Building Collaborative Partnerships between Behavior Analysts and Families

Abstract

Collaboration practices have been utilized within applied behavior analysis (ABA) to build relationships among relevant stakeholders. A recent focus within the field of ABA highlights collaborative practices for behavior analysts to utilize in service delivery positions. However, myriad barriers, such as sources of funding and competing stakeholder interests, inhibit behavior analysts’ ability to build collaborative partnerships with families. We describe the barriers behavior analysts face at the systemic, implementation, and training levels of service delivery and their potential impact on behavior analysts and the families with whom they work. We then highlight four fundamental tenets of building a collaborative partnership between behavior analysts and families, which incorporate collaborative strategies utilized in positive behavior support (PBS), family-centered practice (FCP), and ABA. We then offer practical recommendations to be used within the context of the current barriers that behavior analysts and families experience. These recommendations are precisely indicated to establish practices providing technically sound ABA services while continuing to deepen collaborative partnerships with families.

Introduction

Applied behavior analysis (ABA) has become the primary means of supporting children with autism spectrum disorder (ASD) and their families in the United States (Baller et al., 2016). ABA is grounded in evidence-based practices (EBPs), which have been demonstrated to build skills for people with ASD (Steinbrenner et al., 2020). ABA services are often provided by agencies funded through insurers in various settings, most notably in families' homes, schools, and clinics. Current data on how many children receive ABA services is nonexistent (Xu et al., 2019). However, “autism mandates” established within all 50 states and Washington, DC, have led to more children receiving ABA services (Choi et al., 2022). Unfortunately, differences in reimbursement rates between private and public insurance funders have limited the scope of service delivery, with 30% of children with ASD reporting not receiving treatment (Baller et al., 2016; Choi et al., 2022). Nevertheless, an increase in families receiving services has resulted in more families having the ability to share their positive and negative experiences with this service system (Taylor et al., 2019). Families have reported that behavior analysts can overlook their past experiences with service delivery and implement interventions that do not align with their familial needs (Angell et al., 2016). Moreover, caregivers have expressed feelings of mistrust with the behavior analyst working with their family, which has led to communication issues between the family and the behavior analyst (Čolić et al., 2021; Zuckerman et al., 2017). Researchers in the field of ABA have attempted to remedy these concerns by outlining culturally responsive practice (Čolić et al., 2021; Dennison et al., 2019; Fong et al., 2016, 2017; Mathur & Rodriguez, 2021; Miller et al., 2019), building collaborative relationships with clients and other stakeholders (Slim & Reuter-Yuill, 2021; Taylor et al., 2019), and utilizing family-centered practice (FCP) to establish better connections with families (Brown et al., 2022; Rohrer et al., 2021). Researchers have also pointed toward increased training for behavior analysts as a critical element to streamline interventions that more effectively meet the needs of families (Fong et al., 2016).

In contrast to research centered on service delivery, research in the science of ABA continues to highlight a robust evidence base with studies demonstrating effective behavior-change interventions that behavior analysts often implement in home settings (e.g., Fettig et al., 2015; Gerow et al., 2020; Rose & Beaulieu, 2019; Tsami et al., 2019). However, behavior analysts often lean heavily on the “science” of ABA and prescriptive intervention methods for intervention (Taylor et al., 2019). In doing so, behavior analysts may prioritize the science of behavior change over families’ wealth of knowledge and expertise about their routines and dynamics. Intervention approaches that lack careful consideration of family experiences and understandings can fail to integrate information about the family context, which is critical for implementation adherence to create and sustain behavior change (Albin et al., 1996; Slocum et al., 2014). Behavior analysts’ rigid implementation practices more explicitly affect families from diverse cultural and linguistic backgrounds who are often not involved in forming evidence-based practices (West et al., 2016). These practices have led to families dropping out of services, which can lead to poorer long-term outcomes for individuals with ASD (Choi et al., 2022). On the other hand, behavior analysts experience obstacles that affect their ability to provide individualized and effective ABA treatment in home settings (Garner et al., 2022). To produce socially significant and lasting behavior change, EBPs should instead build upon existing family knowledge and expertise (Čolić et al., 2021).

Why Collaborative Partnerships Are Critical in ABA Service Delivery

Behavior analysts’ ability to develop collaborative relationships with families is essential to delivering socially significant interventions to families (Brown et al., 2022; Taylor et al., 2019). A central component of ABA service delivery is that behavior analysts design comprehensive interventions that address challenging behaviors, improve child development outcomes, and are usable by families to increase generalizability outside of ABA service sessions. Practitioners utilizing collaborative practices lead caregivers to implement behavioral strategies with greater fidelity, reduce challenging behaviors (Fettig et al., 2013, 2015), and improve child engagement (Brookman-Frazee & Koegel, 2004; Buschbacher et al., 2004). Behavior analysts implementing such collaborative procedures can lead to the type of outcomes necessary in ABA service delivery. Research in the field of ABA has begun to utilize outside practices such as FCP as frameworks for delivering ABA service in family settings (Brown et al., 2022; Rohrer et al., 2021), but an exploration of the current barriers and practical recommendations remains a consistent gap where behavior analysts crave functional expertise. Thus, we have undertaken to outline a means of developing equitable, collaborative partnerships between parents and behavior analysts to more effectively facilitate behavior-change interventions that not only meet the family and child’s needs but continue to utilize the basic tenets of scientific ABA principles.

