I typically think of this in terms of a setting choice (where do we deliver this clinic?), but what’s really being changed is the many variables that a single location can control for a team (antecedents, reinforcement, peer access, density of sessions, etc.). A location’s ability to control for these variables above and beyond a kitchen table is the true mechanism. The following sections elaborate on the many programming decisions that a single location makes for you and where a clinic falls short as well as what to ask a clinic before you recommend a location to a family.
What a controlled environment changes about instruction
For many skills it is very important that the clinician is able to control for competing stimuli in the environment, so that access to preferred items is through the instructional arrangement. For example, for very early learners working on cooperation, on learning a mand, on learning to deny access to preferred items, it is critical that the sessions take place in an environment that is under the clinician’s control in terms of reducing the impact of competing stimuli.
This also affects the supervision economics of a program. It is generally easier for a BCBA to travel to a clinic and see several programs in one hour, to correct any mis-implementation of any part of a program in that hour, and then modify a prompt hierarchy or change the sequence of skills for the next week of data collection than it would be for a traveling supervisor to travel to a family’s home for remote supervision. Even when supervisors travel to a location for center-based services, the cost of their time typically exceeds what would be paid for center-based services.
Trial density and the honest trade-off
Yes, higher opportunity counts per hour in structured settings. But density is not an end in itself. That a program may be running eighty discrete trials per hour (with no opportunities for natural response within that hour of program) does not mean that those responses are going to be very generalizable. That will depend on the proportion of the session which is structured as opposed to the total number of trials. That is a matter for the treatment plan, not for the technician on any given day to decide.
Matching session format to the target behavior
In general, Centers that deliver more than one Type of Program throughout the day do so based upon the class of skill that is being targeted on a given day, NOT based upon Staff Availability.
| Format | Best suited to | Main limitation |
| One-to-one discrete trial | Early listener responding, imitation, discrimination training | Weak generalization without planned transfer |
| Natural environment teaching within the clinic | Manding, play expansion, spontaneous language | Harder to measure consistently across staff |
| Dyad or small group | Waiting, turn taking, observational learning, peer initiation | Requires peers at compatible skill levels |
| Routine-based blocks (meals, toileting, transitions) | Daily living and self-care chains | Clinic routines may differ from home routines |
| Caregiver-led session in clinic | Parent fluency with procedures before home use | Depends on caregiver availability during business hours |
Peer access is the clearest differentiator
It’s very hard to teach skills that require other people, such as to play or work with others. A center offers a clinician the opportunity to select a peer and program for him/her in the skills of interest. He/she can also increase or decrease the difficulty of the activity, as well as decrease the amount of adult prompting, across trials. When reviewing a program for skills that require other people, find out if the program lists out the peer pairings for each session and reviews them prior to session, or if they just list out that there is group time scheduled for that day.
Keeping families central when the work happens off-site
Most families who engage in in-center ABA therapy in Rhode Island want to know whether or not what they are paying for in terms of in-center sessions is actually translating to improvements in the family’s home environment, so it is worth asking any program you are considering to show how that translation happens. This is an issue that should be explicitly addressed.
The practical structure to support these aspects in clinic is 1) a set time each week for BCBA coached caregiver skill rehearsal of that skill to practice that skill (not just to talk about it), written goals in the skills of the families of the children receiving services with corresponding home/routine targets, and video review of that particular skill(s) that the family/caregiver reports being particularly ‘stuck’ on.
Three things to document from the start
- Which home or community routines the family wants to change, ranked by how much friction they cause
- Who will run each procedure at home, and what their realistic capacity is on a difficult week
- How progress on home routines will be measured separately from clinic data
Planning generalization rather than assuming it
For skills that only seem to generalize in the clinic then transfer needs to be a part of the skill’s plan as well. Mastery on a skill should include some untrained people and some untrained locations. Techniques for assessing a skill that has only seemed to be acquired in the clinic include having other technicians on the team test out the learner on previously acquired targets, taking skills out into the hallways, or the waiting room of the clinic and testing the learner in the surrounding community and occasionally assessing the skill in the home or at the school of the learner.
Questions that reveal how a center actually operates
- What is the supervision ratio, and how many of those hours involve direct observation of the learner?
- How is the daily schedule split between structured and natural teaching, and who decides?
- What is the technician turnover rate, and how are transitions handled when someone leaves?
- Under what conditions would the team recommend reducing hours or moving to another setting?
- How are restrictive procedures reviewed, and who signs off?
- What does the discharge or transition plan look like, and when is it first written?
Are answers to these questions concrete, recorded in some way, even occasionally embarrassing? Or are answers mostly about hours delivered and feelings evoked?
