Revisiting '40 Hours' ft. Jennifer Stephens

ABA on Tap is proud to introduce Jennifer Stephens, a BCBA and clinical counselor, in this latest installment of our behavioral brew. Jennifer is owner/operator of the Stephens Consulting Group in Kentucky and also a long time listener of ABA on Tap. She took inspiration from our inaugural episode 'Why 40-hours?' and has graciously agreed to join as a guest and continue the conversation. In this episode, you will hear more about considerations toward recommendation of levels of service as affected by client availability, fiscal motives as well as research-driven, empirical validation. Pour a nice, tall, cool one and enjoy---cheers!

AND--if you are ready to enjoy the benefits of Magic Mind and boost your brain performance, please use the following link and use the discount code ABAONTAP20 to receive 20% off your purchase:
https://www.magicmind.co/ABAONTAP

Transcript

SPEAKER_04: 0:00

Welcome to ABA on Tap, where our goal is to find the best recipe to brew the smoothest, coldest, and best tasting ABA around. I'm Dan Lowry with Mike Rubio, and join us on our journey as we look back into the ingredients to form the best concoction of ABA on Tap. In this podcast, we will talk about the history of the ABA brew, how much to consume to achieve the optimum buzz while not getting too drunk, and the recommended pairings to bring to the table. So without further ado, sit back, relax, and always analyze responsibly.

SPEAKER_03: 0:51

All right, all right. And welcome yet again to another installment of ABA on Tap. I am your co-host, Mike Rubio, along with...

SPEAKER_04: 1:00

Daniel Lowery, very, very excited for this episode, Mike. Let me pass it back to you for intro. It's been a long time coming, man.

SPEAKER_03: 1:07

So, I guess an official first. We've had one guest on the tap before. Sure. A colleague, somebody we knew, we were familiar with. Very excited to have, I guess, officially our second guest.

SPEAKER_04: 1:19

When we started, just a real quick aside, when we started this podcast, our number one goal was to get engagement from the community, both on our side and potentially detractors, to create a helpful discord and discussion and maybe even debate. So this being our first guest outside of our social circle and from the podcast, super, super excited.

SPEAKER_03: 1:39

And to your point, we've gotten the trolling, right? One of the things we talked about is I guess no press is bad press. Sure. Of which we offered

SPEAKER_04: 1:47

to

SPEAKER_03: 1:48

come on that refused. So we'll get into that a little bit. But amongst the trolling, we got Jennifer Stevens. Hi, Jennifer. How are you doing? I'm doing great. How are you guys? What you do might be kind of obvious in the sense that you're involved in applied behavior analysis, but tell us about your day-to-day and all the things you're involved in so people get a nice framework of your expertise.

SPEAKER_00: 2:39

Absolutely. So I am definitely a behavior analyst, but I am definitely more than just a behavior analyst. My husband and I co-own a company called Stevens Behavior Consulting out in rural Kentucky, where I work as a licensed therapist and a licensed behavior analyst. And my husband works as a licensed behavior analyst, primarily with adults through a Medicaid waiver system that we have in Kentucky. Okay. I also supervise several counseling interns that are working on their graduate school degree for counseling and then also supervise BCBA students working on their fieldwork hours towards their BCBA and operate under both umbrellas. And as I also work towards my registered play therapy certification as well. And I've been doing this for over a decade, almost 20 years.

SPEAKER_04: 3:29

Wow, that's awesome. Quite the diversified experience. And you also own a CrossFit gym, correct? Absolutely. That's awesome. We'll definitely get into that a little bit later. We're super, super excited about hearing all the diversified experience and how we can, you know, in the tap, we're always looking at how we can broaden ABA from what maybe people think of. And I think you've done a really awesome job of even creating some other outside of the box, you know, aspects of therapy for your clients to make it even more inclusive.

SPEAKER_03: 4:01

So that combination of therapy setting and CrossFit gym that probably works to your advantage, right? So one of the things we talk about with collaborative treatment is, or we've mentioned here is, you know, historically, maybe ABA and occupational therapy, not being the friendliest in the, playmates in the sandbox, but knowing that whenever we walk into an OT space, it's amazing. The resources, the things that are there, you probably have a very similar type of setup with your CrossFit gym, things that kids are gonna be very intrigued by that are gonna serve very well for all sorts of motor activities.

SPEAKER_00: 4:36

Oh, absolutely. We use our CrossFit gym space all the time for our clients age, you know, two years old, all the way up, we can do obstacle courses, we can work on, you know, executive functioning skills, we can work on that planning, organizing component of, you know, how do you create an organizational space? How do you create an obstacle course? And then how do you go through it? How do you remember these multi step directions? How do you wait your turn when you're in a group? So when we have groups that run through it, you got to wait your turn You got to work with your peers to build that obstacle course. It allows them to move versus having to just sit still. People have energy. People need to move. And when your brain starts moving in a physical way, a lot of things can happen too.

UNKNOWN: 5:19

Yeah.

SPEAKER_04: 5:20

especially young boys. They obviously want to move and explore their environments and things like that. So that's a really awesome collaboration that you have there. And like you mentioned with multi-step instructions and things like that, making it functional rather than just giving an instruction, like touch your nose and then pick up the pencil or something like that, making it functional and then rewarding for them so that they have a reason to do it and reinforcement that's naturally embedded in whatever you're asking them to do.

SPEAKER_00: 5:44

Absolutely. And just watching the progress of them going from saying, let's build an obstacle course where we've had some kids come in and their obstacle course consists of a whole lot of work. And then when they got done building it, you'd ask them, well, what do we do? How do we do this obstacle course? And they go, you just run straight down the middle. And I'm like, oh, okay. And then we finally got to a point where there was actually 10 different steps and they could move through them and they could do different things and they could use different equipment and they could teach their friends how to do them as well. So just watching that progress of their skills grow over time was kind of cool as well.

SPEAKER_03: 6:14

We talk a lot about just the basic premise of imitation and ABA and you're talking about observational learning too from a social perspective. That's amazing. So really integrating many, many aspects of development in general, which I think is a fascinating, fascinating thing.

UNKNOWN: 6:30

Yeah.

