Shalini & Sumanta Das—both BCBAs and OTs, and Founders/Directors of Symbiosis Pediatric Therapy—join Erika to discuss the multidisciplinary nature of their clinic. They provide plenty of insights for both OTs and behavior analysts who are working together. They also impart some wisdom about collaboration that they have honed over the years.
Shalini and Sumanta’s professional journey [2:53]
They started Symbiosis back in 2008 when they moved from Singapore to Canada.
They found a big gap in the services for children, especially in the Lower Mainland area. This led them to start their own company
Prior to that, both of them had worked in Singapore and in India in a lot of different ways with children with disabilities (in schools, group homes, private clinics, etc).
Symbiosis started as an OT company, where they primarily provided OT services. As they grew, they realized that parents were having a very hard time trying to get their kids from one clinic to the other (for OT, speech, and behavior services).
Around 2010-2011, they added speech therapy, and added behavior services after that. Right now they are a multidisciplinary team where they provide speech, OT, and behavior services to children from neurodiverse backgrounds.
Currently, Symbiosis has five locations across the Lower Mainland. Their headquarters is in Surrey. There also are locations in Burnaby, Delta, Abbotsford, and Port Coquitlam.
At Symbiosis, they provide both clinic-based as well as community-based services. Their staff go to schools, homes and childcare centers. Wherever their services are needed, they are there!
Shalini and Sumanta studied together—same school, same class—doing OT together back in the early 1990s.
They started as OTs.
More recently they became BCBAs.
Sumanta did his master’s in special education.
They both took SIPT training—Sensory Integration and Praxis Test—which is a test to diagnose sensory integration in kids with sensory integration issues.
When they put on the OT hat, they were only thinking from the sensorimotor perspective. But when they became BCBAs, they thought there are a lot of other variables which affect the child’s behavior on a particular day.
Based on both areas of practice, they provide intervention.
At Symbiosis, they also have speech services because a lot of communication challenges can compound behavioral challenges.
They have had a physio join them too.
They also added BCBAs and BCs in their team to give a whole spectrum of services.
Shalini shares an example when looking at a child through a particular lens [9:28]
She used to work with a child that was diagnosed with ASD in early elementary school.
Behavior wise – not so many issues (he was doing well in school). Kindergarten, Grade one, Grade two -were okay.
Grade three – he suddenly started lashing out at other kids. The parents didn’t know what was happening.
Shalini’s team went in and did some observations at school and it turned out that the child had an auditory sensitivity that people had missed.
At school, they were doing percussion instruments and he hated the noise. He quickly figured out that if he used drumsticks to hit the kids next to him, he would get sent to the principal’s office.
From a behavior perspective, it appeared he was escaping from the task.
Giving him noise canceling headphones changed everything. He was back to that sweet little kid who was happy with his friends and happy making music.
Some acronyms used in this conversation [12:46]
OT: Occupational Therapy
BCBA: Board-Certified Behavior Analyst
BI: Behavior Interventionist (a term used in British Columbia to describe the role of a front-line worker carrying out therapy). Some BIs may be Registered Behavior Technicians (RBTs) but not all BIs have RBT credentials.
ESDM: Early Start Denver Model
SPD: Sensory Processing Disorder
ADL: Activities of Daily Living
Tips to better understand each other as BCBAs and OTs [13:19]
Respect for each other as professionals.
The focus is on the child. The focus should not be on the conflict between the two professions. The focus is more on the child and working together.
Something that they do at Symbiosis is cross referrals.
A child may come to them for behavior services, but if the behavior consultant or the behavior analyst feel that there are some red flags for OT, they would get the OT involved.
This is the same with OTs. A learner might come to them for OT services; the child is coming to learn writing, but maybe they’re not even sitting at the table yet. They’re not ready for it. The OT would get a behavior analyst involved in order to understand the skills needed to get to a place where they can attend to writing tasks
BCBAs have a huge advantage in the research-based training that they get (how to run programs, how to take data). That’s one of the big strengths that they have, which Shalini doesn’t see so much in the OT field, at least not right now.
When we collaborate, we depend on each other for our strengths.
The OT might be running a program, whereas the BCBA has devised a data taking mechanism for that. Even though it is an OT program, the data is helping the BCBA determine whether this particular program was effective or not.
There are a few clinical observations that they have seen in Symbiosis.
In terms of ADL: for example, buttoning. There might be some factors with motor skills where the kid might not be able to do buttoning.
This is more of a community-based activity, which the OT might not be able to do in the clinic, but the BCBA or the BI can go to their house and teach the child how to do that and take data on how many times they have done it successfully or whether they need assistance or not.
They have adopted a model called the Early Start Denver Model by Sally Rogers.
At Symbiosis they collaborate between professionals. It can be a BCBA, it can be an OT, it can be a speech therapist, and that is where they see the child as a whole. There are different functional domains like communication. There might be social skills, feeding, sleep, dressing and other components where they work as a team.
In the ESDM, any one person can be leading the team. They’re doing the assessment, the planning, setting up everything — which BCBAs are very good at — getting the whole team together and leading them.
On the actual intervention, the BIs can be running OT goals and communication goals.
The activities are run in such a way that you are not taking data every second or even every minute. It’s broken into chunks and very natural environment-based. ESDM is not table-top discrete trial teaching, but rather more of a natural environment-based model.
ESDM is not the only model they use in Symbiosis.
They also have BCBAs who are traditionally trained in ABA.
They have some OTs who are more inclined towards sensory-based activities.
They have a lot of workshops where that collaboration part comes in, where they discuss two different professionals sitting with two different lenses, but they’re seeing the same child.