Identifying Barriers to Building Collaborative Relationships with Families

Research and literature have begun to document families’ and providers’ voices to define the barriers they encounter when delivering or receiving ABA services (Angell et al., 2016; Čolić et al., 2021; Dennison et al., 2019; Taylor et al., 2019; Vazquez et al., 2019; Zuckerman et al., 2017). This literature highlights barriers at three distinctive levels that can inhibit families and providers from enacting more “family-centered” and collaborative practices: (1) systemic level, (2) implementation level, and (3) training level. Within these levels, families and providers encounter many individualized barriers that we will attempt to unpack.

Systemic Level

Although many barriers to collaboration exist on a micro-scale with implementation and training, they also are present within a more extensive system of ABA services. The ABA services we will be describing are those provided privately or by insurance-funded agencies. Families note that they need a more comprehensive understanding of the ABA service provision for their health-care rights and also experience difficulty in receiving and sustaining ABA services (Dennison et al., 2019; Pickard & Ingersoll, 2016). The lack of understanding stems from families having to learn and navigate a complex system of health care, which commonly requires long wait times for both diagnosis and service (Hine et al., 2018; Kunze et al., 2021). It is not surprising that the ability to navigate these complex medical systems is more attainable to families with a higher SES and who experience fewer life stressors (Fleming et al., 2011), but most families still report some degree of difficulty navigating the health-care system (Hine et al., 2018; Kunze et al., 2021; Stahmer et al., 2019). Moreover, more racially and ethnically diverse families have begun to receive ABA services through their Medicaid health-care provider (Mandell et al., 2016), with 59.7% of families receiving Medicaid services identifying as nonwhite (KFF, 2022). Thus, these racially/ethnically diverse families may encounter a contingent of behavior analysts who are primarily white (71%) and female (86%; Behavior Analyst Certification Board [BACB], n.d.), and who may not align with their respective cultures. This incongruence of race and/or ethnicity may illustrate why family values are not always aligned with the values of the behavior analyst (Fong et al., 2016, 2017; Taylor et al., 2019). On the other hand, behavior analysts are often bound by the restrictive nature of insurance providers funding the service (Čolić et al., 2021). For instance, a family may feel strongly about a goal being included in the treatment plan related to teeth-brushing. When the behavior analyst includes this goal on the treatment plan and submits it to a health-care funder for approval, the health-care funder may deem this goal medically unnecessary and is not addressing “the core deficits of (ASD)” (Council of Autism Service Providers, 2020, p. 4). This situation places the behavior analyst in a difficult position where they must manage the funder's demands while providing family-centered support. Moreover, families have reported incongruences in the dosage and delivery of ABA services prescribed by behavior analysts and the family's preference (Angell et al., 2016). Again, this may result from behavior analysts prescribing treatment hours and services based on what health-care funders deem necessary instead of what families need. Behavior analysts also report having dosage constraints due to funding and lack of training on prescribing hours of services, typically relying on a “1 hr per one goal” method of determining appropriate dosage and service delivery (Rothway, 2019; Čolić et al., 2021).

These conditions emphasize the incongruence that exists between behavior analysts, their agencies, policy, and funders' recommendations for services provided to individuals with ASD and their families. In general, funders are most concerned with the efficiency and effectiveness of ABA services to reduce costs and to provide effective treatment that aligns with a medical model of child development. A behavior analyst’s agency is also for the most part concerned with effective treatment and ensuring that funding for services continues. The current policy stipulates that funders must provide reimbursement for ABA services provided a child has a diagnosis of ASD (Baller et al., 2016); however, there is no such policy that service providers (agencies and behavior analysts) must provide the service for any family that is seeking ABA services (Mandell et al., 2016). These systemic issues of organizations, policymakers, and funding affect behavior analysts and their ability to provide practical, collaborative services (Miller et al., 2019). However, the systemic nature of these barriers leaves behavior analysts with little agency to amend these conditions.

Implementation Level

As the field unpacks family voices on ABA service, a clear emerging barrier concerns the implementation process (Angell et al., 2016; Zuckerman et al., 2017). Taylor et al. (2019) illustrated how behavior analysts can overlook the importance of building collaborative partnerships, resulting in challenges for families navigating building these relationships. Families in this study also reported that behavior analysts struggle with enacting empathy and compassion, which affected how relationships between the two parties developed. Families also highlighted that behavior analysts could have “their own agenda” about their children and noted difficulties in finding compromise when there were disagreements (p. 658). These disagreements are often centered on the appropriate dosage of services and the intervention types used to make behavior changes (Angell et al., 2016). Furthermore, families have reported that treatment plans have been too prescriptive in nature, leading these families not even to attempt to build a relationship with the behavior analyst and move away from receiving ABA services (Čolić et al., 2021). Thus, family perceptions centered on a lack of contextualized treatment plans and behavior analysts’ rigid adherence to the science of ABA can make families feel like they lack the skills, expertise, and agency necessary to “properly” collaborate with behavior analysts on the treatment plan design.