SPEAKER_04: 6:31

Before we move on forward, I want to just take a quick step back. And so, you know, Mike was mentioning that we both get positive and negative feedback on our podcast from supporters and trolls. But, you know, you and another person have been supporters almost since day one. So first of all, I want to thank you for that. It means a lot. But I want to just open up the floor in kind of what resonated with you with our podcast that you found to be I don't know. They interest you and made you supportive of our podcast.

SPEAKER_00: 7:05

Oh, lots of things. And it's kind of funny because the way I found you guys was there was a conversation on a Facebook group about a certain number of hours being required and people being upset because the insurance company only gave them 20 or 30 hours. And so there was a whole dialogue that happened about that. So I went on a mission to find any research or anything that proved that that was not necessary. And so I typed in why 40 hours and your podcast came up. And so that's ironically how I found it. And I was like, this is amazing. Yes. And so I listened to the whole thing and then proceeded to listen to all the rest of them. And I was like, oh, I ran out of them. There's no more. But, you know, I think every single episode that I've listened to, which is all of them, have resonated with my clients and how I operate. Just that, like, this is what's real. This is how we live. This is how we operate on an everyday basis. We don't exist in a clinic. We don't exist in a contained space that's sanitary. We have real obligations and real siblings and parents that have jobs and other things that need to happen. And so being able to advocate for like, hey, what are we doing? And how are we making this actually work? Like, if you want to do applied behavior analysis, like Let's make this work in a way that actually helps families and that they can take something from it and

SPEAKER_03: 8:27

it reduces the stress that they currently have. A lot of the sentiments you're expressing are questions that we had actively asked. I'm in my 26th year of practice and having worked for almost everybody here in town, it was always an odd pressure as a clinician to have these extensive weekly supervisor meetings and spend Absolutely zero time talking about applied behavior analysis, but talking about hours. Got to

SPEAKER_04: 9:11

maximize

SPEAKER_03: 9:12

your hours, man. Maximizing hours. Now, I'm not trying to be highly critical of that because I know from a fiscal perspective, that's also very important. You have to be solvent. If you're going to help people, well, you've got to be able to run a business. And I think that's probably another ABA on tap episode at some point in terms of the business experience of most clinicians in our field, which is sometimes close to zero. You're an exception there. there. But yeah, we harken back to the idea of where does this idea come from? We know it comes from Lovaas. Or we're going to assume pretty safely that it comes from Lovaas. And one of the mantras we've always got us started here was this idea of from the lab to the living room. Even in the way we practice our things, Dan alluded to your CrossFit gym and the idea of imitation and do this or touch your head, these more simple nonverbal or verbal imitation techniques we've used. And it was things like that that made Dan and I go, man, we've been doing this so long and nothing's evolved. Everything seems to sound the same, look the same. Even our voices were saying, do this. Good job. You know, so much of that sort of wrote like, and again, you know, I'm sounding facetious a bit. I'm being a little bit critical, but it was for us. It's time to change. Where did this idea come from? Dan, on your end, you were also working with some of our insurance payers who were now asking for us to, we were doing some of the utility management, asking for us to try and navigate this idea that we Right. Right. Right. Over

SPEAKER_04: 11:07

eight hours a day is time and a half, right? And with school, a lot of these kids are doing over eight hours a day.

SPEAKER_03: 11:12

Well, and they have school in many situations, right? So that's kind of where our conversation started. And now you've got a whole different perspective in running your business. We're in California. You're in Kentucky. There might be some differences there with regard to the state mandates and how they actually play out. So let's jump right in. Tell us a little bit about your experience. You had mentioned that in your introduction with this Medi-Cal. What was that like? waiver. Yeah, is that right? Did I get that right? Medicaid waiver? There's a Medicaid waiver, yeah. I said Medi-Cal because I'm in California. Stuck in that rut. So that Medicaid waiver will be something interesting to discuss. And then, yeah, this idea of 25 to 40 hours certainly works. And that was a starting point. Where are we now, right? What if you can't afford the time or the expense of that? Where does that leave us as clinicians? And does it mean that if we're not operating at that level, then what we offer is insignificant. I would quickly disagree, but let's lay that out.

SPEAKER_00: 12:08

Now, I would also quickly disagree that if there is a, in quotes, recommended number of hours based on some completed assessment, if the family says, well, I can only do X number of hours, Does that mean that you say no or because they can't do the max hours that you've suggested or do you go with what they can do and you meet them where they're at? And my answer is you provide them with what they can and you support them in making the decisions that actually work for them in the moment and long term. Because a lot of families, just from working with parents of autistic individuals as a therapist, being a therapist for the parent, And working with these families as a BCBA, seeing both sides of that, there's a lot of stress and pressure that the parents put on themselves to do whatever the clinician has told them they need to do because they feel as though if they don't, that maybe they're not doing enough. And I don't want a parent to ever feel like I didn't do enough. So I got to put myself on the back burner or I got to put my family or siblings or we can't do other things because if I don't, do those things, we won't be able to provide this thing. And that makes me insufficient in providing my child with what he needs and he won't make the growth that's necessary. So looking at, you know, what can we do with the time and really what is the maximum amount of time that you could use, be efficient with, gain a lot from and still have your life still live. You know, I've had parents say, I really want to go to the gym. A parent the other day said, I really wish I could go back to the gym. I miss going to the gym, but between all these different therapies and stuff like that that are going on, I just don't know when that's going to happen again. You know, just maybe in a few years that might happen. And to me, that's really sad that we can't make that a realistic possibility because we have so many other therapies that have to happen. And if we don't do those, then what?

