Occupational Therapists Discussing Their Journeys with ABA: Part I

Interview conducted by David Celiberti, PhD, BCBA-D
Association for Science in Autism Treatment

Interviewees:
Amy Stango, OTD, OTR, BCBA
Angela L. Seal, MOT, OTR
Kristina Gasiewski, MEd, MOTR/L, BCBA
Tanya Browne, OT Reg NB, BCBA

Occupational therapy is a form of therapy provided to many, but not all, individuals with autism. Sometimes the targets of the therapy are global, and the relationship between the therapist and the client is more long-term (e.g., play skills, feeding) and in other instances the targets may be more focused or the contact more time-limited. Services may be direct (e.g., session focusing on shoe tying or using a spoon) or via consultation (e.g., recommendation to teaching team regarding pencil grip).

Historically, the relationship between behavior analysts and occupational therapists has been marked by misunderstandings, misconceptions, and bias. This has resulted in some confusion by consumers. To address this relationship and explore some ideas for moving forward, I had the opportunity to interview four occupational therapists from diverse backgrounds who share their insights and impressions. Given the scope of the topic, the interview will be shared in two parts, In this part of the interview, our participants share their prior education and training and discuss areas of overlap with behavior analysis, as well as some common misconceptions.

David: I have really been looking forward to this interview and am grateful that each of you were able to take time from your busy schedules to participate. By way of background, could you share with our readers a little bit about your occupational therapy (OT) career path and what led you to the field of autism treatment?

Amy Stango, OTD, OTR, BCBA

Amy: I knew from a very young age that I wanted to work with children with disabilities. I began volunteering at a community-based center for children with disabilities when I was 11 years old. I worked with children with many developmental disabilities, including autism. I was hired by a parent to implement an ABA (applied behavior analysis) program when I was in high school. Through my work on my very first case as a high school student, I was exposed to ABA and occupational therapy for the first time. I learned how ABA and occupational therapy could improve the quality of life for individuals with autism, as well as individuals with other diagnoses. Before I graduated high school, I had developed a plan to pursue graduate degrees in both occupational therapy and applied behavior analysis. I did not want to choose between these two great fields, so I chose them both!

Angela L. Seal, MOT, OTR

Angela: I graduated with my master’s degree in occupational therapy at the end of 2003, with the hopes of entering the pediatric realm but not in the field of autism. I took a position at a nursing home originally until I acquired a job in a pediatric rehabilitation unit. After focusing on this area for approximately 5 years, I left to pursue a position that allowed a more positive work-life experience. This is when I found a job with an ABA center. As I began to learn about ABA and autism, I realized that many of the treatment techniques were like the ones I was already using in my practice. I realized that working in this area was the perfect fit and have continued in this practice area for the past 13 years.

Tanya Browne, OT Reg NB, BCBA

Tanya: My initial experience with occupational therapy as a profession is a personal one, whereby following a serious injury I was supported in my rehabilitation process by an OT. From the perspective of a 16-year-old, this was the clinician whose goals were most representative of what was important to me: to wash my own hair, go to the prom, drive my car, socialize with friends, and get back to the classroom. It was this individualized approach to care, founded on my current level of skill (as the patient), and targeted through achievable goals and motivation, that resulted in me pursuing OT as a profession. As my formative educational journey progressed, my volunteer pursuits, choice of practicum opportunities, and part-time employment all gave rise to connections with individuals who had autism, and the feedback from supervisors always encouraged me to pursue this area of professional practice. Despite exploring other options, the path has always led me back to autism treatment, and most recently to become a BCBA.

Kristina Gasiewski, MEd, MOTR/L, BCBA

Kristina: I have always known I wanted to work with children but didn’t know in what capacity. I considered being a nurse, teacher, therapist, and more. This led me to pursue an undergraduate degree in psychology while I explored what avenue to take. I was talking with a friend and explaining that I wanted to help children with special needs learn to live life to their fullest potential. I jokingly said that I wanted to be a teacher of life! He suggested that I consider occupational therapy. After researching the profession, I reached out to the head of the OT department at the University of the Sciences in Philadelphia where I was completing my undergrad. She invited me to discuss the opportunities with her the next day. I fell in love with the profession! During my time as an OT, I have primarily worked in the school setting and currently work at an approved private school for children with autism and intellectual disabilities.

David: Such wonderful stories! Could you tell our readers about your current position and what you do now?

Angela: I am currently the Senior Occupational Therapist with the Behavior Analysis Center for Autism within the LEARN Behavioral network. I work with clients from ages 2-22 years with a primary focus on 2 years to 8 years. Along with my caseload, I provide oversight to the other OTs within our practice. An important component of my position is collaborating with and educating RBTs and BCBAs on the areas I am addressing through treatment. With the education provided, RBTs can continue addressing deficits throughout the week allowing for greater progress with our clients.