The science of ABA utilizes EBPs to effectively change behavior in socially significant ways for the client(s) (Baer et al., 1987). Practices such as modeling and prompting are common EBPs implemented to shift behavior (Steinbrenner et al., 2020). Though these practices are documented as common ways behavior analysts train parents to implement behavior-change strategies effectively; these EBPs do not guide practitioners in incorporating family expertise and knowledge and building collaborative relationships (Taylor et al., 2019). For instance, behavioral skills training (BST) heavily emphasizes behavior-change strategies, but the practice offers no clear guidance on how to center families’ experience and intuition.

Implementation barriers are also present for behavior analysts when collaborating with families. Although families report feeling “left out” of the collaborative process, behavior analysts report experiencing a lack of buy-in from families in implementing a treatment plan (Stahmer et al., 2019; Taylor et al., 2019). Behavior analysts often observe low fidelity of treatment implementation by families, which negatively affects long-term outcomes for clients (Fryling, 2014). Thus, substantial efforts by behavior analysts are placed on increasing parent adherence to the treatment plan rather than building relationships to create more contextually appropriate interventions (Fryling, 2014; Moore & Amado, 2021; Yi & Dixon, 2021). When the emphasis is placed on treatment fidelity rather than building collaborative relationships, this can position the family as the party in need of remediation. Lastly, our experience in the ABA field illustrates that behavior analysts may feel hampered by rigid steps within a curriculum endorsed by their agency. These curricula can result in limited opportunities for modification that consider the context and cultures of families.

Training Level

Professional development for behavior analysts is critical, but they often do not get the training they need within areas related to collaboration (Rohrer et al., 2021). Furthermore, behavior analysts often need additional support beyond didactic training to implement complex skills such as effective collaborative practices. When behavior analysts lack training around collaborative practices, this deficit trickles down to how families perceive the ABA services they receive. Namely, families report a lack of communication and collaboration from behavior analysts concerning their child and the behavior change programs, as well as unclear expectations of the family (Čolić et al., 2021). Behavior analysts and their ABA agencies may not prioritize families’ involvement in their child’s treatment (Čolić et al., 2021; Taylor et al., 2019). The Ethics Code for Behavior Analysts (Behavior Analyst Certification Board, 2020) highlights behavior analysts needing to collaborate with “colleagues from their own and other professions in the best interest of clients and stakeholders.” However, the qualification of “profession” seems to not include caregivers as a part of those collaboration efforts that should be made (Behavior Analyst Certification Board, 2020, p. 11). Furthermore, many families experience a lack of understanding about the U.S. medical system in general, along with a lack of knowledge concerning where to go for help in learning how to navigate the system (Zuckerman et al., 2017). When behavior analysts do not see empowering families about their rights as a priority, this can result in families experiencing issues with trusting in their ABA service providers (Angell et al., 2016). The lack of training for behavior analysts around collaboration and relationship-building can lead to significant barriers for families attempting to meaningfully communicate with their behavior analyst providers, particularly when these families are unaware that collaboration is a right contained within their service provisions.

Although behavior analysts are trained to rely on the science of ABA intervention when developing and implementing treatment plans, there are concerns about the lack of training in culturally responsive care, trauma-informed care, and building therapeutic relationships with families (Brown et al., 2022; Mathur & Rodriguez, 2021; Rajaraman et al., 2022). Behavior analysts may also operate without properly reflecting on or acknowledging the power dynamics that exist between themselves and the families with whom they work (Fawcett, 1991; Pritchett et al., 2022). This can lead to prescriptive treatment plans that lack a firm framing of the contextual variables present (Moes & Frea, 2002; Slocum et al., 2014). Behavior analysts have demonstrated this incongruence of values of prescriptive treatment plan recommendations, a lack of cultural self-reflection, and not appropriately prioritizing family goals (Fong et al., 2016, 2017). For example, Fong et al. documented this phenomenon when describing behavior analysts implementing skills for independence despite families not valuing independence skills at an early age. This lack of culturally responsive training particularly affects historically marginalized families due to behavior analysts not having an understanding of various families’ cultures (Čolić et al., 2021). Thus, these barriers highlight the need for increased training and support around relationship building, collaboration, and utilizing strengths-based approaches by behavior analysts when working with families.

Recommendations for Building Collaborative Partnerships

To address barriers to family-provider collaboration, we offer recommendations to steer behavior analysts into establishing meaningful collaborative partnerships with the families they work with. These recommendations are based on a collective review of FCP, ABA, and contextual fit literature that emphasize strategies for effectively building and sustaining collaboration when delivering family-based behavioral services.

Building Foundational Collaborative Relationships

We believe the most significant obstacle to addressing the previously outlined barriers lies in behavior analysts’ inconsistency in collaborating and building strong partnerships with families. Slim and Reuter-Yuill (2021) described several core tenets of building collaborative care competencies (CCC) among behavior analysts and other professional providers. Moreover, researchers in the field of ABA have done considerable work centered on the language and compassionate skills needed for behavior analysts to engage in collaborative relationships (Rohrer et al., 2021; Taylor et al., 2019). The field of positive behavior support (PBS), utilizing an FCP approach, have done extensive work highlighting collaborative practices to promote effective collaborative practice (e.g., Albin et al., 1996; Bailey, 1987; Lucyshyn et al., 2002). The research field of ABA has begun to consider how a family-centered approach can benefit practice (Brown et al., 2022; Rohrer et al., 2021) but has not yet incorporated PBS literature into building sustainable ABA practices that fit family cultures and routines. By amalgamating these literature bases centered on collaboration, we have comprised four fundamental tenets that comprise collaboration between behavior analysts and families: (1) Facilitating Communication; (2) Establishing and Sustaining Co-Constructed Values; (3) Establishing Roles and Responsibilities: and (4) Committing to a Teamwork Approach. In the following section, we denote how these concepts can be jointly applied to collaborating with families for treatment planning and implementation of ABA services.