SPEAKER_03: 14:00

What are some of the constraints you think people are hitting? I mean, so this becomes, again, that balance of running a business as well as giving some recommendable, some helpful level of service. Now, as a business owner, you probably understand some of the constraints that people are running to, but you've chosen to find more creative solutions. So you alluded to the idea of... which I think happens to be a standard across some providers. If you're not available 25 hours, then we can't schedule you for services because otherwise our logistic becomes much more difficult to manage and to plan. So I know that I don't prefer that route. When I pitch it that way, I can understand exactly why people go that route. Outside of our conversation here today, I believe you've alluded to that as the easy way out, which I think is a really good way to put it. Tell us a little bit more about your approach. Yeah,

SPEAKER_00: 14:55

I definitely think that it feels, especially as an outsider and being someone that's in charge of scheduling and trying to navigate the schedules of parents and our technicians and the BCBAs and just life in general, trying to make all that stuff work. it would be really incredibly simplistic. If I just said, you only come these hours, these is your, this is your scheduled time. You're always going to come 20 hours. You, this tech has two kids and that's just how we're going to operate it. And we'll switch every, I don't know, six to eight weeks, you'll get a new tech and that'll be your generalization period in quotes. But I've chose to operate differently because I, Feel as though that's not necessarily while it's convenient. And it has some benefits to it on that end. It isn't necessarily the thing that meets the clients where they're at. Clients have different lives, different schedules, different siblings have stuff they they adults have work lives, things like that they want to join. horse camp or they want to go do an art club after school or they join archery. Life's change stuff comes up and I want them to be involved in the naturally occurring things with their peers whenever they're available. I would much rather them do that than show up to our office.

SPEAKER_04: 16:12

Which always goes back to the generalization piece that you mentioned earlier, as well as the least restrictive environment. That's the whole reason that we do home sessions is because if, you know, what people do in the lab doesn't necessarily translate to the living room, like Mike said. So we might be able to get a child at our office to follow all of our instructions. But as soon as they go home to grandma or whoever else and the TV's on and their living rooms, you know. chaotic, then the skills might not translate. So like you're mentioning, maybe sometimes that actually worked against us asking for these excessive therapies because now we're not generalizing to school or to the horse therapy or to karate class or things like that because they're not able to experience these things because they have to do the ABA session. So in fact, we're kind of doing the exact opposite that we're designed to do. We're designed to go into the environments and help people succeed, but by virtue of asking for however many hours, we're pulling them out of those environments and then trying to kind of do it on the back end, which may or may not be successful. I was looking as you were talking, trying to find the new under the new ethics code, how I was reworded under the previous ethics code. It was environmental situations that hamper implementation of ABA services. And I feel like sometimes that's what the companies relied upon or maybe even the service relied upon of saying, well, if we can't do 25 hours or 40 hours of services, then we're not going to be effective. And if we're not going to be effective, then it's not, you know, we shouldn't do our services because we're not going to be effective. So I do think it's interesting because there isn't as much research. In general, there's not a whole lot of research maybe debunking that. And a lot of companies, like Mike said, whether it's done fiscally motivated or they do it clinically motivated, have kind of relied on that and stuck on the 25 hours to 40 hours. Well, if you can't commit to that much, then we can't be effective with your kids.

SPEAKER_00: 18:09

Absolutely. And I think it's our job to help move the field forward and having those open discussions with, you know, both the science of like, what can we, what do we need to do? What can we do? And then how do we teach these other people in these other environments to do the things that would help these individuals succeed. So instead of helping an individual succeed in a very sterile environment and then harming hoping that we can make that happen in another environment that's less sterile why don't we just go to the archery camp and help them figure out on day one what's going to help them be successful at archery camp or can we go to the grocery store with them and help them figure out why going to the grocery store is such a difficult task for the family to do like why can't we just dig straight in go go to the deep end figure it out put stuff in place and make things change a lot quicker and in a way that really matters to the families because now they're able to do the things that they really want to do versus dreading doing those things because they're anticipating a meltdown or their kid eloping or things like that and not being able to make those things happen.

SPEAKER_04: 19:17

Or even better, really work with the parents on teaching them how to manage their kids' behaviors at archery camp or whatever, or at school, working with the school staff. Again, that's a little bit more nuanced because of a lot of different variables, but work with those supporters and collaborators to give them the ability to have these skills rather than, We come and the parents leave for two hours and we run a whole bunch of skills. And then we're like, okay, parents, we're going to leave now. And somehow they're expected to have that transfer through osmosis through two stories of their house and then be somehow implemented into archery camp.

SPEAKER_03: 19:51

So it was an underlying assumption too, which I think is an active evolution in our field. When we're talking about 25 to 40 hours, I would assume that there's an underlying assumption there that we are the ones and the singular ones driving the therapy. So to your point, Dan, the idea of parent participation is almost eliminated. When you think about the assumption underlying without being spoken is, I remember when I first started this, right, one of our intake questions was, is there an isolated space in your household that we might be able to utilize? Because the idea of parents being involved, and again, I'm dating myself, I've been doing this for a long time and glad to be speaking about this particular evolution. But yeah, there was an underlying assumption that the parents were not going to be involved, that they were going to, that we were going to control the situation, and then at some point... In fact,

SPEAKER_04: 20:37

sometimes we told the parents to leave because if the parents were there, they were maintaining too many of the behaviors, so they had to leave. I

SPEAKER_03: 20:44

just dealt with that very issue a couple weeks ago with, I guess, behavioral contrast, right? The idea that the therapist was very earnestly telling me, you know, when mom's not around, this goes a lot more easily, and I'm like, and that's why we want mom around. If we're not taking the difficulty head-on, then we might not be prioritizing, you you know, one of the key behaviors that we're trying to change here, or, you know, for this kiddos, given their particular age, what they're trying to develop into and learning how to comport themselves accordingly across different people, settings, you know, expectations. So I do think that that's something that spilled over even into some of our procedures, right? So going back to this idea of imitation or any of the procedures that have been historically run, things that we, you know, people call programs that are translated into goals, the idea that we're the only source of SDs in the environment. We're going to be the only source of reinforcing consequences in the environment. And again, I think that all sort of fits together. But again, it all sort of goes back to this general premise that we were the only ones that were available to sort of run these procedures or to make these things happen. And then to both of your points, the idea of parents sort of got excluded there, a really, really important piece that we need to learn how to better reintegrate and to keep integrated from the beginning.

