Conducted by Maithri Sivaraman, MSc, BCBA
Association for Science in Autism Treatment

I had the good fortune to speak with Dr. Francesca degli Espinosa who runs a behavioral clinic in the UK offering ABA family consultation and professional training services. She also teaches in the ABA Master’s program at the University of Salerno in Italy, and supervises BCBAs and aspiring certificants.

Maithri: Francesca,could you please tell our readers a little bit more about your multiple roles?

Dr. Francesca degli Espinosa

Dr. Francesca degli Espinosa

Francesca: As a behavior analyst with a background in psychology working between two countries, the UK and Italy, having multiple roles has enabled me to have a varied professional life, contacting many sources of reinforcement. While it is true that I wear multiple professional hats, they all share a common fabric: a passion for a behavioral interpretation of child development, cognition, language and social responding. In essence, I am a teacher to a range of students with diverse needs: adult students interested in learning about behavior analysis, children with autism who need behavior analysis, and parents seeking better ways to interact with their children.

Currently, I teach the applied modules in the ABA master’s course at the University of Salerno, a public university, together with other esteemed Italian and US colleagues. For the past couple of years, I have taught an advanced verbal behavior class at Penn State University in the US and at Queen’s University in Belfast, where I also supervise a few master’s theses each year. I feel very privileged to be able to combine, through the work of these students, a passion for research and the development of procedures to establish generative verbal responding.  As for my clinical work with children, that has never stopped. I believe it plays an important role in keeping me grounded in the intervention world and in touch with the difficulties that families experience in bringing up a child with autism. Clinical work is also what makes me a better teacher to my university students.

Although I no longer run regular weekly sessions with specific children, as I once did as a tutor 25 years ago, I see about two to three families per month for two to three consecutive days of assessment, programme evaluation, and support. During that time, I am able to work directly with the child, as well as coach parents and the professionals who accompany them on altering their interactions and modifying interventions where needed. This work is carried out at the ABA Clinic, a 1920’s former-garage that was recently renovated into a flexible professional space: it can be an assessment room with toys and games one day, and turn into a training room for small groups of professionals seeking supervision the next. Although I spent about 10 years mentoring students to become BCBAs, I have spent the past few years mainly focused on providing advanced curriculum development training and direct supervision to certified professionals, as more and more BCBAs were asking for direct clinical supervision and further specialised training after they were certified. I try to do this in small groups or individually, through watching videos of their work or working directly with the BCBA, the family, and the child.

Maithri: Wow, that is a long list of activities. You published a paper recently in Behavior Analysis in Practice (BAP) regarding a support model for families during the COVID-19 lockdown in Italy. Tell us more about the circumstances that led you to form this model.

Francesca: To understand what prompted my colleagues and I to put together the model described in the paper, it is important to give an outline of the unique context in which it was developed. There are fundamental differences between the way ABA services are delivered in European countries, such as Italy, compared to the insurance funded or specialist classroom model that enables many children in the US to access ABA intervention.

In Italy, despite the publication of national guidelines recommending ABA intervention for autism and a national health system, ABA-based intervention is not generally publicly funded. There are some exceptions, of course, but ABA is not typically featured as one of the interventions provided by the national health service and therefore is not free at the point of use. Thus, most families fund ABA consultations and tutor sessions “out of pocket.”  We try, to the extent that is possible, to work collaboratively with professionals from other disciplines (e.g., speech and language and neuro-rehabilitation therapists) who may be involved in the case, while maintaining leadership over the child’s objectives across all significant environments.

Maithri: Very interesting! So, what does the actual working model look like?

Francesca: The model we use is one in which the behavior analyst designs and monitors a programme across all of the child’s significant contexts such as the home and the school, working with and teaching all participating adults in the delivery of the individualized objectives. This kind of organization essentially means that many of us work directly with the parents, who, especially early on in a programme, carry out much of the teaching themselves, are present during tutor sessions and actively participate in the team meetings. There are advantages and disadvantages to each system, of course. The fact that we have always worked with families, in their homes, not just on educational targets but on skills parents deemed as being valuable to them (e.g., going to the supermarket, keeping the seatbelt on, playing nicely with siblings, walking without running off) meant that as we transitioned to the whole household support model described in the BAP article, we already had an effective and trusting working relationship with the families we served. The main difference was that we had to move the intervention from multiple environments with trained tutors to only one environment with parents living under stressful conditions. Our parents, however, were not complete novices, by virtue of their previous ongoing participation in their child’s programme.

Our utmost objectives were to minimize parental burn-out, as well as to reduce socially-mediated problem behavior and prevent loss of adaptive skills in the child. To do these, we needed to view the child as part of an enclosed self-reliant social system. The parents became, almost overnight, the only agents for meeting all the needs of every family member. The household became the only source of both primary and secondary reinforcers for all its inhabitants. Our job in designing behavior change programmes starts with understanding one’s context, and therefore, we had to consider the whole household and each individual’s unique environmental variables. Understanding parents’ MOs and SDs for shaping positive interactions with their children was just as important as understanding each child’s controlling variables.