Facilitating Communication

The ability to communicate desires, needs, strengths, and barriers is an essential component for behavior analysts to engage with families. Behavior analysts should engage in the communication skills of demonstrating perspective-taking, empathy, and compassion with families (Rohrer et al., 2021; Taylor et al., 2019). We acknowledge that this will take time and will be a concerted effort on the part of the behavior analyst. However, behavior analysts should consider maintaining a balance between parent training activities, e.g., modeling and role-play, and relationship maintenance activities, such as engaging in light, personal conversation (Forgatch et al., 2005). Too often, a rigid focus on parent training activities can lead to attrition by caregivers or produce resistance to participating in skill-building activities (DeRubeis & Feeley, 1990). By including relationship-building activities during parent training, behavior analysts can empower families to feel included, leading to less attrition and resistance to training activities.

Prior to understanding empathy or compassion, behavior analysts must be firmly grounded in their ability to take and analyze various perspectives (Catagnus & Rock, 2020; Slim & Reuter-Yuill, 2021), i.e., “walk in another’s shoes,” (Taylor et al., 2019, p. 655). Behavior analysts should covertly process what families are explaining and, as needed, clarify or ask questions about what families may be describing (Rohrer et al., 2021). This may be particularly important for circumstances that behavior analysts may not have experience or knowledge about. For instance, a family could describe a recent increased difficulty in caring for their children, and the behavior analyst may not have any experience as a parent. In this scenario, the behavior analyst should ask clarifying questions about the demands facing the family to gain a better understanding of the depth of the issue. In addition, the behavior analyst should envision how these difficulties could affect service delivery in the home, particularly when families are tasked with participating in implementing and planning interventions.

Once behavior analysts can successfully take the perspectives of family members, then compassion and empathy for the families can be fully realized. Taylor et al. (2019) define empathy as requiring perspective-taking, and behavior analysts must “perceive the experience from the other’s perspective and have an understanding of the person’s emotional response within that experience” (p. 655). This requires that the behavior analyst acknowledge the emotions family members are experiencing and be able to process them as the parent instead of processing them from the perspective of a behavior analyst. To do this, the behavior analyst should tact, question, and converse with families about the individual struggles they are noticing through the lens of family members to ensure that the perspectives they are taking represent the family's realities.

Behavior analysts should utilize the previously mentioned components of perspective-taking and empathy to go further to engage in the act of compassion: committing to an actionable step (Taylor et al., 2019). Taylor et al. recommend “reorienting the goals” for the family, perhaps centering on being “more compassionate with (themselves) as a parent” (p. 656). We believe that behavior analysts could take many steps towards engaging in compassionate care, including reducing the demands of intervention implementation in the home, identifying and shifting environmental constraints, engaging in collaborative assessment practices, or utilizing other behavior-analytic strategies that better match family needs to yield similar behavior-change results. Behavior analysts should be creative in engaging in compassionate care that effectively centers the needs of families.

Once behavior analysts have a core understanding of perspective-taking, empathy, and compassionate care, they can utilize actionable items to facilitate meaningful communication. From the initial interaction, behavior analysts should engage in clear and complete communication with the family, honoring the family’s experiences and transparently communicating information (Brown et al., 2022). This communication should be free of behavior analytic jargon (Behavior Analyst Certification Board, 2020) and delivered in a manner that any family could find approachable. Behavior analysts should also be honest, listen intently, and participate in frequent exchanges with families that coordinate meaningful information and resources about their child’s progress (Blue-Banning et al., 2004; Dunlap & Fox, 2007). Moreover, this communication should be framed with a strengths-based approach, a core tenet of FCP (Epley et al., 2010). Caregivers and families can appreciate when practitioners utilize these tools and have indicated so through qualitative research methods (Blue-Banning et al., 2004; Rocco et al., 2002). Indeed, many communication skills we have highlighted involve basic principles that many individuals value. Still, it is imperative that behavior analysts take the lead to model these behaviors as being essential for the caregiver-practitioner partnership. Lastly, behavior analysts can communicate effectively by demonstrating a genuine interest in the family, outside of just the child the behavior analyst may be working with (Miller et al., 2019). By indicating genuine interest in the family, a behavior analyst can tangibly incorporate family experiences, values, and knowledge into their partnership.

Behavior analysts can then combine these components to build effective intercommunication between themselves and their families. Engaging in perspective-taking, attaining empathy from taking perspectives through another lens, and creating actionable items are critical base layers for behavior analysts to incorporate into these partnerships.