SPEAKER_04: 22:25

Absolutely. And that's where the 25 hours to 40 hours certainly makes sense. Sure. But if we can, if schools have become a lot more informed and effective with individuals on the Well, if they're at school, I don't know if they're preschool, you know, that's four hours a day times five days a week. So that's 20 hours right there. If they're a regular school, that's like six or seven hours a day times five days a week. So that's your 25 to 40 hours right there at school. Also, the parent training, they're with the kid 24 hours a day or outside of school, another six hours a day. So I think, yeah, it makes sense if we're the only ones that know how to interact with these individuals with autism, like it was during Lovaas' day when they were either institutionalized or mainstreamed and there was no overly in between sure that made sense but now i would argue and and um i'd be interested to hear your perspective too jennifer because you know we're in california which is uh in san diego specifically which is pretty urban pretty progressive um our schools may or may not be um you know as as great as a lovas academy or something like that but they they're pretty they're at least they know what's going on um and i would assume that they have some fairly effective programs um What's your situation or your experience where you're at, Jennifer, in terms of the quality of education that the clients that you're working with in Kentucky are receiving on a preschool, elementary school, middle school, high school level?

SPEAKER_00: 23:45

Yeah, so we are in Shelby. And so we're one community. one county over from Jefferson County. So Jefferson County is where Louisville is. And so the school districts out here are based on counties. So whatever county you go to or live in, that's where you go to school at. And so I would definitely say that the counties vary in what services and supports they have available. I know within the county that we live in, they have, I think, four or five BCBAs that are hired for the school district to work within the

SPEAKER_01: 24:16

schools.

SPEAKER_00: 24:17

One of our employees actually, she works... part-time with us, but she works full-time as a BCBA for the school district as well, and so they have one, I think, dedicated for the preschool, and then they have others that work within the elementary, middle, and high school, depending on what the needs are. We also have mental health consultants within the school districts as well to address kind of any mental health needs that kids have, and that's kind of, they don't have enough people, to be honest. They need more, but They're doing the best they can with what they have. So within the school system, we definitely have the capacity to support individuals in a public school setting with IEPs to get those additional supports in place. There are counties that do not have that, though. They are just more rural. They don't have as many students. They only have One, one County in particular has two elementary schools and one middle high school. So there's only three schools in the whole County. And so they don't have a mental health consultant. They don't have a BCBA, but they do work really well with me. So they allow me to come in and support the teachers and collaborate with them on ideas and stuff for the students. So those students can go to school there, get the education that they need and work together on coming up with ideas and Will any school system have everything that a kid needs? No, absolutely not. There's always going to be something that someone needs, whether it's an extra assistant or like a para. There's a lot of kids that would benefit from having an extra one-on-one person just available within the classroom to support them to maintain in that general education classroom because they just need support at times, but not maybe all the time. So not everyone has those that they need. But that doesn't necessarily mean that those kids need to go to a private school to get those needs met either.

SPEAKER_04: 26:12

Yeah, that's an interesting thing that's come up a lot, Mike. I don't know if we get into it today or if it's an episode on itself, but that idea of, well... With our ABA, if you come to our ABA social groups instead of school, we can have a one-on-one aid and somebody to work with your kid all the time, or they'll get all sorts of supports and structure and things like that. And because of that, then that makes it better than the corresponding school district, which may or may not be the case because that's a lot harder to fade out. So maybe that child may get a little bit more individual attention, but a lot of times what you're doing there is circumventing that child learning to listen to a teacher to now they're listening to this person who's always over their right shoulder the whole time And it's also a much more restrictive environment.

SPEAKER_03: 26:53

So I think we can get into it a little bit today, and it probably is a freestanding episode. But again, it harkens back or points back to this idea of optimizing our hours. We want to give the highest recommendation. And to what both of you are speaking to here with schools, you know, if you're an agency and you're trying to contract with the school district, you're usually trying to put your own person in there because that's going to optimize that fiscal exchange. And again, it makes an assumption that we have to be there in order to make the ABA come to life. Now, I don't want to downplay our expertise. Yes, we're certainly important, but the way you're describing it, Jennifer, you're collaborating, you're giving ideas for procedures, you might be modeling, you might have hands-on directly for a little bit, but by and large, you're letting them run the show, you're letting them try it out. It's much more an act of collaboration as opposed to a foot in the door that is never going to leave the door. It's just going to inch closer and closer inside, which I know has been a big criticism, a long-standing criticism of our particular service and field, especially from schools, you guys get your foot in the door and then you never leave. And that's really diametrically opposed to our, you know, sort of self-obsolescence approach, which is if we're doing what we're doing right, you should see less and less of us over time. This amazing concept we call fading, which we're not always very good at.

SPEAKER_04: 28:11

That's what I see is probably the biggest issue is I saw that you mentioned that we used to review insurance companies for an insurance contract as they were third party providers that, yeah, the the fade out just wasn't there uh it was oh if your child can use services then we can come up with goals and that whole one goal per one hour of service adage that started i don't know where

SPEAKER_03: 28:33

are you familiar with that one is that something

SPEAKER_04: 28:36

who

SPEAKER_03: 28:37

started that that's we need

SPEAKER_04: 28:38

to find that

SPEAKER_03: 28:39

out and have them on the show

SPEAKER_04: 28:40

and if i make my turn and your turn different goals under turn taking or if i make turn taking and waiting look that's two goals that justifies two hours of playing a game and then we just have a million hours

SPEAKER_03: 28:50

how many goals can i add to my report just to make Sure, we justify the 25 hours. I'm going to

SPEAKER_04: 28:55

have the attending goal, the flexibility goal, the transitions goal, the everything based on this one activity. And I got 12 goals for one game. And now I can get my 12 hours of service.

SPEAKER_03: 29:06

And you need those 12 to 25 goals to be able to. conduct during a four to six hour session, right? Because that's what you're going to... So, I mean, again, it all fits in. There's a logic to it, but clearly all of us are saying, I mean, what do you...