Other common areas where there’s overlap between OT and BCBA [20:49]
Handwriting is one of the biggest or common areas where BCBAs might teach writing in a different way, especially if the kid is going to school.
The OT might have foundations of sensory motor skills of the challenges that the child is facing (e.g., different types of grips or biomechanical principles that are used in writing).
When we learn letters in school traditionally, we learn from A to Z. Whether you’re doing the sounds or the writing, traditionally we go from A to Z.
When OTs are teaching writing, they go in developmental order.
OTs do a lot of assessments on visual perception skills where letter reversal comes in the picture.
Some kids might be able to master writing S but sometimes it is the reverse, so it becomes 2. That is where the OT comes into the picture and says, yes, he has that skill, but there might be some visual motor integration factors, which the OT can do an assessment and figure out what can be the next step to address that.
They do some visual motor activities during the OT sessions, and then they come back, collaborate with the BCBA, and then perhaps practice more on writing S— as per the example
Speech therapists, OTs, behavior consultants – they’re all working on social skills in their own ways using their own strengths.
A social skill group run by an OT might be more focused on sensory motor activities, but they’re still working on social skills.
A speech therapist might be having more communication-based activities.
Some areas can be difficult to navigate between occupational therapy and behavior analysis [24:57]
The most common one is sensory integration.
General sentiment in the field of behavior analysis is that sensory integration is not evidence-based.
STAR Foundation does a lot of research on sensory integration. There’s a huge bank of literature on sensory integration available.
The reason why a lot of behavior analysts feel that it’s not evidence-based is because maybe the sensory integration research has not been done in the way that BCBAs are familiar with
To anybody who’s concerned about sensory integration being evidence-based or not — look at the OT research. Look at research from the American Association of OTs.
Also check out AJOT (American Journal of Occupational Therapy).
OTs might feel that BCBAs only do discrete trials, which we also know is not true. There needs to be an understanding of each other’s work
“We need to be more aware of each other’s professions and respect that. That’s where collaboration will come.” — Shalini Das
There are a lot of strategies to support proprioception, so you cannot make the generalization that sensory integration doesn’t work. It has to be customized based on the child and how much training the OT has or how much training the BCBA has.
Not all OTs are trained in sensory integration. We are taught about it as part of our curriculum. Yes. But there is specialized training and certification that is needed.
Just like getting certification as a BCBA: we learn about feeding and sleeping, but not all BCBAs work on sleep. Not all BCBAs work on feeding.
Are all OTs trained in understanding interoception? [31:32]
Interoception is a very new term in sensory integration. It is basically the 8th component of sensory integration skills.
The OT curriculum right now — the Master’s in OT level — does include content about sensory integration or sensory processing.
In school, we learn about the five senses (sight, hearing, taste, smell, and touch).
OTs used to learn about seven senses. This includes proprioception, which is the sense that comes to us from our muscles and joints. And the vestibular sense, which is more about the balance coming from our inner ear.
In the last couple of years, interoception is getting added on as the 8th sense that consists of the feelings that we are getting from inside our body (ie., the feeling of fullness after a meal, or a need to avoid bladder or bowel movement)
The sensory integration from the way OTs are taught is a very neurologically-based process. It’s happening at the brain level. Interoception is happening there as well.
They believe that all the sensors are working together to give us a map of where we are in space and how we use our body. Interoception is part of that.
Theoretically speaking, somebody who knows sensory integration should be able to work on interoception.
This is a book meant for parents, but a lot of professionals like it too. It talks about how a sensory rich environment gives a child more chances to develop their sensory systems, which leads to better outcomes.
They have many topics like the toilet training videos from Pat Mirenda and feeding issues.
Some advice for when professionals are in a tricky situation in which someone is challenging whether something is evidence-based or not [40:54]
We have very different ways of doing research between OTs and BCBAs or even speech therapists. What is evidence-based to a BCBA may not be evidence-based to another person as an OT, and may not be evidence-based to another person as a speech therapist.
Start with a feeling of trust. If the OT is telling you from their research background that this thing works, give them the benefit of the doubt. Don’t start out by saying that it won’t work.
The same thing goes for OTs. If a behavior consultant is putting a behavior change program in place, they likely have research to back it up.
Come with a feeling of trust to the table. Bring trust to the table and then go from there. If you have questions, you can still ask respectfully.
Try to come to a consensus.
Even at Symbiosis, though they are multidisciplinary, there are odd cases where two professionals are coming to the same child’s case with different perspectives and different methods. The question becomes, ‘which method do they need to apply?’ Sometimes they can’t apply both at the same time, especially if they’re in a disagreement over methods.
They have to find a midpoint. If, at the end of it, they still cannot come to a consensus, they get the parents involved. The parent has the final say as to what approach they will take.
All professions, whether it is speech or BCBAs or OTs, have different educational backgrounds. They have their own research. They might have different ways of doing research. Rather than contradicting each other, why don’t you collaborate and complement each other’s services?
Reach out to other professionals when you’re stuck.
In OT training, there’s this undertone there that “you should now be ready to treat anything” [54:30]
Occupational therapy is about a person’s occupation. So whether it is their work, their play, or their activities of daily living, as long as it is something skill-based, OTs are expected to treat the issue.
The expectation: an OT who’s graduating out of school should be able to work with any population.
The reality: when they get into jobs, they get a lot of on-job supervision, and a lot of on-job training.
Once you’re in the field as an OT or as a BCBA, you should have some specialized training and certification based on your niche or what you want expertise in.