Establishing and Sustaining Co-Constructed Values

Another critical component of building relationships with families is for providers to create shared common values with families. Beginning this work, behavior analysts should engage in the job of reflecting on their own values and biases (Behavior Analyst Certification Board, 2020; Conners & Capell, 2020). The Ethics Code’s “Cultural Responsiveness and Diversity” describes behavior analysts engaging in professional development around cultural responsiveness and also states that behavior analysts “evaluate their own biases and [their] ability to address the needs of individuals with diverse needs/ backgrounds (e.g., age, disability, ethnicity, gender expression/identity, immigration status, marital/relationship status, national origin, race, religion, sexual orientation, socioeconomic status)” (Behavior Analyst Certification Board, 2020, p. 9). We underscore the need for behavior analysts to consistently engage in the process of critical reflection to gain a sense of their own biases (Conners & Capell, 2020; Fong et al., 2016). In addition to reflecting on their biases concerning what is mentioned in the Ethics Code, it is imperative for behavior analysts to critically reflect on the power dynamics that can emerge when working with the client and their family. Behavior analysts must be aware of how clients perceive the dynamics in the therapeutic relationship (Fawcett, 1991; Pritchett et al., 2022). We firmly believe examining the levels of power each party holds is crucial to building equitable and sustainable partnerships (Miller et al., 2019). For instance, families may feel obligated to adhere to all the behavior analyst's treatment recommendations, feeling that questioning them may jeopardize their ability to receive future ABA services. The family may be fully aware that they cannot carry out all the behavior analyst's proposals as prescribed but consent to the recommendations to avoid a perceived loss of services (Mathur & Rodriguez, 2021). The behavior analyst may unknowingly possess this power of being an arbiter of services and must reflect on these dynamics to avoid these situations. After reflecting, behavior analysts should invite families to share their needs and listen to their concerns (Slim & Reuter-Yuill, 2021) and reorient the intervention to match the values and needs described by the family more appropriately. This may be an area that behavior analysts continually review to flexibly match the intervention to a family’s cultural values.

The co-construction of values within a caregiver–behavior analyst partnership is an essential element of the assessment process. Families that feel empowered to participate and co-construct interventions for their children tend to experience less stress and higher confidence levels (Brookman-Frazee & Koegel, 2004). Including families in the assessment process goes beyond asking for input and the family's experiences. This process involves deliberately centering family knowledge, experience, and practices to disrupt the commonly hierarchical nature of behavior analyst/family relationship (Lucyshyn et al., 2002). Moreover, behavior analysts must exhibit a sense of humility when assessing family culture that is focused on developing a therapeutic relationship filled with personal growth from both parties' perspectives (Miller et al., 2019). To effectively commit to this, behavior analysts should again participate in the “action of compassion” and engage in behaviors that demonstrate a real effort to center the families’ input (Albin et al., 1996). For instance, a behavior analyst should nix or amend a proposed intervention when a family member articulates that they have tried it previously without any positive results (Fong et al., 2017). The family’s expertise in this realm is their own experience with their child, and when providers dismiss it, this can disrupt a budding connection and partnership between families and behavior analysts (Rocco et al., 2002).

Behavior analysts can also shift their assessment goals to align with family goals to build congruence between the values of themselves and the family. In alignment with the communication tenet, a behavior analyst must first learn the values of the family with regard to their child’s goals in the near- and long-term future (Albin et al., 1996). This establishes the family’s values as the baseline for obtaining a semblance of congruence within this collaborative partnership and can be done through interviews, informal surveys, or an ecological assessment (Lucyshyn et al., 2002). In turn, the behavior analyst must be clear about their agency's values, their funder, and then themselves. Together, the behavior analyst and the family must continue transparent communication to build and collaborate on establishing shared values. For instance, a family may demonstrate the importance of having mealtime as a family gathering. A funder and agency value likely align with remediating “the core deficits of ASD” (Council of Autism Service Providers, 2020, p. 4). Thus, the behavior analyst must acknowledge the family value, clarify their agency’s and funder’s values, and co-construct an intervention that is congruent with each party’s needs.

Establishing Roles and Responsibilities

An extension of communication and establishing values between families and behavior analysts is determining the roles and responsibilities of each party within the partnership (Blue-Banning et al., 2004; Brookman-Frazee & Koegel, 2004; Buschbacher et al., 2004; Dunlap & Fox, 2007). Establishing the responsibilities each party holds enables both families and practitioners to hold one another accountable in building a supportive space for rapport building and eventually collaborative partnerships (Slim & Reuter-Yuill, 2021). Moreover, when behavior analysts and families communicate and elaborate on their values and ethics, both parties can share their abilities and point out the strengths and expertise the other party holds (Horner et al., 2014). It is vital for behavior analysts to highlight the family's expertise and to fit their roles within those strengths that they already carry (Epley et al., 2010). Families of a child with a disability have often been told by numerous providers the things they cannot do, the things their child cannot do and have been repetitively shown the ways in which they struggle, often by providers who are attempting to help remediate an existing challenge for the family. However, behavior analysts must highlight the areas in which families thrive and utilize strengths to address other areas where they may seek improvement (Brookman-Frazee & Koegel; Lucyshyn et al., 2002). For example, a family may struggle with a mealtime routine and have sought support with that particular activity. Rather than solely focusing on the “deficits” within the mealtime routine, a behavior analyst must emphasize how the family is exceptional at their bedtime routine. They can then highlight the constructs within the bedtime routine that the family does well, i.e., following a consistent pattern, going to bed around the same time every night, and always reading a book. Behavior analysts can then describe how those types of solid skills can generalize to other settings, like mealtime, and support families to build upon these strengths but within new routines, e.g., produce generalizable traits. In doing so, the family and behavior analyst have begun to establish their roles and responsibilities collaboratively using a strengths-based approach instead of deficit framing.

