with an emphasis on behavior. Instead, it focuses on the skills a child needs to support their development under the premise that unwanted behavior occurs when children cannot meet expectations that exceed their “capacity to respond adaptively.”

CPS focuses on teaching positive social skills such as “empathy, appreciating how one’s behavior is affecting others, resolving disagreements in ways that do not involve conflict, taking another’s perspective, and honesty.”

Dr. Vanderbilt tells us that CPS is similar to a cognitive behavior approach and is about addressing a child’s concerns. “You can’t reinforce your way out of some meltdowns or tantrums because the child doesn’t have skills to self-manage.” So, it is essential to engage in problem-solving with them.

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.

CPS offers a list of providers in California.

Respond but Don’t React

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.

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.

You may still be able to obtain funding for another intervention through:

• Private insurance

  • Review your plan or contact your insurance provider’s customer service department to learn which services are covered under your policy.

  • Contact the treatment provider to find out if they accept your insurance.

• Medi-Cal

  • 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.

  • For BHT services to be funded, they must be recommended by a physician or psychologist as medically necessary.

  • 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.

  • To learn more about the changes to Medi-Cal going into 2022 and 2023, read about them here and listen to Undivided's Public Benefits Specialist, Lisa Concoff Kronbeck, break it down on our Instagram page.

• Regional Center

  • Your local Regional Center will provide BHT services if your child remains in fee-for-service Medi-Cal. (Find your Regional Center here.)

  • Regional Center requires evidence-based treatments, so you’ll need to check with your service coordinator to see if the type of therapy you would like to pursue would be funded.

  • It is also important to note that Regional Center is the payer of last resort, so you must go through insurance first.

• Self-Determination Program

  • 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 (IPP).

  • The chosen provider will also need to sign up with the client’s Financial Management Service (FMS). Learn more about Self-Determination here.

• Your child’s school or district

  • 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).

• Out of pocket

  • 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.

Check out Undivided’s Guide to Funding Resources for more information.