OTs might not be trained in sensory integration, but it is expected from the general public or from other professionals that because he’s an OT, he might have specialized in sensory integration or he might be an expert in handwriting, but that is not the case.
All OTs are not working in sensory integration.
Same as BCBAs. All BCBAs might not be able to do toilet training
Shalini & Sumanta’s advice for BCBAs or OTs when working together [1:07:31]
The communication and the trust between the professions, and just respecting each other.
No one person can do everything, so let’s work together.
“Our main focus should be the kids and the family, rather than different professionals’ research or expertise or skills.” — Sumanta Das
Meet Our Guest
Shalini is a co-founder/Director of Symbiosis Pediatric Therapy which provides multidisciplinary therapy services to children.
Being an experienced Board Certified Behavior Analyst (BCBA) and an Occupational Therapist gives her a unique perspective and helps her create programs for children diagnosed with Autism Spectrum Disorder(ASD) and other developmental disabilities.
Her current role at Symbiosis is to oversee the clinical and administrative departments of Symbiosis at all the locations. It also includes managing the Symbiosis Team of 50 professionals (Behavior Consultants, Occupational Therapists, Speech-Language Pathologists, Behavior Interventionists etc.)
Shalini has worked with children with various diagnoses including but not limited to Autism Spectrum Disorder (ASD), Dysfunction of Sensory Processing and Modulation, Attention Deficit Hyperactivity Disorder (ADHD), Developmental Delay, Learning Disabilities, Developmental Coordination Disorder (DCD), Down’s Syndrome, Cerebral Palsy, etc..
She has extensive experience working in different school systems, private clinics and providing home-based intervention in various countries including India and Singapore prior to migrating to Canada in 2007.
She currently is teaching and mentoring students of different Universities in India, Singapore., Australia, Thailand, and Hong Kong along with mentoring Occupational Therapy students from the University of British Columbia, Canada.
“That trust and respect for the other professional, if we can bring that to the table to our discussions, that would go a long way in understanding whether what the other person’s saying is evidence-based.” — Shalini Das
Sumanta is a Board Certified Behavior Analyst (BCBA)/Behavior Consultant and an Occupational Therapist, one of the few professionals in Canada, who has the vast experience to offer programs for children diagnosed with Autism Spectrum Disorder(ASD) both as a Behavior Consultant and also an Occupational Therapist. His current role is the facilitation and overall growth of all the 5 multidisciplinary clinics of Symbiosis Pediatric Therapy Inc.
He has experience of 25 years working with children with various diagnoses includes but not limited to Autism Spectrum Disorder(ASD), Dysfunction of Sensory Processing and Modulation, Attention Deficit Hyperactivity Disorder (ADHD), Developmental Delay, Learning Disabilities, Developmental Coordination Disorder (DCD), Down’s Syndrome, Cerebral Palsy, etc..
Sumanta has vast experience working in different school systems, private clinics and providing home-based intervention in various countries including India and Singapore.
He is equipped with the knowledge of various intervention techniques and modalities within his scope of practice and has published Occupational Therapy protocols that are being used in various school settings, non-profit organizations, and private clinics in Asia.
Sumanta has taught and mentored students of many international Universities in India, Singapore., Australia, Thailand, and Hong Kong along with mentoring OT students from the University of British Columbia, Canada.
“All professionals have limitations and strengths, so why not tap on each other’s strength and collaborate. Look at the bigger picture and then you’ll see the kid as a whole.” — Sumanta Das
We’re trying out transcribing our podcasts using a software program. Please forgive any typos as the bot isn’t correct 100% of the time.
Welcome to the Behavioral Health Collective Podcast—a community of behavioral health professionals who are passionate about working together across disciplines to improve client outcomes by valuing collaboration, connection, humility, and evidence-based practices in a variety of behavioral health fields.
The goal of the Behavioral Health Collective is to highlight stories of collaboration between practitioners, the work they’re doing together, and how thoughtful and ethical collaboration between fields can lead to better client outcomes. Thanks for joining me today to dive deeper into stories of professional collaboration.
As behavior analyst, it seems sometimes that there’s a number of misconceptions about occupational therapy, especially when it comes to sensory issues and related factors that face neurodivergent client. There can sometimes be overlap with behavior analysis and occupational therapy, but there are also two very different fields with different ethics codes, different bodies of research.
Sometimes the sense we get as behavior analysts is that some of the things OTs do, especially in regard to sensory processing, is not considered evidence-based by our field of behavior analysis. On the other hand, OTs may think that BCBAs are sometimes practicing outside of their scope when treating sensory challenges for clients or doing so in a way that is not neurodiversity affirming.
So I’m looking forward to getting into these topics a little bit more with our guests today. And so joining me today are two very seasoned professionals who are trained and certified and also currently practicing as behavior analysts and as occupational therapist. Sumanta and Shalini Das are the co-founders and clinical directors at the multidisciplinary Symbiosis Pediatric Clinic in the Lower Mainland of British Columbia and Canada.
And they’ve both been in the field of behavior sciences for a really long time and have practiced in Canada, Singapore, India, and also trained extensively in the US. Our conversation covers the multidisciplinary nature of their clinic and plenty of insights for both OTs and behavior analysts who are working together. They also impart some wisdom about collaboration that they have honed over the years. It was such a rich conversation and I’m so excited to be sharing it with you. So, let’s get started.
Good morning, Sumanta and Shalini! Thank you so much for joining me today. I’m so looking forward to chatting with you.
Thanks, Erika. Thank you for inviting us to this podcast.
Yeah, thank you Erika. Good to be here. And if we can contribute to the podcast for the larger audience who would like to listen towards to get a perspective of BCBA and an OT, we’ll look forward to this podcast. Thank you.