SPEAKER_04: 29:20

And what I would say to that, just finalizing that, that foot in the door, if that worked, and if we were to be able to do that many hours in a year or two, and then really, really fade out to like a console model, then I'm sure insurance companies would be totally good with that. We'd be all good. We'd be able to front load it. But the problem is, again, whether it's fiscally motivated, I don't know why it is. But a lot of times once these habits get established, even though sometimes the parents, if you talk about reducing hours on that end, they get frustrated. Interesting. So there's that end too, taking it even outside of our end. But I just bring it up because I know when we've moved over to our new company and some of the insurances have asked about like QC measures and quality control and, well, how do you justify your success rates? Even in ABA, that's a really tough justification. Like, how do we know if we've been successful with a client? Is it skills taught? Is it hours reduced? Things like that. I think a lot of times we would look at hours reduced, but a lot of people, judging by the contracts I've reviewed by third-party providers, are not reducing their hours.

SPEAKER_03: 30:22

Right, and over a long period of time.

SPEAKER_04: 30:23

Long period of time. And then the data is just all over, all variable and all over the place. And, well, we can just keep working

SPEAKER_03: 30:31

on the program then. So the idea that we're the gold standard for treatment but are by and large ineffective by that metric, that's not incorrect in that particular circumstance. I don't like that idea because we should be effective. But, yeah, there's a lot of variables at play here that, you know, point to a lot of the criticisms that we're getting right now, some of them way too harsh for me to ever accept, but then some of them, you know, having some real substance and going, yeah, we are– We are sort of guilty of that. And if you're running antiquated procedures now, you haven't come up to speed. You're still giving very, very large recommendations, very heavy amount of hours. There's reason. There's reason for those criticisms, right?

SPEAKER_00: 31:14

You know, I also think that if we compare our field to other fields that are similar, OT, PT, speech, mental health therapy, just the... the general hours that kids receive of those other services. So if I work with a kid who's non-vocal and they receive speech therapy, they maybe get speech twice a week, but generally only once a week. And it's usually 45 minutes, not even a whole hour. So if a child is able to go to speech therapy for one hour or 45 minutes a week, Work on some very specific skills. And then that speech therapist, ideally, in my opinion, not a speech therapist, but in my opinion, they would then say to the parents, hey, we worked on X, Y, and Z. Here's how you can work on that and reinforce that throughout the week. When they do this, try this. When they do this, try this. The parents, the kids go home. They have their entire week, all their normal activities going on without having to stop and work on skills. They just kind of like incorporate that into their natural day, come back the next week. The speech therapist can then, in my opinion, assess kind of like, okay, where are they at now? Let's work on these things. We're still working on those goals or we're working on adding this new thing in, get the parents feedback. And this whole cycle happens. It's the same thing that happens for mental health. I see a kid. We do a play therapy session, say, hey, we're working on cooperation, we're working on engagement and turn-taking. This is some of the things that I said. This is the language that I used. If you could maybe use some of this encouraging language with them, this is kind of what it looks like. Try that out and let's see what happens. They come back next week, they tell me what's going on, and we go from there. And so that's one hour. Our Michelle P. waiver, which is the Medicaid waiver in Kentucky, behavior analysts generally get three hours. If you're If you're in a really odd circumstance where the kid has a lot of big behaviors and absolutely no other services, you might get a little bit more. But in general, you're going to get three. So you get three hours per

SPEAKER_04: 33:16

week or what?

SPEAKER_00: 33:18

Per week, yeah. So I get three hours per week. And that time is spent... you know, figuring out programming, planning, you know, whatever we need to work on, but also working directly with the individual, consulting with the parents, any outside people that might be involved, giving them strategies and coming back and reassessing. So if I go to a school and work with a kid and they get three hours a week and I go there once, maybe twice a week for an hour and a half or so, the rest of the week is up to the staff. So my job is to give them the tools to manage for all the hours I'm not there.

UNKNOWN: 33:49

Yeah.

SPEAKER_04: 33:49

So out of curiosity, on the mental health side of things, are you granted much indirect time that you're able to bill?

SPEAKER_00: 33:57

No.

SPEAKER_04: 33:59

Because I wonder if that's an issue with ABA as well, because there is, you know, program development and things like that, that currently we don't really get, that's not billable. We get a little bit of assessment code, but outside of that, everything we do that's billable has to be face-to-face. So I wonder if that also has something

SPEAKER_00: 34:15

to do with that. That's how therapy is too. That's how

SPEAKER_04: 34:18

therapy is.

SPEAKER_00: 34:19

Yeah, it's all face-to-face. So I can't bill for a client unless I'm actively working with them. I don't have any codes that I can use where the client's not present.

SPEAKER_03: 34:29

Gotcha. Okay. So one thing that comes up here with that Medicaid waiver, the three hours and how you're utilizing them, and just to be fair, the entire theme and topic of today, are there times where those three hours just don't stretch far enough where you do find yourself saying, man, I wish we had more time. And what's the contrast there? How do you reconcile that? Because it is, I mean, we certainly run into that, right? More time would be better, but the family's only available and we're going to have to make do with what we have and do our best. But to just sort of, you know, play devil's advocate here, tell us about that. Does that sometimes not stretch far enough? And what are the options?

SPEAKER_00: 35:06

So the only times that I run up against that is when I have kids that have really big behaviors within like the school setting and it's happening on a regular basis. And so I have to kind of stretch my time and be more and just I just have to be intentional in how I use that time and how I consult with them and give them as many tools as possible. So and and with that said, you know, for me. You know, any particular kids like that. I can go to the case manager and say, hey, we've got some really, really big behaviors. Could I have four hours a week instead for right now? And really all and that is a possibility. It just takes time. a one hour or two hours away from a different type of service that they use through the waiver. So if the family's on board, which if I, if I went to the family and said, Hey, like we both know that we're really struggling with this. We're working on putting a lot of stuff in place to try and get things under control right now. Would you be open to me having four hours instead of three? So I can really support you, the school and everyone involved. And if the family's like, Oh yeah, absolutely. Then the case manager can make that happen too. So.

SPEAKER_04: 36:07

What have you found? So if you have a client that does have significant behaviors, challenges, things like that, and you're given three or four hours, however many hours that you receive, what have you found to be the best use of that three to four hours per week?