Tanya: For the last 15 years, I have been a member of the autism team within the provincial tertiary level neurological rehabilitation center in New Brunswick, Canada. The team, with representation from developmental pediatrics, dietetics, education, speech-language pathology, social work, and occupational therapy, strives to work using a transdisciplinary model of care where those involved with a client contribute collaboratively on each goal based on individual clinical perspective/training; one goal and action plan is the contribution of all team members. The role of our small team is primarily consultative whereby we support local clinicians, teachers, and service providers in their provision of assessment and intervention to children/youth with complex needs. I would typically be assigned to cases when a client’s performance challenges are impacting their ability to engage in the daily activities which they want or need to do, and provide support until they achieve a level of skill/competence which is deemed acceptable to the individual and their unique abilities. We work collaboratively and directly with those individuals who provide daily support to our common clients within the community.

Amy: I am the founder and clinical director of two companies that provide services to children and youth with disabilities. I oversee transdisciplinary evaluations and therapy provided to children, adolescents, and young adults with a wide range of disabilities. I mentor graduate students who are studying to become behavior analysts or occupational therapists. I founded the Occupational Therapy Special Interest Group within the Association for Behavior Analysis International (ABAI) and currently serve as its President. Additionally, I conduct and publish research related to occupational therapy, applied behavior analysis, and the intersection of these fields.

Kristina: I am currently an occupational therapist at the Melmark School. I work alongside amazing team members, and while I do have a set caseload, I have the opportunity to consult and extend the indirect time for my students as needed. I feel that the flexibility with my schedule truly allows us to focus on the needs of our students to provide the most beneficial programming. As an OT, I train teachers and staff on how to work on and teach our goals throughout the school day. I oversee this in the classrooms and can collaborate on goals within the students’ Individualized Education Plans (IEPs). As a school-based OT for children with special needs, some of the skill areas I work on include Activities of Daily Living (ADLs) such as feeding or dressing, as well as Instrumental Activities of Daily Living (IADLs) such as education (i.e., handwriting, keyboarding), play and leisure, meal preparation, housework and chores, and pre-vocational skills (to name a few). Therapy may include refining fine motor skills, teaching the motor planning required to perform the ADLs/IADLs, or may involve adapting or modifying the environment or task to best promote independence and participation.

I have also had the opportunity to work on research projects with some wonderful colleagues at Melmark. My research interests include collaboration between occupational therapists and behavior analysts and bridging the gap to best serve individuals with autism and developmental disabilities.

David: Some of you are dually certified. What led to your decision to seek a second certification in behavior analysis? How has your training and education in behavior analysis enhanced your work as an occupational therapist?

Kristina: When I started at Melmark, I did not really know what a behavior analyst did or even what ABA was. Both schools that I worked at previously had BCBAs, but I barely interacted with them as our contract days never lined up. Melmark has an integrative model and team members of each student meet on a regular basis to review academic and clinical data. It was in these meetings that I got to know more and value the benefits collaboration brings. During team meetings, I found that students were making improvements based on suggestions from behavior analysts using terminology unknown to me. This sparked my interest in behavior analysis and enticed me to collaborate further with my BCBA peers to find the evidence behind their decision-making. I grew more curious about the science of ABA and how I could integrate it into my OT practice. I decided to continue my education with a second Master of Education in autism and applied behavior analysis from Endicott College. I enjoyed the classwork and learning all that ABA has to offer. Through supervision, I learned how to incorporate ABA teaching strategies into my practice. I have learned to utilize Behavioral Skills Training to better train staff on the implementation of OT-related goals. Being a dually certified clinician has furthered my ability to empower my peers to collaborate more effectively through communication breakdowns as I can empathize with multiple professions.

Amy: I always had a strong interest in science and health care, including areas such as anatomy, physiology, neuroscience, and kinesiology. I knew that these sciences are typically not included in behavior analytic coursework, and I wanted to be well-trained to work with children with a wide range of needs and in multiple settings. Because of this, I planned to first complete my Master of Science in occupational therapy and then immediately complete a second Master of Science degree in applied behavior analysis. My training and education in behavior analysis have taught me to think like a scientist in all facets of my clinical work. I learned ways to optimize my data collection, ways to better motivate those around me, and strategies to promote faster, more enjoyable learning experiences for those we serve. I also became more adept at discriminating between research-validated interventions and pseudoscientific interventions that may be ineffective or even harmful to individuals with disabilities.

Tanya: For a multitude of reasons, there was a time when our team was aiming to meet the complex needs of our clients without the expertise of a behaviour analyst. Though the remaining team members had extensive experience related to the principles of applied behaviour analysis, they lacked the formal training and credibility that would come with a BCBA designation, in a province that had come to expect this level of training when working with individuals who have an autism diagnosis.