Maithri: So, with this new context and these environmental factors in mind, how did you apply it to the intervention programmes?

Francesca: The simplest way to explain this is to say that we tried to build an environment that promoted contact with positive reinforcement for all its belonging members by bringing order, organization, and motivation in shared and independent activities, as well as access to time off from interaction. The first step was to assess the risk in each family- working with parents to identify times during the day with a high probability of problem behavior, and working on a schedule to reduce those times and to maintain reinforcers at high value. One crucial aspect of this organization was to reduce the need for parents to come up with new fun activities to entertain their child.  Our parents expressed clearly that they were exhausted after the first two weeks of lockdown. They wanted a simple, efficient, effective, and sustainable system for the child and the siblings. They wanted their children to self-occupy some of the time, to do things for themselves, to cooperate with their demands, to engage when they were available to play, and to communicate without problem behavior. We listened and realized that the experimental literature and some old papers on comprehensive reinforcement system offered a potential pathway. The term “closed economy” came to mind immediately. Because the household was now the only living context, it was important that if parents wanted children to engage in specific behaviors, they had to control access to reinforcement. We had to shift the contextual control from “home means iPad all the time and no demands” to “there are some rules at home, I do what my parents ask, sometimes on my own, sometimes with them, and then I get what I want.”

Maithri: As you mentioned, there are several parents out there who are struggling to keep their child engaged in learning-related and fun activities. Can you elaborate on how parents can go about identifying and choosing activities for their child to do at home?  And how does this relate to controlling their child’s access to reinforcement?

Francesca: First, be kind to yourself. You cannot do everything. As for some general tips, here they are: schedule, rotate, and reinforce. List activities in two main classes: solitary ones and interactive ones. Solitary ones can either be independent instructional activities or reinforcing ones. The first type relates to activities that are generally carried out because your child accesses something reinforcing afterwards; the second type relates to things your child likes to do on his own (e.g., watching cartoons) and can do for a reasonable period of time. Those are your lifeline– they buy you free time, but only if you limit access. If you do not, your child will satiate and will seek something else, likely your attention at a time when you are busy, as you are the person correlated with giving good things. The interactive ones can also be instructional (e.g., chores or a structured lesson) or reinforcing ones – things your child likes to do together with you (e.g., jumping together on the trampoline or playing a board game). Rather than trying to find new activities and new materials all the time, list all the activities you know of first. You may find there’s a lot more there and rotate them daily to keep them interesting.

View engaging your child as an ongoing objective that can be achieved at multiple levels during these day-to-day activities. If you focus on responses you want to achieve, the activities become a framework of support and you can engineer them using whatever material is available in the house. It’s really about the interaction with your child, rather than the items per se. Think of all the activities that are typically carried out around the house: setting up the table, getting dressed, emptying the dishwasher, putting dirty clothes in the washing machine (to name a few). These routines are already naturally occurring, the chain of tasks is well known to you as a parent, and no new materials are required. Now you need to think of simple objectives to carry out with your child that can be embedded in these naturally occurring routines and a way of reinforcing participation.

Maithri: When you think of it that way, I think it takes a lot of pressure off of having to find fun activities to do all the time. How would this work for children with different skill levels?

Francesca: What you choose to focus on will depend on your child’s skills. Don’t think you always need to teach your child new targets. The main objective is that he or she listens to you and participates in the event. Most of the time you will be able to find something your child can do in many household activities. For example, if we take emptying the dishwasher, he or she can pass you things to put away, or vice versa – no language is necessary for this skill. If your child is able to understand language a little, you can ask to pick up specific items and put them in various places. The idea is to try and embed instructions to promote cooperation and interaction in day-to-day activities so that your child (and sibling) can then earn access to favorite items by having engaged with you at some level, however small. By delivering reinforcement this way you gain greater educational control. Of course, ideally, we would want the shared activity itself to be intrinsically reinforcing for your child, and these activities and your attention may in fact gain intrinsic value over time.

Maithri: Such a neat example! Tell us more about your personal experience with this model. What has been the toughest challenge for you while implementing this support model?

Francesca: The biggest challenge for me has been to involve the secondary caregiver and to motivate them to do things with their child. I am still learning how to do that, but one of the things that has helped is to work with them in the absence of the primary caregiver and to agree on their own personal goals, listening to what was important to them in their role as a parent. An additional challenge has been to support parents in accepting that their child may not make the same academic progress they were achieving before lockdown and the importance of realistic expectations. This called for additional flexibility from both parents and practitioners in identifying goals that were appropriate to the situation and which we could all successfully meet. Our 1-hour coaching sessions (these happened every day for some parents) always began with a 15-minute conversation during which they expressed their concerns, doubts, or reported their successes. Because the goals were set regularly, they could be changed and revised frequently depending on what was happening in the family at the time and what the parents felt they could take on both psychologically and practically.