However, initially establishing these roles and responsibilities is not a matter to be reviewed once and then put to rest. There should be consistent conversations about how roles will change over time due to the shifting treatment plan or caregiver demands (Horner et al., 2014; Slim & Reuter-Yuill, 2021). Referring again to the mealtime example, the treatment plan may have initially called for a large amount of reinforcement that should be faded over time. Caregivers should have a clear understanding of how and when this shift happens and what their role is when the fading of reinforcements takes place. Furthermore, a good behavior analyst should highlight how their role will shift during the intervention, from initially modeling and providing a large amount of coaching support to fading out support as the family becomes more comfortable delivering treatment independently. Along this path, the behavior analyst should be clear about their role at that moment but always be willing to support the family should they need it.

Committing to a Teamwork Approach

Building a collaborative partnership should utilize a teamwork approach that involves conflict resolution, reflective practices, and providing feedback based on those reflective practices (Slim & Reuter-Yuill, 2021). Committing to a team approach involves utilizing the tenets mentioned above: employing clear and consistent communication, sustaining co-constructed values, understanding what each party’s role and responsibility entails, and constantly negotiating shifting roles as time passes. Utilizing these tenets can limit conflicts and ensure a truly collaborative partnership that centers on family values. However, this negotiation entails each party engaging in a reciprocal approach and centering their roles in an equitable manner (Blue-Banning et al., 2004). The share of the work should be as equal as possible, but the workload should be distributed equitably, i.e., aligning roles and responsibilities with the respective strengths of each party. However, a committed team approach does not include members becoming territorial over their strengths and roles (Brookman-Frazee & Koegel, 2004); instead, team members focus on understanding their strengths, opening their horizons to gaining more knowledge, and expanding their strengths-based repertoire (Miller et al., 2019).

During team building, conflicts will arise that must be resolved for treatment to be effective. Addressing these conflicts involves communicating shared and differing values and each party displaying transparency about their desires for future outcomes (Segal & Smith, 2018). A behavior analyst must be direct and transparent with families about future goals (Čolić et al., 2021) and how those may not always align with the family’s goals, especially in cases where agency or funder values inhibit how a behavior analyst can function. For example, an agency may require a behavior analyst to utilize a parent training curriculum that does not center on families as part of the intervention but focuses on ABA developmental skill building. The behavior analyst being transparent with the family that this curriculum is a requirement of their agency may help families understand the systemic nature of the intervention implementation. Otherwise, the family may feel slighted or as if the behavior analyst does not care about their specific needs.

When conflict cannot be avoided, each party must be cognizant of their emotions and self-reflect on why they may be experiencing such feelings (Segal & Smith, 2018). Behavior analysts must be aware of their power in this relationship (Mathur & Rodriguez, 2021; Miller et al., 2019) as it will be their responsibility to undertake the lead in resolving the conflict. They must also be conscious of their complicity in the conflict, even when they have not explicitly contributed to creating it. Perspective-taking and empathy are critical elements for behavior analysts to practice understanding why a family may resort to conflict (Taylor et al., 2019). Remaining calm and seeking out a complete image of what the family is experiencing is essential for behavior analysts to facilitate resolving the conflict and moving forward in the partnership (Segal & Smith, 2018).

After a conflict has been resolved, behavior analysts need to reflect upon the variables that contributed to a dispute arising and envision how they can prevent such an incongruence in the future (Čolić et al., 2021). A behavior analyst should get feedback from families centered on resolving the conflict and what measures they could use to prevent such a situation in the future (Miller et al., 2019). Obtaining these social validity measures is vital for behavior analysts to understand how their communication may not be clear or strategies/situations they should be more transparent with in the future.

These tenets can serve as a framework for behavior analysts engaging in collaborative partnerships with families to create effective and sustainable interventions. With the family feeling empowered (Brookman-Frazee & Koegel, 2004), they are more likely to engage in intervention strategies outside of ABA hours that can lead to better child outcomes. By building these collaborative partnerships, behavior analysts can embolden caregivers to demonstrate generalization of skills across family routines and implement strategies with greater fidelity. Moreover, behavior analysts can see these partnerships beginning to establish socially valid goals, interventions, and outcomes for families.

Once a collaborative relationship has been established with this firm foundation, there are several recommendations that are imperative to address the diverse barriers outlined by families and behavior analysts. Below are suggestions we hope behavior analysts can acknowledge and utilize in their practice. These brief recommendations for behavior analysts are broken into the following sections: Acknowledging systems strengths and barriers, integrating family goals in implementation, and enhancing behavior analyst training.

Acknowledging Systems Strengths and Barriers

Before discussing recommendations for a singular behavior analyst to address systemic barriers, we must acknowledge the lack of agency a behavior analyst has when navigating the world of insurance-funded ABA services and the myriad of systemic obstacles that lean on how they can conduct behavior-analytic services. We strongly believe that agencies, behavior analysts, funders, and policymakers could utilize the above collaborative framework to improve alignment among goals, procedures, and policies to collectively support the development of collaborative partnerships and the empowerment of families. It is outside the scope of this article to suggest tangible strategies that can enable each of these parties to engage in this kind of work. However, we would be remiss not to acknowledge systemic structures' profound impact on individuals but still offer suggestions for behavior analysts to utilize to disrupt and ethically navigate these difficult situations.

