u/Asleep-Big3131

Looking for advice from other BCBAs.

I’ve been dealing with the same issue with one of my 4-year-old ASD clients since January. Dad reports he wakes up around 3AM-4AM most nights, so he’s given an iPad while the adults go back to sleep. ABA starts at 8AM, and by 9AM-10AM he’s often trying to fall asleep. I’m not talking about being a little tired. He’ll fall asleep standing up or enter such a deep sleep that meaningful ABA isn’t possible.

I’ve recommended seeing his pediatrician and offered to help establish a behavioral sleep routine, but the family has declined.
Last week, the RBT was scheduled 4 days and only completed 1. One day, she knocked, called, texted, and waited nearly an hour before leaving, and the family later said they had been sleeping. The other days, the client either couldn’t wake up or fell asleep shortly after session started.

We’re trialing afternoon sessions, but I’m worried we’ll see the same pattern if the overnight sleep doesn’t improve. Mom feels we’re penalizing him for being sleepy and says his previous provider continued services even if he slept. I don’t see it that way. I don’t think he should lose services because he’s tired, but I also don’t know how to provide effective ABA to a sleeping child.

How would you handle this? At what point does this become a service delivery issue rather than simply “meeting the client where they’re at?” I am also trying to be mindful of my staff who need a paycheck but isn’t able to meet their hours with this client.

Hi! Has anyone done a peer to peer review with Evernorth recently? Any tips? This is my first peer to peer review so a bit nervous. I have the denial letter and I know what they are saying needs to be revised (the fading/transition section needs to be more detailed) but am still a little worried. Thanks!

Hey, I’m a BCBA and would love some outside perspectives on a situation I'm dealing with.

I have a 2-year-old client who was originally authorized for 30 hours/week of ABA. At the time, she was attending school and engaging in significant elopement. The daycare she attended had an open floor plan so most rooms did not have doors.The school was threatening dismissal due to safety concerns, so her father requested the maximum hours possible so she could have an RBT with her at school.

I was also still building rapport with the family and gaining caregiver buy-in when the initial treatment plan was developed. While I would not typically recommend 30 hours per week for a client this young, I felt there was clinical justification at the time due to the safety concerns, school setting, and risk of school dismissal. I wanted to address the family's concerns while continuing to build a collaborative relationship.

The schedule was:
RBT #1: 8AM - 12PM
Nap 12PM - 2PM
RBT #2: 2PM - 4PM

Recently, the family lost childcare assistance, so services transitioned to the home. The father works from home and wants ABA from 8AM - PM every day with no nap break. He reports that he puts her down for a nap at 3PM when he finishes work.

The problem is that she is clearly exhausted by around 11AM. She whines, tries to lie down, disengages from activities, and has very little tolerance for demands. Running programs after that point is extremely difficult. I have the data to prove around 11AM or 12PM, a tantrum happens almost each session. I suggested ending services around 12PM and having a RBT return after her nap, but the father declined. He believes she can last longer and just needs physical movement. He always suggests walks around the neighborhood (we live in Florida its HOT) or implementing the sensory routine the occupational therapist has recommended the parents do. My clinical director and I did a 3-way call with the family to explain that longer hours doesn’t always mean more effective ABA. They said they are rejecting the recommendation to reduce hours and expect a RBT there from 8AM - 3PM next week. (Even though say somehow my company became short-staffed and a RBT was only available to do only do 8AM - 12PM then they’d have no choice but hey.)

Her reauthorization is coming up, and I am still considering reducing services from 30 hours/week to 20 hours/week. The reason is not that she no longer needs ABA. Rather, it appears that extended treatment hours are no longer clinically effective because she is unable to meaningfully participate for a large portion of the day. I am worried that this will look weird to her insurance.

Any opinions? Would you reduce the hours? How would you justify it to insurance?