As an OT with 18 years of experience, my professional identity was well established, which was a contrast to the BCBAs who needed to create and clarify their position within a multidisciplinary team that overlapped with other professionals. Similarly, existing members of the team had to figure out how to use the skills and resources of the BCBA which I know is an important topic that we will all be discussing later in this interview. It was not until we were without formal BCBA support that I reflected on how I had developed the professional habit of adapting my occupational therapy-related goals to align with the principles of applied behaviour analysis “because it just made sense.” Daily, I found myself asking parents and teachers, “What does it look like – paint me a picture with your words,” creating data sheets so that changes could be measured – whether it was the number of times they were out of their seat or the bites taken at mealtime, discussing ways to support changes across environments, and outlining recommendations step-by-step for parents so they knew exactly what to do was part of my work. Though not as precise as what I would do today, I recognized the importance of these practice components and realized that my perspective in practice somewhat set me apart from others in my field. Through this reflection, I realized how complementary the skill set of a BCBA would be to my role and professional values. With this in mind, I submitted a formal proposal to my leadership team, requesting their direct support so that I could earn my Master’s in applied behaviour analysis and complete the necessary supervisory requirements to earn my BCBA designation. The proposal was accepted, and I have since become the first dually certified OT/BCBA in my province.

David: There are many areas of overlap between behavior analysis and occupational therapy with respect to targets, strategies, and overarching goals. With respect to the scope of practice, how do you view the overlap and areas of unique contribution?

Amy: Behavior analysts are experts in changing behavior. Within behavior analysis, the definition of behavior is very broad, encompassing any action of the muscles or glands. Given this broad definition of behavior, behavior analysts have a broad scope of practice and can teach new functional behaviors while reducing behaviors that are problematic. Occupational therapists are experts in occupation or the purposeful behaviors we engage in as part of our everyday lives. Occupational therapists have extensive training in personal factors that impact occupational performance, such as age, culture, social background, and level of health and fitness. Behavior analysts have extensive training and expertise in identifying the reason that someone is engaging in a particular behavior, and how to use science to change behavior. Occupational therapists are trained in how the human body works, as well as how to adapt tasks or the environment to make tasks easier or more efficient. Both behavior analysts and occupational therapists are trained to break everyday tasks into simple sequential steps. Occupational therapists are also trained to recognize motor and neurological components of tasks, such as which muscles, nerves, and regions of the brain are needed to tie a shoe.

Kristina: Both disciplines provide services to individuals throughout the lifespan with a primary focus of promoting independence. OT is focused on improving participation in meaningful occupations. OT practitioners define ‘occupations’ as any activity in which an individual engages in throughout their day. ABA focuses on producing socially significant changes in behavior. ABA professionals define ‘socially significant behaviors’ as any behavior that is important to the client and that can improve the life experience of that individual. Both disciplines, therefore, work on/target the same skills. From self-care to play and leisure, or from housework to vocational tasks, both professions are skilled to address the same domains. It is how each discipline approaches intervention that is unique.

OT practitioners have more of a medical background with coursework in neuroscience, physiology, kinesiology, and health conditions. In addition, an in-depth knowledge of how one physically participates in various tasks (i.e., “occupations”) further informs our unique perspective. Additionally, OT practitioners are trained to utilize multiple theoretical principles and models, which provides more of a top-down approach to intervention. For instance, both professionals, after completing their evaluations for a child, may determine handwriting as a target behavior/functional skill to work on. OT’s may utilize a developmental approach and determine, based on what foundational skills the individual is able to demonstrate, where to start (i.e., pre-writing strokes, certain letters based on stroke sequence, letters, words, etc.). They will also look at fine motor skills such as grasp patterns, hand strength, or finger dexterity. Visual motor skills such as visual perception and visual scanning will also be addressed, as these all are factors that would affect handwriting. Furthermore, core strength and postural control will be evaluated, as one will need core stability before they can engage in fine motor coordinated skilled tasks such as handwriting. While handwriting may be the goal, occupational therapy will work on these foundational skills through meaningful occupations such as play. Furthermore, an OT may determine that adaptive materials may be useful in promoting improved handwriting (i.e., adaptive paper, pencil grip, raised boundaries, etc.) or modifying the environment (i.e., increased lighting, change is seating/positioning, etc.). All of these are unique contributions an OT can bring to the team.

ABA professionals are well versed in the principles of learning theory. They have extensive knowledge of teaching procedures such as discrete trial instruction (DTI), shaping, and chaining procedures, which are effective and evidence-based strategies for teaching skills such as handwriting. Furthermore, ABA professionals are skilled in utilizing errorless learning and providing prompts based on the least restrictive but most effective necessary for the student. They will also assess the behavior of handwriting as well as any maladaptive behavior that may be impeding the student’s success with handwriting. These are some of the unique contributes that ABA professionals can bring to the team.