To address families’ limited knowledge concerning service provision and the constraints of the BACB Ethics Code, it is imperative that the first step behavior analysts take when collaborating with families is to be communicative and transparent with families about the limitations they face from funders, primarily in the health-care realm. There will be instances in which the behavior analyst simply cannot accommodate a goal that a family desires due to the funder's restrictive guidelines; it is imperative that in these instances, behavior analysts be transparent with the family about why they cannot address their need (Čolić et al., 2021). Sharing this information with families is rooted in the idea of treating families as equal partners in the budding relationship and establishing collaborative tenets that emphasize value sharing and interpersonal communication (Brookman-Frazee & Koegel, 2004; Slim & Reuter-Yuill, 2021). This could be perceived as a way of pushing responsibility onto a system that inadequately addresses family needs. Still, we believe it simply addresses the reality of the current service delivery model and exhibits the communication value of honesty that families often appreciate (Blue-Banning et al., 2004). Including families in the systemic circumstances that constrain behavior analysts for why certain skills cannot be addressed could embolden individuals within these families, and behavior analysts themselves, to take paths that can drive systemic change in the future.

Conversely, behavior analysts would be keen to seek creative solutions when family goals and what insurance funders deem as “medically necessary” do not align. For example, families might wish to address academic goals (e.g., handwriting) that are likely not covered by insurance during service delivery. However, the behavior analyst may acknowledge the family’s concerns, collect data on the child engaging in an academic task during their assessment, and ascertain that the potential issue for the family is the challenging behaviors that arise when the child is prompted to engage in academic work. Behavior analysts could discuss intervention plans that address the challenging behaviors during an academic task and provide further referral for academic support if necessary.

Integrating Family Goals in Implementation

Many barriers to implementation voiced by families and behavior analysts focus on limited offerings of family voice in treatment plans and a perceived lack of family buy-in to the selected intervention (Angell et al., 2016; Taylor et al., 2019). We have highlighted several mechanisms that encapsulate the ingredients of a truly collaborative partnership. We maintain that these core concepts are a great building block for establishing collaborative practices with families and highlight how these have been routinely demonstrated through research practices (e.g., Blue-Banning et al., 2004; Brookman-Frazee & Koegel, 2004; Buschbacher et al., 2004; Lucyshyn et al., 1997, 2007; Moes & Frea, 2002). A core piece that must be outlined before services are delivered is outlining each party's roles and responsibilities (Behavior Analyst Certification Board, 2020). Behavior analysts should be clear about what their professional duties entail and should invite families to outline what their roles and responsibilities will be as well. Behavior analysts should be very clear that their commitment is to support families and not to inundate them with extra responsibilities. Behavior analysts being cognizant of a family’s capacity for implementing behavior-change strategies is critically important at this juncture, but also remaining keenly aware of the family’s strengths as well (Albin et al., 1996). Maintaining this balance is imperative for behavior analysts to build a collaborative relationship with families.

Likewise, behavior analysts should check in and review each party's roles and responsibilities periodically throughout the relationship to ensure that they and the families can still maintain their roles or they should be adjusted as necessary (Slim & Reuter-Yuill, 2021). For instance, a family may be asked to implement a complex token system in the home for a toilet training goal but have recently had a second child. The behavior analyst should check in with the family and ask how they can be supportive. This could result in a conversation where the family feels they need to stop or amend the delivery of the toilet training goal due to the new child. The behavior analyst may need to stop the goal or amend its implementation to better meet the needs of the family delivering the intervention. Establishing these roles and responsibilities before implementing the intervention enables behavior analysts and families to be clear about their respective abilities and to continually adjust these roles as needed.

In recent years, many ABA agencies have developed their own curricula or adopted a curriculum for providing ABA service, such as the Research Units in Behavioral Intervention (RUBI) Curriculum for parent training (Scahill et al., 2016) or the PEAK Curriculum developed by Mark Dixon (Dixon et al., 2017). These curricula provide a strong starting point for behavior analysts to assess their families and clients, but it is imperative that behavior analysts not be overly reliant upon scripted ABA curricula. These curricula are helpful guidelines for behavior analysts to reference. However, they can lead to behavior analysts providing prescriptive care outlined by the curriculum that aligns with funders' and agencies' values but does not address families' contextual needs and values. When families’ voices are not valued, the family is less likely to buy into the treatment plan (Angell et al., 2016; Brookman-Frazee & Koegel, 2004). To be more responsive to the needs of each family, behavior analysts may use these curricula as a starting reference point for treatment and then invite families to co-create a final intervention plan that is built around their strengths and needs in conjunction with the curriculum. For instance, a behavior analyst who has adopted a developmental ABA curriculum should collaborate with families to select goals within the curriculum that would appropriately elevate the family’s strengths and address their needs. Behavior analysts and families could choose developmental goals from the curriculum that best fit into the family routine, such as a goal of learning to button one’s shirt to aid in independence with getting ready for school. When behavior analysts intentionally collaborate with families to select goals and priorities that match their needs, the field of ABA ensures that service delivery does not take a “one-size-fits-all” approach and delivers contextually appropriate services for families.