Maithri: And what would you consider your biggest success in this context?

Francesca: The biggest success has been seeing parents engage with their child in a way I’ve not seen before – taking ownership of the interactions with all their children, and eventually coming to understand the basic principle that it is largely the social environment that shapes behavior and that they represent such an environment. I have seen parents deliver some of the best naturalistic and structured teaching and maintain it throughout the day, comparable to the repertoire of an experienced tutor. I have seen parents actively seeking interaction with their child, rather than avoiding them.

Maithri: Fantastic – you captured the essence of ABA and behavior analytic interventions in one sentence. Earlier when you described the model in Italy, it seemed like you established a collaborative network with fellow BCBAs in Italy. How did this come about?

That’s an easy question to answer. I have been working in the field of ABA in Italy for more than twenty years, so at some point in the past, my current colleagues have been students in courses I have taught, participants in workshops I have given, tutors in families with whom I have consulted, or supervisees working toward the BCBA. Most of the BCBAs I have supervised keep in close contact and reach out when a second opinion or additional training is needed. When the COVID-19 crisis happened, many former students called for additional supervision, which culminated in a free webinar at the end of March 2020 describing the model outlined in the article.

Maithri: What would you say is the role of a collaborative network in a country like Italy?

Given that most of us are self-employed in a country where ABA is beginning to be accepted but is still not regulated, we all understand the benefits of a support network and the need to actively create opportunities to learn from each other. We run several collaborative initiatives throughout the year, workshops to disseminate evidence-based practices to the general public, parents and other professionals, and social skills groups as well as a summer school programme for children with autism. The latter is a big annual project organized by the association Pane e Cioccolata and it offers two weeks of full-day ABA intervention to about 40 children and adolescents with autism. The project is a collaborative effort between a group of independent BCBAs, BCaBAs, RBTs and volunteers who get together each year to run the programme and to receive additional teaching. The project also offers several trainee places for professionals who want to learn more about ABA. Each trainee is assigned a BCBA to follow during the day with opportunities to ask questions. They are also provided with daily lessons on various intervention aspects.

Maithri: Do these collaborations extend to allied professionals working with children with autism?

Francesca: Yes.  One way is through coursework and training.  An increasing number of professionals from other disciplines are enrolling in one of the 14 Italian Verified Course Sequences, and there are many organizations (some run by parents, others by BCBAs), whose main goal has been the accurate dissemination of information regarding ABA and evidence-based practice in autism.  While this helps with those seeking to learn more about ABA and to facilitate conversations, equally important are our less didactic interactions with our non-behavioral colleagues.  While some of our non-behavioral colleagues can be skeptical of ABA at times, it is up to us to educate them – not with our words, but with our deeds.  Ultimately, the integrity of our work and intellectual honesty will speak for itself.  We can alter our colleagues’ misunderstandings of ABA in the same way we alter the behavior of the children we teach – with understanding and without judgment.

Maithri: Very inspiring to hear about the positive impact of forming collaborative partnerships with allied professionals. Coming back to the present crisis, governments are looking to ease lockdown restrictions but it is unlikely that the situation will be back to normal right away. Is there any final advice you would like to provide for BCBAs to prepare for this period of extended shutdown and eventual resumption of services?

Francesca: Continually assess the needs of the families as they transition. For example, many of our parents will soon be returning to work and leaving their children with grandparents for most of the day. It will be important that parents continue to practice the skills they have learned in managing their children. Our challenge will be to continue to support them so that as the contingencies return to pre-lockdown conditions, they maintain the level of engagement and educational control so effortfully achieved.

Each individual’s situation is likely to be different and I have no real practical advice, other than to say that it will take time for life to return to normal, and it won’t be the same. This event has touched us all in many ways, and because of its magnitude it is likely to have fundamentally altered many of our repertoires, both professional and personal. The only advice I can give is to stop for a moment and reflect on what have we learned and how we can use these lessons to serve our families better in the future. For me personally, I will resume services with greater respect for the challenges parents face in managing the many facets of their life while bringing up a child with autism; with greater understanding of the guilt that many of them carry because they feel they can’t always meet all of their children’s needs; and greater faith in the principles of our science and their flexible application at times of crisis.

Maithri: On that positive note, I would like to end this interview. Thank you so much for taking the time to describe your support model for ABA services in Italy during the pandemic for our readers. It has been a truly enlightening interaction for me.

Citation for this article:

Sivaraman, M. (2020). An interview with Dr. Francesca degli Espinosa Science in Autism Treatment, 17(6).

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