That’s great. I mean, it’s so rare to speak with people who are both behavior analysts and occupational therapists, so I just, I’m very thankful to have this experience. And for both of you who work in a multidisciplinary company, so I’m sure you have a lot of valuable things to share.
So, maybe to start could you tell me a little bit about your current respective roles and just a quick recap of your professional journey to this date?
So we started Symbiosis back in 2008 when we actually moved to Canada from Singapore.
And we found a big gap in the services for children, especially in the Lower Mainland area. So we thought of starting our own, you know, bringing our experience in. Prior to that, both of us have worked in Singapore and in India in a lot of different ways with, you know, children with special needs in schools, in special schools, in group homes, you know, private clinics and stuff like that.
So 2008 is when Symbiosis started as a OT company where we were primarily providing OT services. And then as we grew, we realized that parents were having a very hard time trying to get their kids, you know, from one clinic to the other to try to get OT here and speech somewhere else, and then behavior services maybe at home or at another center.
And there was very little collaboration happening between the different professionals. Not because they didn’t want to, but more because of the time crunch, I would say. Like nobody had the time to, you know, sit together and have a team meeting and things like that. And so we started exploring more and thinking what, you know, adding to our services.
So we added speech therapy I think about 2010, 2011. And then we added behavior services after that. So right now we are a multidisciplinary team where we provide speech, OT, and behavior services to children from neurodiverse, you know, backgrounds. We have kids who are diagnosed. We also have kids who do not have a diagnosis, but maybe they’re struggling with writing or maybe they’re struggling with some behavior components, you know, at school or at home.
And so we work with a whole different group of kids out there from all, all Asia Pacific.
So currently Symbiosis have five locations across Lower Mainland. Our headquarter is in Surrey. Then we have one in Burnaby, Delta, Abbotsford, and Port Coquitlam.
And do clients come to your clinic or do you also do some in home? Is it a combination?
We provide both clinic-based as well as community-based. We also go to schools if some school request for some services there even daycares, even childcare centers. So wherever our services needed, we are there.
Amazing. So could you tell me a little bit about how you came to this point as like, were you an OT first, BCBA first? What how did that happen for you both?
OT first. So we actually studied together. We were in the same school, same class doing OT together back in the early 1990s, which actually dates us now. But yeah, early 1990s, you know, we started as OTs. And then it was only about a few years ago that we became BCBAs, where we were thinking what more, you know, like when you are working as OTs, you’re working on certain skills.
And then it, there was a part that was missing. Like we had, that we had the developmental aspect in, you know, like we completely understood how the child is developing and where are they, you know, a little bit delayed or what is their stretch that they need to work on. But the biggest challenge was why is the child doing this?
You know, that “why” that function of the behavior was missing in our practice at this point. And so we started, you know, we were collaborating with some BCBAs at that point, and that actually got us thinking that why don’t we, you know, go in this direction and get that certification as well. So both of us got our masters.
Yeah, I did my master’s in special education. And then we went, we did the supervision for BCBA. So basically what Shalini has told, I’ll just add something. Basically when we were OT and we are trained into neuro developmental therapy which is again a certification course from USA.
And then we did our SIPT training—Sensory Integration and Praxis Test—which is again a test to diagnose sensory integration kids with sensory integration issues. What we, again, the OT and BCBA have a common interest is the function of behavior. Yeah. Whether it is in activities of daily living whether it is dressing, whether it’s feeding even sleep.
So we were told, and there is a quote in OT community is “See behavior think sensorimotor”. But there are a lot of factors which goes behind the behavior whether it is the motivation of the child, whether it might be regulation, emotional regulation thing. Again when we became BCBA, we talk of lot of A, B, C antecedent and what are the consequences of that behavior.
We somehow, as a, when we put the OT hat, we were thinking only from the sensorimotor perspective. But when we became BCBA, we thought there are a lot of other variables which affects the child’s behavior on the particular day. And that is where we take data and other, we do other analysis or other behavior analysts, and then we can more or less pinpoint why the behavior is happening.
And based on that, we provide intervention. So that is the difference between wearing two separate hats of BCBA and an OT. And then that, that is where the collaboration part comes in the picture. So we can collaborate and we can think why the behavior is happening from two different professional perspective and then work for the benefit of the child and the family that is.
That makes so much sense. Yeah, cuz every child is so different. So if we’re just looking through our own lens, we will miss some things. You know, maybe one case with that one child is primarily a reinforcement issue or, you know, the consequences behavior’s been reinforced over time. But then maybe for another child we’re looking at it that way and thinking it is that, but it really is a sensory issue.
So yeah, that makes a lot of sense that every child is different. So having both perspectives so valuable.
So that is how Symbiosis from a OT company. Then we had a speech because yeah, a lot of communication also adds on to a behavioral challenges. Then we had a physio joined us too. But yeah we work together and we still collaborate.
And then we added BCBAs and BCs in our team to give a whole spectrum of services which we provide in Symbiosis currently.
And just to add to your point about, you know, what you said about when we look at a child through a particular lens, how things may be different. I’d just like to share a little example here.
No, no names because of confidentiality, of course. But, so I used to work with this little kiddo and diagnosed with ASD you know, going in early elementary school. Behavior wise, not so many issues, like he was doing well in school and everything. Kindergarten, okay. Grade one, okay. Grade two, okay.
Grade three, suddenly he started lashing out at other kids. Like that was the parents’ words. Suddenly lashing out. They don’t know what’s happening. And I was like, this kid has never had, you know, these issues where he would show aggressive behavior. So what’s happening now? So we went in and, you know, did some observations at school and it turned out that this child had auditory sensitivity that people had missed.