David: What are some misconceptions of occupational therapists and their work (either by behavior analysts specifically or in general)?

Angela: Some of the main misconceptions stem from the word “occupational,” as people work from different definitions of the word. For a person that has no experience with OT, the common misconception is that OTs focus on a person’s career in some manner. However, from an OT perspective, an occupation is anything one does throughout the day with an emphasis on the functional and meaningful completion of it. A common misconception from behavior analysts is that every OT works solely from the theory of Sensory Integration and that we believe every behavior stems from sensory deficits. Another misconception is that OTs only focus on handwriting or activities of daily living.

Kristina: I think the biggest misconception is that OT is synonymous with sensory interventions. While sensory theory and sensory-based interventions are utilized by OTs, it is one of many frames of reference or theories that are used as we focus on everyone as unique and multifaceted. Through this framework, we work on promoting life skills through fine motor, motor planning for ADLs/IADLs, and adapting their environments for improved success.

Another misconception is that OT is not evidence-based, which is far from the truth! The OT profession is based on science and our knowledge of the human body guides our decision-making as we utilize evidence-based interventions within treatments. OTs are taught to value quality research and to both synthesize and utilize peer-reviewed journals. The utilization of evidence-based practice (EBP) is embedded in key OT documents including the Occupational Therapy Practice Framework (OTPF)-4 (2020), the Occupational Therapy Scope of Practice (2021), the Standards of Practice for Occupational Therapy (2021), and the Occupational Therapy Code of Ethics (2020). It should be noted that AOTA defines EBP as “based on the integration of critically appraised research results with the clinical expertise, and the client’s preferences, beliefs, and values” (AOTA, 2020). While there is an emphasis on research, it is just one part of the process with occupation-based theories, frames of reference, and clinical reasoning being equal parts of the equation that should guide OT intervention. Furthermore, as in any profession (not just OT, but also ABA, medicine, education), there are therapists that may utilize non-evidence based procedures; however, this is not best practice, and should not be an assumption of the entire profession. The reality is that there is not a universally accepted definition of EPB shared across multiple disciplines which may further contribute to some misunderstandings.

David: Aside from the belief that behavior analysts typically target skills without regard to prerequisites, as well as scope and sequence, what are some misconceptions of behavior analysts and their work (either by occupational therapists specifically or in general)?

Amy: One misconception is that participation in behavior analytic services is generally an unpleasant or even traumatic experience for people with autism. When behavior analysis is practiced ethically, it can empower people with autism in a supportive manner. There are adults with autism who value behavior analysis so much that they chose to become behavior analysts themselves. Another misconception is that behavior analysts neglect biological, pharmacological, cultural, or social variables when designing and providing treatment. Behavior analysts work in conjunction with clients and other members of a treatment team to provide comprehensive care that takes into consideration biopsychosocial factors.

Kristina: One misconception is that the field of ABA is not client centered. Some even go as far as to advocate against it. Just as in any profession, lack of understanding and overgeneralization leads to rigid inaccurate perceptions. ABA is not a one-size-fits-all approach. It is the science of individual behavior and therefore is individualized for each client based on the needs and preferences of the individual.

Thank you all for a wonderful interview. We are very grateful that you were able to share your experiences and hope that your insights and perspectives will be helpful to both behavior analysts and occupational therapists alike. Whereas it takes a village to help a person with autism realize their fullest potential, a strong multi-disciplinary team that relies on science and is grounded and guided by data is essential. Therefore, in the second part of our group interview, we will focus upon collaboration between these two disciplines. I look forward to sharing these additional thoughts with our readers.

References:

American Occupational Therapy Association. (2020). Evidence based practice & research. Retrieved from: https://www.aota.org/Practice/Researchers.aspx

American Occupational Therapy Association (2021). Occupational Therapy Scope of Practice. The American journal of occupational therapy: official publication of the American Occupational Therapy Association, 75(Supplement_3), 7513410020. https://doi.org/10.5014/ajot.2021.75S3005

American Occupational Therapy Association. (2020). AOTA 2020 occupational therapy code of ethics. American Journal of Occupational Therapy, 74(Suppl. 3), 7413410005. https://doi.org/10.5014/ajot.2020.74S3006

American Occupational Therapy Association. (2021). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 75(Suppl. 3), 7513410030. https://doi.org/10.5014/ajot.2021.75S3004

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Citation for this article:

Celiberti, D., Stango, A., Seal, A., Gasiewski, K., & Browne, T. (2022). Occupational therapists discussing their journeys with ABA: Part I. Science in Autism Treatment, 19(11).

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