SPEAKER_00: 36:20

The best use of that time is definitely training, working directly with them so we know what we're up against and what they need to really be in there and be fully present to see the behaviors happen, to really understand what needs to happen or maybe what's missing, what people aren't seeing, to be able to observe how other people are interacting with them because maybe there's small things that they're doing. Maybe they're They're putting task demands in place when a kid is escalated. So thinking about you guys' episodes on escalation and de-escalation, those were perfect because we don't really always recognize that their brain is not in a space to be able to operate and to do the task or work that's presented to them. So sometimes you'll see... They're in that brain space. They can't think and function and do tasks, but we're still asking them to do stuff. We're talking to them. We're having conversations with them. So just being able to get in there and to see what is going on, maybe what's causing it, what environmental factors, and then spending the rest of time being able to give them strategies they can put in place.

SPEAKER_04: 37:23

So speaking of getting into a good brain space, let me take a quick second and pass it to Mike. I think there's something that you use to get yourself in an optimum brain space

SPEAKER_03: 37:32

as well. I appreciate the opportunity. Let's talk a little bit about mental clarity and its importance toward productivity. So it seems like everyone's always desperately wanting to do more, to be more efficient, to be more effective. At least that's what I'm always hearing people talk about. And especially on their way to that sugar-laden caffeine fix at the corner coffee shop. So somehow that extra dose of caffeine. The second wind in the late afternoon is what people are always after. So I want to introduce you to a little elixir that has helped me launch into every day and avoid the late afternoon crash. It's called Magic Mind, and it's the perfect brew to have on tap for my mental clarity and acuity. Now, don't get me wrong. It has not replaced my morning coffee, but it has assured that I can keep it to one cup and still have the mental performance and alertness I need. So I take Magic Mind because Thank you. propels my brain right into action. So instead of reaching for a second and third and fourth cup of coffee to keep my energy levels, now I just take this little green shot every morning alongside my first cup of coffee, and I'm good to go for the rest of the day. I started taking these green shots in the morning, and I love them. They help me so much by getting me in the right state of mind for a productive day. I keep them cold in the refrigerator and enjoy my shot along with the hot coffee. The contrast of hot and cold is invigorating just on its own. Very, very easy to use. It tastes clean and healthy, and it's helped me jump right into my day without jitters or stomach discomfort, which can be a common side effect of caffeine overload. So if you want to be more productive, more focused, have a little less stress and anxiety, that's why I use Magic Mind. It helps me get more done, but it also contains some really important compounds like L-theanine, adaptogens, nootropics. It's a little matcha, a little honey, and that's about it. So if you want your... If you want to boost your brain performance, your memory, your mental acuity, your alertness, try Magic Mind today. In fact, please do look at the episode description to find a link with a discount. toward your prospective purchase. I hope you try MagicMind and enjoy the benefits that I've discovered. Thanks for that opportunity there.

SPEAKER_04: 40:00

Yeah, you're welcome. I remember the sound. We were trying some new sound stuff, and that was extra frustrating before you were able to find your MagicMind and power through it and then get the sound as clear as it is today.

SPEAKER_03: 40:11

I hope it has something to do with it.

SPEAKER_04: 40:14

Going back to what you were saying, Jennifer, so about task presentation and working with the stakeholders, and you find that to be the most effective use of your time. That seems to make complete sense, right? Because behavior is a product of the environment, according to ABA. So why would we expect if we work with a child in a different environment and we present the task perfectly that when we put them in a school environment that does not present the task perfectly, that they would respond any differently? Even if we teach them great self-regulation strategies, we got to teach them in that current environment or teach the people that are working with them so that it generalizes and translates. That seems to... I couldn't resonate more with what you're saying there.

SPEAKER_00: 40:54

I wanted to pick up on a word that you just said that when kids have all the regulation skills, I think regulation skills and having that as a goal of self-regulation is a very interesting goal that we often put on plans. But I want to, I guess, throw out there the idea of co-regulation and the expectation that our clients will be self-regulating when they can't co-regulate. And the importance of us teaching the people in that environment to be a co-regulator versus expecting them to go off and to use their fidgets, their wiggle cushions, their swings, and just kind of like send them off and hope that like, if I put you over here and the things that you enjoy, you will be regulated. But what they really need, and, you know, from a biology perspective, brain perspective, that they need that ability to know that they are regulating with someone. Watching someone else regulate can help them feel safe and have the capacity to regulate as well. And we can build upon their ability to self-regulate, but our goal should always be co-regulation first, especially when we're working with those little kids. They haven't developed the capacity to do that. I

SPEAKER_03: 42:01

have to unpack so much of what you just said. It's perfectly stated. So what you're saying, in a sense, is the idea of escalating and simply de-escalating, that might be your direction. That could be the only thing you do. And a lot of times I think we feel dissatisfied with that, right? Especially if you've got a list of 25 different goals. That was a bad session. Oh, that was a bad session. All we did was learn to deescalate. Well, wait a minute. Isn't that a good thing? And if we were to take data on the duration of that deescalation and it showed a downward trend over time, wouldn't that be a good thing? But again, I think it points back to the idea that a lot of our technicians are are still carrying these 25 to 30 goal, you know, data books, learning trees, whatever you want to call them. And the idea that now my supervisor's coming next week and I didn't run any of these goals today because all we did was work on that de-escalation with some co-regulation, that wouldn't be, that would be frowned upon by and large. I think by most people, we take a different attitude on that. I know I like to say, if you did one thing, okay, well, you did one thing, let's try two next time. But this idea that you're trying to squeeze in 15 different activities on your own accord as the adult directing and kind of monopolizing the whole session, that's something that we've moved away from by and large, which I think then affords us a chance to run shorter sessions and fewer hours over the week and make us feel effective.

SPEAKER_04: 43:31

That co-regulation, too, and then I'll pass it right back to you, Jennifer, is so important because it was just fresh in my mind. I was at an IEP meeting the other week, and at the school, the school had a self-regulation goal for this child. Child will advocate for a break when they are overstimulated or need a break from the work. So they were talking in the IEP, and they were like, well, we presented the work to the kid, and the kid advocated and said... He felt stressed about the work, but I know he was just doing an excuse. So he needed to do it anyway. And it's like, well, so often our old authoritarian stuff comes back in because they're regulating, but we don't want to help them co-regulate because it's impeding on the 25 programs that we have to run or for the school, the other kids that are going on. So we go back to the blanket extinction or whatever. Again, I think that we do a pretty good job at our company of avoiding this, but I know historically, and I know it's out there based on what I hear from other parents of, yeah, they have the self-regulation goal, But when it comes down to it, we're not even going to honor that self-regulation goal because it doesn't work for us. We

SPEAKER_03: 44:30

don't have time for

SPEAKER_04: 44:30

it. Yeah, we don't have time for it. Anyway, go ahead, Jennifer.