When a contextually appropriate intervention plan is offered, it is more likely that families will buy into implementing a program that is co-constructed and meets their needs (Albin et al., 1996; Čolić et al., 2021). When the plan is not aligned with family values and input, participation by families is often lacking (Angell et al., 2016; Taylor et al., 2019). In these instances, revisiting the roles and responsibilities of each party is an excellent starting point for realigning each party's obligations (Slim & Reuter-Yuill, 2021). For instance, a family struggling to take ABC data may feel overwhelmed by the frequency of the behavior (and thus the frequency of recording) and stop collecting data without communicating their struggles to the behavior analyst. The behavior analyst consistently checking in with the family and having frank conversations can illuminate the struggles the family is encountering. In the end, the behavior analyst is responsible for contextualizing the data collection method to a more manageable volume.

Enhancing Behavior Analyst Training

Training nuanced soft skills related to collaboration remains a difficult task when preparing behavior analysts to enter a field with such vast applications, from working with families to working in schools and other community centers (Rohrer et al., 2021). However, behavior analysts who will be working with families need training centered on three core areas to address the barriers families currently face: understanding and implementing collaborative practices, clearly understanding patient/family rights and the ability to relay this information to families receiving services, and training centered on culturally responsive practices.

Behavior analysts should receive better training surrounding collaboration practices, particularly those encapsulated when forging partnerships with families utilizing a collaborative partnership framework. Given the importance of collaboration for enabling caregivers to implement interventions with care and fidelity, it would behoove the field of behavior analysis to train pre- and in-service behavior analysts in the foundational skills of perspective-taking, empathetic listening, and utilizing compassionate care. We acknowledge that no training can perfectly prepare someone for enacting these complex skills in the field. However, consistent opportunities to practice while accruing BACB hours and role-playing during supervision can enable behavior analysts to feel prepared to engage in these practices when working directly with families (Taylor et al., 2019). Behavior analysts who are in the role of supervising future behavior analysts should utilize indirect supervision hours to conduct role-playing exercises. For example, a behavior analyst in training who has had multiple opportunities to role-play perspective-taking with their supervisor on a topic with which they do not have experience (e.g., having kids when the trainee has none) allows them to freely make mistakes and receive meaningful feedback. Building upon these role-play experiences, a behavior analyst can work through difficulties connecting with families and be primed to forge meaningful relationships once they begin actual practice. On the other hand, a supervisee without this training may struggle to connect and build partnerships with families or not develop the skills until well into their tenure as a behavior analyst.

The BACB Ethics Code have gone through recent revisions to ensure that it supports diversity, inclusion, and collaboration (Behavior Analyst Certification Board, 2020). However, some codes, such as “Collaborating with Colleagues,” could be interpreted as behavior analysts and other professionals collaborating among themselves to make clinical decisions about the family and their child without gaining insight from the family within the planning process. By not explicitly mentioning the inclusion of families as a part of the collaboration process, behavior analysts may inadvertently miss this essential ethical element that is critical in the treatment process. Although these changes to the Ethics Code are a step in the right direction toward creating an ethical and responsive behavior analyst, these codes only describe working with other professionals and explicitly leave out families in the decision-making process. We believe that to act in an ethical manner as a behavior analyst, it is vital that behavior analysts be explicitly trained to understand that families, caregivers, and other such persons should be considered “professionals.” Their knowledge, experiences, and expertise about their family and children rival any professional opinion and should be treated as such by behavior analysts.

Addressing the power dynamics among behavior analysts and the families with whom they work is an essential component of building collaborative partnerships (Čolić et al., 2021; Mathur & Rodriguez, 2021). Within this relationship dynamic, it is vital that behavior analysts also receive training about the rights of the families with whom they work and clearly articulate those rights to these families. If families are unclear about their rights regarding the partnership, it may lead to distrust of ABA providers and irreparable damage to the partnership (Angell et al., 2016; Rocco et al., 2002). Behavior analysts must be fluent in health-care systems, HIPAA, and insurance providers to teach families about their rights to service and what rights their health care can afford them. By learning and becoming fluent in these systems, behavior analysts can help ebb the onus of learning these complex systems on families. Behavior analysts being transparent and informative about the systems within which they work can potentially alleviate some of the perceived power dynamics at play between themselves and the families they serve.

Conclusion

A myriad of barriers influence behavior analysts' ability to collaborate with families when providing ABA services in home and community settings. We have assembled what we believe is a compelling framework for behavior analysts to reference when considering how to best build collaborative partnerships with the families they work with. We acknowledge that this framework does not perfectly address all of the barriers affecting behavior analysts and families receiving ABA services, but we maintain that utilization of this framework can facilitate better relationships with caregivers. We hope future researchers can test this framework’s efficacy in empowering families to engage in assessment, goal planning, and fidelity of implementation. Moreover, examining how this framework can be utilized across systemic stakeholders (funders of service, agencies employing behavior analysts, families, and behavior analysts) could behoove the ABA industry to understand the importance of collaboration in producing better quality of life outcomes and more empowered families.

Funding

No funding was received to assist with the preparation of this manuscript.

Data Availability

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Declarations

Conflicts of Interest

The authors have no relevant financial or nonfinancial interests to disclose.