So this year three, like grade three in school, they were doing percussion instruments and he hated the noise. And he quickly figured out that if he uses those drumsticks and hitch the kids next to him, he gets sent to the principal office. So it was like, okay, I can escape from this. So, you know, from a behavior aspect, it was like he’s escaping from the task, you know, he’s escaping from the music room, hitting people so he can get sent to the principal’s office.
If people had not looked at the sensor the auditory sensitivity behind, they would’ve said, oh, well, okay, we have to stop this. You know, he’s learning to escape. We have to stop this from happening. But the reality was that just giving him noise canceling headphones changed his whole life over there.
Right. He was back to that sweet little kid who was happy with his friends and, you know, happy making music and everything. Right? So just a little thing there, but if we miss that and we are just thinking that, oh, it’s escape related behavior. You know, it’s, we have, you have to just stop it at the root.
Don’t let him escape because he’s just going to, you know, that behavior’s just getting reinforced and he’ll keep hitting because he knows he can get out of it. Right? So he’s looking at it, things from a different perspective does help often.
That is such a valuable story to illustrate that. And I think you’re so right that we can’t just stop as behavior analysts at what is the function.
There still can be a why are they escaping? Why are they seeking attention? Do they not feel any attachment to anybody in their life or, yeah, is there a sensory issue that they’re escaping from? You know, so the “why” behind it. I think for all functions, like it shouldn’t stop there.
And I think that’s such a great place where OT and behavior analysis can come together because we know the functions of behavior are real and exist but then there might be more deeper. And that’s where we, we don’t have all the answers in behavior analysis and need the other fields to help us with that. That’s a great story. Thank you for sharing that Shalini.
So since you are both OTs I’d really love to hear your perspective on how maybe BCBAs and OTs can better understand each other because I think we often find ourselves working together on teams with funding issues. As you said, we’re not often working maybe at the same time or having a lot of time to collaborate, but the OT could be seeing a child, the BCBA is seeing a child at different times.
There might be some emailing or a bit of phone calls back and forth, but do you have any tips for how we can work together better? But maybe before we get into that, are there any acronyms that you might use frequently? I forgot to ask that.
I think the one is to the SPD, right?
Like, again, starting from BCBA (Board Certified Behavior Analysts). OT is Occupational Therapy. ADL is Activities of Daily Living. SPD is Sensory Processing Disorder. I think
that’s the most common ones, which would come between the two.
Great. I just like to go over that in the beginning sometimes so people know what we’re talking about.
So yeah, do you have any tips on how we can better understand each other, I suppose, as BCBAs and OTs?
I think one of the things which is a hallmark, at least at our practice, is that is respect for each other, respect for all the professions. There used to be a time, you know, when we would hear from BCBAs saying that, oh, you know, the OTs working on this particular thing, and that’s not evidence-based.
Or the OT might say, you know, that the BCBA is stepping on their toes kind of a thing. Right? But I think more and more in the recent years that has sort of gone on the back burner. The focus is on the child. The focus is not on, you know, conflict between the two professions. The focus is more on the child and working together.
And something that we do at Symbiosis is cross referrals. A lot of cross referrals happening. So a child may come to us for behavior services, but if the behavior consultant or the behavior analyst feels that there are some red flags for OT, they would get the OT involved. They would explain to the parents that, let’s get this profession’s input as well, because that might be helpful.
Same way between OT. And so a kid might come to us for OT services and they’re like, you know what? This child is not, they’re coming to learn writing, but they’re not even sitting at the table yet. They’re not ready for it. Let’s get the behavior analyst in order to say, why are they not focusing on the task?
No the “why”, the function of the behavior, right? So if a child has adequate fine motor skills, why are they still not wanting to write or wanting to, you know, why are they not motivated to do certain tasks? So there is a lot of cross referrals happening, you know, between the two professions.
And just understanding the strengths of both, understanding the strength of each other. BCBAs have a huge advantage in the kind of research-based training that they get. You know, how to run programs, how to take data. That’s the, that’s one of a big strengths that we have, which I don’t see so much in the OT field, at least not right now.
And so when we collaborate, we depend on each other for the strengths. So the OT might be running a program, whereas the BCBA has devised a data taking mechanism for that. Right? And so even though it is a OT program, the data is helping the BCBA determine whether this particular program was effective or not.
Oh, that’s a great insight. That’s interesting. Cuz I mean, it’s so special, you can see both fields and strengths in both. Yeah.
Oh yes. Yeah.
And that happens not just with OT and BCBAs, but also like speech and BCBAs, at least within Symbiosis. We’ve had kids where maybe when they first came in the BCBA might think, oh, I want to use specs.
And the speech therapist said, no, touch chat is a better AAC for this child. Right? But communication, you know, that’s like the foundation for everything. They have to talk to each other. They have to, you know, come up with a common solution for the family.
Yeah. There might be few like clinical observations what might we have seen in Symbiosis. So for example when we talk of Activities of Daily Living, so for example, buttoning. There might be some factors of motor skills where the kid might not be able to do buttoning. But then, and there might be some adaptive devices which a kid can use to maybe bigger buttons or something.
And then, because this is more of a community-based activities, which the OT might not be able to do in the clinic, but the BCBA or the behavior interventionists can go to their house and train the kid how to do that and take data off how many times they have done successfully or whether they need assistant or not.
So that is where that collaboration part comes in the picture. Even like we had speech therapist in our clinic where the kid might not be working sitting on a table, but the speech therapist can take the kid to the sensory gym. Maybe sitting in the ball pool and talking about colors, talking about and it is more of a verbal communication part.