SPEAKER_00: 44:33

I was just going to say, looking at those goals, are we going to take a top-up approach or a bottom-down approach? Are we looking at building all these skills and hoping that this will happen, or are we going to look at maybe a bigger umbrella of saying, we're going to do this one activity, and in essence, it's going to cover those 15 goals? Because one activity can actually cover a whole lot of goals. I mean, I can get a cooking activity with my kids, and we can do that, and we've covered a mass number of skills. If you want me to break it down and say, okay, well, when we were cooking, we were working on this, this, this, this, this, and this. Or I could individually say, let's work on this skill. And then once we master that, we'll work on this skill. Let's just throw it all together. Like I said earlier, like why are we baby stepping towards some stuff when we could just immerse ourselves, figure out what's working, what doesn't work. And that's the assessment piece. And as a therapist, You know, sometimes, you know, I might do one activity as a intervention and sometimes I might do the same exact activity, but more of an assessment tool. And so I might use that. We'll go back to that obstacle course task. giving a family the task of, or a group saying, let's build this obstacle course. And so the assessment piece is go build it. And I don't really assist a ton just to kind of see what skills do we have? What are we lacking? Where does it all fall apart? And once I can assess that, then I know the next session, okay, here's the skills we don't have. Here's the ones that we do have. We're going to build upon those and we're going to grow in this one. I'm going to pick one skill to grow, but we're going to still do this big activity. And so I think that A lot of times, students in the BCBA world are taught from a top-up approach versus a bottom-down approach, and making that transition can be really challenging because it requires you to intuitively think, pay attention to your environment, assess the kid, and do it quickly and effectively while still remaining engaged and participating with that kid.

SPEAKER_04: 46:24

You said something that really resonated with me last time we talked last week. And then right now, you mentioned that you had, it was either a supervisor or multiple supervisees that essentially wanted a plan for how to deal with a situation. Like when this individual does this, what do you want me to do? And you had a really interesting response that really resonated with me. Can you talk a little bit about how you talked with that supervisor, how you went about that situation? Do you remember what I'm talking about?

SPEAKER_00: 46:52

I think so, when there was a bunch of interventions occurring.

SPEAKER_04: 46:55

Yeah.

SPEAKER_00: 46:56

Yeah. So we talked about, you know, basically, there's a lot of interventions out there that we can use, and they can be really effective. They're research-based, they're evidence-based, they've, you know, they've been effective in different environments. But sometimes the biggest intervention that we can use is actually doing nothing, sitting there, and it goes back to that co-regulation piece, kind of tying that all back together. You know, in that moment, what that kid needed was just for someone to sit and to be patient, to be present, to acknowledge where he was and what he needed, and to not involve all these extra interventions and have patience and faith that that is going to get us where we need to be.

SPEAKER_04: 47:32

Yeah, that's actually a different example. The one I was thinking of that resonated with me as well, that one was a great one, was I believe you mentioned that you had a BCBA that you were supervising that wanted a plan on how to specifically respond to the situation. And you're like, well, if I'm not there, I can't tell you exactly how to respond. So you're going to have to kind of figure out some of these things yourself? Do you remember that example?

SPEAKER_00: 47:54

Yeah. Yeah. I've had a couple of those situations and it kind of threw me off because prior to those situations, I hadn't really supervised other BCBAs. I've been in the field for a long time, but I'd worked in that lower level model of less hours, and in that natural environment setting of having a general plan, like I know where this kid's at, I know what goals they generally need to work on, I know what skills they have, and what kind of is going to create behavior problems to occur and how we're going to handle those things. But going into those sessions, you're going to go into that with all that information in your head without a step by step plan. And the reason being is because if you have a step by step plan, and when you get to step three, if everything goes awry, you've got nothing. And then now you're going to be in a more panicked state because you don't have a plan. So, you know, plans are great, but they should be general and they should be in the back of our head and they should be something that guides our direction. But they shouldn't be something that we are so rigidly focused on following, because if that happens in a crisis situation, you're going to you're going to feel overwhelmed. a lot more stuck.

SPEAKER_04: 48:58

And that's that top down versus bottom up approach, right? A lot of times we've been so inundated with the bottom up. Well, we do this and this and this. If we're playing a game, we say my turn, your turn. And then we wait for three seconds and then, well, we have to teach each one of those skills rather than, hey, can we just teach a game? Or in your example with the behavioral the BCBA that you were supervising like okay well I want this this this and this rather than let's let's take a step back and look from a top down what's the end goal that we want to have here more of like that kind of perspective rather than always just trying to put these small little whether we call it targets or goals or interventions whatever together that may or may not even get to that top goal that we're trying to achieve.

SPEAKER_03: 49:37

Yes, I mean, so much of this, again, it starts to make sense about why we've done things a certain way. So the idea of a recipe, right, knowing that you've got your SD, you're going to expect your SR, and then you're going to do some sort of reinforcement after that. And if it doesn't happen that way, well, then we prompt through it because the exact answer that we had envisioned has to happen every time. And if you are not that good at percentages, it has to happen throughout 10 trials if you're running really old school. And if it doesn't happen every time through this errorless approach, then we're We're not teaching the right thing. We're never going to get to those skills, not to mention we've probably overly task-analyzed these skills. We've got a goal for every verbal operant as opposed to looking at it as a whole language structure. Again, I understand why we've gotten stuck in that rut a little bit, but to your point for more of a top-down approach here, Jennifer, you're saying– Yeah, you're going to plan some activities and they may not go as you envisioned. And you have to be ready to respond to that and have hopefully not 25 to 30 goals in mind, but maybe a handful in mind that you can actually review before your session. Have actively in your mind. And if you're able to work on three, four of those. Killer. We did it. We had a good session, especially if you started with a 30-hour escalation, de-escalation premise, and you ended up actually running some programs, as we like to say, and getting some data. That's amazing. Where I think the general attitude these days is like, well, half the session was spent in a tantrum behavior, and that's a horrible thing. Well, wait a minute, though. Isn't that why we're there? We want to see this idyllic expression or representation of our session and our service from a marketing perspective, but if you get down to it, we're actually there to work with some nitty gritty stuff, some of those more challenging behaviors that you were alluding to that you might have to go ask for another hour. But here we're talking about people that are still saying 25 to 40 hours a week. You're very humbly saying, just give me one more hour for this and I'll work it right up. Good for you. Kind of the contrast that we're elaborating on here today.

SPEAKER_04: 51:42

One of my favorite handouts that I go over in parent groups is the seven steps for earning instructional control for your child written by Robert Shrimp. And I go over this and one of them is know your priorities. And that's kind of that top down approach, right? So what is my priority in this situation? If we're playing a game, like what are my hills to die on? And what are my hills not to die on? If this child doesn't say my turn, am I going to sit there and wait for four minutes and risk a tantrum if they don't say my turn or if they don't wait? Or what if they want to play the toy totally different than I want to play with the toy or that the toy is meant to be played with? Like exactly kind of what are my priorities and understanding that. And I think that kind of relates really well to that top down, that top down premise, because so often, you know, I'll see with parents with homework, right? If we were to break it down, the priority would be that the child will sit down and attend, and then maybe that they'll do the homework, they'll do it correctly, they'll do it correctly and neatly and legibly, and then they'll do it correctly, neatly, legibly, by common core or whatever the method that the school wants them to do. And so often, you know, the parents will fight at one of the lower levels and then finally just give up. And it's like, well, if that wasn't the hill to die on, then we could have just gotten through this activity and they would have sat and attended and maybe done it. And maybe you could have written it for them or something like that. Or maybe you could have went back and forth, but because we fall on this lower level, this, this bottom up approach, we never got to the top thing that we were trying to work on because we spend so much energy on this lower level. So that was just something that really resonated with me that he mentioned in that article about just knowing what your priorities are in any situation. The CrossFit I think is a great example. Um, or anything that we're trying to do, just know kind of where your hills to die on and what your end goal is and where you're willing to, um, to budge a little bit. Cause so often I feel like we've been so hyper focused on every specific thing, every target within that has to be correct that we've actually not been able to get through the entire activity because we've, basically try to pick a fight at a lower level and then they never get to the higher level.

SPEAKER_03: 53:38

This happens very often here on ABA on Tap because it's so fun. Time flies. So we are actually near the end of our... We try to keep things within the hour so that it's easy to consume, easy to throw back, if you will. Jennifer, anything that we haven't touched upon that you're just itching to put out there with regard to this idea of 25 to 40 hours or hours recommendation, maybe more importantly, keeping our services at the least restrictive level maybe that's a good way to put it as opposed to this overly restrictive overly encompassing you know data powered machine anything we haven't mentioned that you want to put out there for us

SPEAKER_00: 54:19

Yeah, I think the lesson that kind of came into my mind when you guys were talking was just, you know, really encouraging BCBA students to gain as many outside resources and creative tools, activities that they can do to engage people where they're at, versus, you know, you, I think the same as counseling, you go to school and you get your, your basics, you get your, your textbook information, you learn your tech, your terminology, and you learn the technology to incorporate these things. But it doesn't tell you how to incorporate those things. It doesn't give you the, when you have an elementary school group of boys who all like Pokemon, what do you do with them? Do you do, do you run these very specific programs that you learned in your program or do you get out Pokemon cards and teach them how to play Pokemon and, and work on those executive functioning skills that are incorporated into games and activities and give them a leisure activity that they can take with them? Do you build leisure activities? Like what is really important? invaluable and to encourage those BCBA students while they're getting their fieldwork hours or once they become a BCBA to really push themselves outside the box to find really creative activities and ways to engage and then take that activity and think about how do these activities apply to your goals? And that's one of the things we always encourage our BCBA students to do is to come up with a list of activities and then from that, say you can have activities and then what skills would you work on from it or come up with a list of skills and what activities could you use to address those skills? And that gives you a good framework When you're in that session, if you're like, oh, I'm working on these three skills, what's on my list of activities I could pull from and then easily go from there.

SPEAKER_04: 55:57

I think what's so interesting with you and why I'm really looking forward to collaborate moving forward is you definitely have the expertise in the field, but you're pretty unique in that you're a parent. So you have the expertise in understanding what it's like to be a parent and also the mental health side of things. I think those second two are something that a lot of people, even like myself in the field, I'm not a parent. I have a psychology undergraduate degree, but that was a long time ago. Like meshing all of those things together, I think is super, super important. We have some other BCBAs in our company that will probably join at some time. And I can think of one of them that has a three year old and a two year old. And he's always like, well, if the board ever saw how, you know, I dealt with my kids, I'll lose my BCBA card. And it's kind of that that thing of like, well, it's so that sometimes it doesn't seem like parenting and the board mesh or parenting and traditional ABA strategies mesh.

SPEAKER_03: 56:48

I think the traditional strategies that I used to say, ABA is no way to parent, used to be one of my mantras. And this was speaking of much more traditional approaches. We've covered a lot of ground here. We're at a really good stopping point. Jennifer, we really hope this is the first of many collaborations with you here on ABA on Tap or otherwise. Really appreciate your listenership, now your contributorship. Thank you for taking us back to the roots, to the very beginning in discussing this. And I think we probably left a few stones unturned, but there's always time to revisit this. Absolutely. So stay out there, stay creative. What else would Jennifer say? Stay with your top-down approach. Coach, know that you can't always direct the session. Sometimes things have to be a little bit client directed. If you spend the time de-escalating for a whole session, that was the lesson that session. Be not afraid. Yes. Anything else, Dan? Always analyze responsibly. Always. Cheers, Jennifer. Thank you so much. Thank you so much, Jennifer.

SPEAKER_00: 57:45

Thank you.

SPEAKER_02: 57:47

ABA on Tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.