So that is where sometimes that collaboration helps.
That’s great. So you could potentially have your behavior interventionists working on some OT goals in the home as well. So that’s helpful cuz it we have that model within behavior analysis of the oversight there.
And that is where we have adopted a model called Early Start Denver Model by Sally Rogers.
That is where that collaboration with among all the professionals comes in. So it can be a BCBA, it can be a OT, it can be a speech therapist, and that is where we see the kid as a whole. And then there are different functional domains like communication. There might be social skills, there might be feeding, there might be sleep there might be dressing and other components into it where we work as a team.
And again, it is age-based and that is one model which works very good in our clinic and which works in a multidisciplinary, it works in a multidisciplinary team approach. And it is easy for the parent to understand that this is how that collaboration among professionals should be.
Yeah. So if somebody wants to do some research in Early Start Denver Model, they can.
Just to add to, like in the ESDM or the Early Start Denver Model, any one person can be leading the team. So it could be that the BCB A is the team leader, so basically they’re doing the assessment, the planning, you know, setting up everything which BCBAs are very so good at, you know, I mean, getting the whole team together and leading them.
Right? But then the actual intervention, it, so the BIs can be running OT goals. The BIs can be running communication goals. There is so much of overlap between the three professions that, you know, it’s very easy to run it like that. It is a program for kids under five. So, kids were in school, we won’t be using that.
It’s a very preschool early, you know, like kindergarten based program. But yeah, I mean the activities are run in such a way that you are not even taking data every second or every minute. It’s like broken into chunks and very natural environment-based basically. So not so much of like, you know, those discreet trial teaching, but more of natural environment-based models.
And I like that you mentioned that it kind of sets a tone. Like if that’s, you know, one of the tools you use for your early intervention clients, then your OTs, BCBAs, other staff are kind of thinking in that way of like, we work together, this is how we do it. So we will also do the same for our school-aged children. So that sets a nice tone.
And that is not the only model which we use in Symbiosis like we also have BCBAs who are traditionally trained in ABA. We have some OTs who are more inclined towards sensory-based activities. So that is where they teach each other. We have a lot of workshops where that collaboration part comes in where they discuss about two different professionals sitting where having two different lenses, but they’re seeing the same child.
Then they make plans and then they discuss the intervention of which is the best thing to do at that particular time. And then as a team, we discuss with the parent. So it is more of a evidence-based based on different professionals point of view, but which works for the kid as a whole.
Would you say some of those areas where there is overlap between those fields, like you’ve mentioned, Activities of Daily Living and sensory challenges. Are there any other common areas where you see overlap between OT and BCBA?
Handwriting, especially if the kid is going to school. Handwriting is one of the biggest or common areas where BCBAs might teach writing in a different way.
But the OT might have foundations of sensory motor skills of where are the challenges that it is facing. Different type of grips, different type of biomechanical principles, which is used in writing.
So just to add to that, like as an example. When we learn letters in school, we learn from A to Z, right?
I mean, you go to any preschool, any kindergarten, they’ll be starting from the first week is letter A and the next week is letter B. And whether you’re doing the sounds or the writing, we go from A to Z. That’s just traditional. When OTs are teaching writing, they don’t do that. They go developmentally.
So developmentally, you learn the horizontal and vertical strokes first. So when kids who have, like, we have two boys and one of them, the name starts with a letter S, and the other one, the name starts with a letter T. Our son, whose name starts with a letter S, had a hard time writing his name because S is like one of the last letters you learned writing.
And first week of school, they’re expecting, you know, kids to be able to start writing their names. Like, S – how do I make it? It’s like so messy. The younger one, we are like, oh yes, let’s go developmental. His name starts with T. It was like so easy for him to write his name. So even like when we are working with kids in our clinic, if a BCBA says that, you know, we are gonna put putting a printing program in place, we’ll add the OTPs to that to say, don’t start with A.
Let’s start with letters like, you know, upper case E and H and T and I, which the child is gonna have success at, rather than starting with their name starts with B and we are going B and they’re not gonna be able to do curves right now when they can’t even do so, right? So, you know, collaborating, they’re putting the OT developmental piece into the BCBA program and helping the…
Even OTs do a lot of assessments on visual perception skills where that letter reversal comes in the picture.
So some kid might be able to master writing S but sometimes they’re like, it is a reverse. So it, it becomes two. So that is where the OT comes in the picture and say, yes, he has that skill, but there might be some visual motor integration factors, which the OT can do an assessment and figure out what can be the next step to that.
And they do some visual motor activities during the OT sessions, and then they come back, collaborate with BCBA, and then they practice more on writing S.
Oh, interesting. Oh, that’s helpful. That’s helpful to know those two areas I think, that are maybe in, in my mind, like less common to go to. Like, I think sensory right off the bat and ADL, but yeah not necessarily the handwriting.
And I think, I mean also to add to the areas of overlap, I mean, social skills I find is a area which is like across professions. I mean, we have, we find speech therapists running social skill groups. We find OTs running social skills groups. We also have, you know, behavior consultants running social skills groups.
So I think they’re all working on social skills in their own ways and their own, you know, using their own strengths. A social skill group run by a OT might be more focused on sensory motor activities, but they’re still working on social skills. While they’re the look of that whole you know, camp or ACT group would be very different, whereas a speech therapist might be having it more communication-based activities.
Right? But again, they’re still working on social skills. That’s what the areas which is all three professions are working in.
Yeah, that’s helpful to think about, you know, that it’s, it doesn’t belong to one profession, like, especially something like social skills. There’s like different angles to look at it and different lenses to, to view those skill sets.
Something else I wanted to touch on was areas that might be a little bit controversial between OT and behavioral analysis in particular. But for the focus and purpose of giving tools to OTs and BCBAs when they’re on a team or sitting down on a table and maybe met with some resistance on either side.
So, I guess, can you mention, are there any areas that are sometimes difficult to navigate between occupational therapy and behavior analysis?
I think one of the most common one that we hear is the sensory integration piece. And I think at least what I feel the reason for that is because a lot of behavior analyst literature or the teachings feel that sensory integration is not evidence-based.
We were talking earlier about, you know, the STAR Foundation out in the States. It was so much research on sensory integration, right? So there is a huge, I mean, and that’s not the only place where we have research literature on sensory integration. There’s a huge bank of literature on sensory integration available.
The reason why a lot of behavior consultants feel that it’s not evidence-based is because maybe their research was not formatted in the same way that the BCBA is doing. Maybe their way of doing the research is a little bit different, but also when behavior analysts are using sensory strategies in trying to see whether it works or not.
I don’t know how to put this nicely, but very clearly. Let’s say you have a child, right, who has a difficulty and you are trying to figure out why. If we just put a sensory strategy in place, it may or may not work because that child may not have a sensory processing issue. So if a child doesn’t have a sensory processing issue and we give them, let’s say a pressure vest or a weighted vest or, you know, one of those modalities out there, and then we say, Nope, that didn’t work.
So sensory integration doesn’t work. So the problem there was not that whether that sensory strategy would work or not. The problem was did the child even need that strategy? Maybe the child was doing something for attention. Maybe the child was doing something for getting his point across, you know, trying to communicate.
He wasn’t running around the room because he has a sensory processing issue, you know, with Proprioception or vestibular system and things like that. But if the research was done trying to give him a weighted vest or a pressure rest, wouldn’t work because that wasn’t the function of the problem. So when we do research like that, if we don’t know the function and we are trying to put a strategy in place, it’s like my professor in Penn State used to say, “If you throw spaghetti at the wall, some is going to stick, some is not.”
Right? So research should be like that. And that’s where I feel, you know, that conflict comes. So what I would like to say to anybody, you know, who’s concerned about sensory integration being evidence-based or not, is to look at the OT research. You know, look at research like the American Association of OTs.
They have their journals, the AJOT (American Journal of Occupational Therapy). Look at other developmental disabilities type of research-based where OTs have, you know, put research in there. So you would find research on sensory integration there. The flip side to that is OT is feeling, you know, if they go back to the start of where ABA came, you know, the lowest method and stuff like that, and they say that, oh no, ABA is very strict and it’s not accepting kids like the way we are supposed to be.
It’s not neurodiversity affirming and things like that. ABA has come a long way from where, you know, LOAs initially started all those methods to where we are now where we are using natural environment-based techniques. Where we have ESDM like models, which are ABA, you know, they have ABA in the route of how they are teaching strategies.
But if OTs feel that, oh no BCBAs only do discrete trial. They only do position teaching. So we need to be more aware of each other’s professions and respect that. And that’s where, you know, collaboration will come. Otherwise that conflict of sensory integration versus, you know, oh no, BCBAs are only using reinforces and punishments that will always stay.
The other aspect of, like, when we’re talking of sensory processing. So for example, we take a equipment of suspended equipment like a swing. OT might have different activities they can do on a swing. And there are different components of how you use a swing, whether it is fast moving swing, whether it is slow moving swing, whether it is a hammock swing, whether it is one anchored swing.
There are some rotational components. There are some linear components of a swing depending on how the child is regulated during that time. So there has to be a pre and post therapy. Maybe a data taken by a OT, which might not be taken into consideration by a BCBA because they are not ideally trained to do sensory integration.
So even a lot of OTs might use the term sensory integration. But my question is, are they properly trained to use sensory integration therapy, first of all? If they’re not trained as an OT, then they might not be using it properly. And there are so many things, like even proprioception. There are different components like weighted invest.
There might be a lycra. There might be a hug vest. There are a lot of strategies to use proprioception, so you cannot or generalize the term that sensory integration doesn’t work. It has to be customized based on the child and how much training the OT have or how much training does the BCBA have.
And I think someone brought up this very good point about OTs being trained in sensory integration. Not all OTs are trained in sensory integration. We are taught about it as part of our curriculum. Yes. But there is specialized training, specialized certification that needs, you know, that you, whether it is the SCERTS or it is, you know, the SPD Foundation or other certificate and other courses.
It’s just like, you know, when we are doing BCBA or getting, you know, our certification as a BCBA, we learn about feeding, we learn about sleeping, but not all BCBAs work on sleep. Not all BCBAs work on feeding, like me as a BCBA, I know maybe feeding is not my passion. So I would work with kids on feeding issues, but I don’t have like extra special training in that.
And so I would rather, if I get a kid for feeding, you know, issues, I would rather refer to somebody else in my clinic who’s, who has more of expertise in that. So again, same with OTs. Not everybody’s trained in sensory integration. Not everybody’s standard on neurodevelopmental therapy. So it depends on what approach they’re coming.
Can I ask how does… A term I’ve heard a lot recently as well as interoception, and I feel like that’s being spoken a lot about, more so in the OT community, it sounds. But also, know, I think BCBAs are kind of getting wind of this and learning a little bit more. You know, Kelly Mahler, there’s podcasts out there and such.
Are all OTs trained in understanding interoception and kind of how does that fit into your work?
It is upcoming research. Interoception is a very new term in sensory integration. It is basically the eighth component of sensory sensory integration skills. So basically it is more about, we have lot of internal organs in our body.
Say for example I would just say a parent might come to us and say, oh, my kid doesn’t feel full, and he just keeps on cobbling food and then he eats so much that sometimes he has to throw up. So that is that feedback feeling of fullness, which is sent by the stomach or some other internal organs to have that feeling of fulfill, like my stomach is full, now you have to stop.
That is part of interoception in a demand stem. But there is a lot of research going on. It’s not so easy because sometimes those things are not observable. So there might be some other specialized equipments they’re using to do that.
So the OT curriculum right now at the masters, you know, masters in OT level, it does include stuff about sensory integration or sensory processing, I would say.
So in school, you know, we learn about, like when we are kids in school, elementary and secondary, we learn about the five senses. You know, the touch, taste, smell, et cetera. The OTs learn about, used to learn about seven senses. So they would include proprioception, which is the sense that comes to us from our, you know, muscles and joints. And the vestibular system, which is or the sensation, which is more about the balance coming from our inner ear.
And now in the last year, last couple of years, interoception is getting added on, you know, the feelings that we are getting from inside our body. Whether it is the feeling of fullness, you know, after a meal whether it is a need to avoid, know, bladder or bowel movement, right? There are some kids that we work with where we are trying everything we can, you know, putting toilet training programs and place, et cetera, et cetera, and the child doesn’t realize when they need to go, you know, empty the bladder.
And so why are they not getting that feeling from inside? So that’s a very upcoming field. So very new to both the BCBAs and the OTs. Like, there’s not huge amounts of research right now in there. But yeah, they are learning about it.
But something to be taken into consideration while seeing the chat whether it is solid training, whether it is feeding, feeding issues, that is one of the components which we might be missing. But that should be taken into consideration.
And is it so new that there are very few OTs that are like certified or, you know, considered competent in this area? Like if you think, you know, as a behavior analyst, do you have a client that might benefit from an OT, from OT services in that, specifically in regard to interoception?
Are there many OTs out there who know quite a bit about it? Or not quite yet?
I would say it’s like a mix because it’s not that interoception wasn’t there in the human body before. It’s just that they started, starting it more now. Sensory integration from the way OTs are taught is a very neurological based process.
It’s happening at the brain level. And interoception is happening there as well. So it, they believe that all the sensors are working together to give us a map of, you know, where we are in space and how we use our body. And interoception is part of that. So, I mean, theoretically speaking, somebody who knows sensory integration should be able to work with interoception. But I use the qualifying word theoretically there, because practically people are still, you know, getting there.
Yeah. Nobody will be trained into one specific sensation. That is why it’s for sensory integration. So there might be some sensory integration. The kid might be doing some intervention and might be the component of toilet training might be impacted with that particular training.
And then you will see results in toilet training too. But specifically training in interoception, I don’t think anybody is doing that. Yeah. Or any of the sensors, like nobody is trained into swings like, oh, how to use swings in tactile or just tactile. Like nobody is doing tactile sensory integration, so called.
No. It’s part of all the sensors working together and how it is affecting the kids’ function.
Okay. That totally makes sense. So it’s any OT who is especially trained in sensory integration processing is now kind of amalgamating this new information and synthesizing that with what they already know. Okay. Got it.
Okay, great. We spoke just now a little bit about areas of overlap. And so I just wanted to ask, are there, you know, I could list off a few different, say, podcasts within behavior analysis. But in terms of occupational therapy, cuz it’s an area that I’m less familiar with, are there some good resources?
I mean, Shalini, you mentioned like digging into the research, you mentioned a journal. Are there any other resources you can think of that are helpful for behavior and analyst, maybe?
I think the SPD Foundation that we mentioned earlier, Dr. Lucy Jane Miller’s work out in Denver. They have tons of research, you know, available there, out of their foundation. In Canada we have CanChild.
Yeah. So CanChild is an initiative started on the East Coast. And they have a lot of work on the motor aspects like developmental coordination disorder and things like that. Which can be concomitant, you know, with children with ASD as well, like it could be a diagnosis which is happening with children with ASD as well who have motor issues.
So CanChild out on the East Coast in Canada has a lot of research as well. There’s a book that I really love, it’s called Raising a Sensory Smart Child. It was meant for parents and but a lot of professionals like that too. It talks about how in general life situations you can use, I wouldn’t say sensory integration strategies, but sensory rich environments.
And so how a sensory rich environment gives a child more chances to develop their sensory systems, which leads to, you know, better outcomes, eventually. And I think something else that Sumanta had wrote down here is in the, we were talking about the Early Start Denver Model, earlier. They have a parent handbook.
It’s called an An Early Start for Your Child with Autism. Right? Yeah. So the ESDM parent handbook is how we know it. That has a lot of information for parents as well as for people who are new in the profession I find. Like, you know, we get BCBAs, we get OTs straight from school and they’re learning how to work with children, you know, independently now or maybe under supervision for the first few months.
And that book, even though it’s written for parents, it actually gives even our clinicians so many ideas of how to work with kids where you’re overlapping goals, where you are, you know, working on more than one area at one.
Yeah, that’s great. Well, that’s helpful. Cause I think just having some simple things to go to for people working in behavior analysis to better understand OT could be really helpful.
Have you found I guess from your OTs, anything that’s been really helpful for them, learning more about behavior analysis?
I think a lot of it comes from, you know, I used to do a lot of courses on the ACT website Autism Community Training. They have like so many things like, you know, the toilet training videos, from Pat Mirenda and feeding issues. I mean so much is there not just the actual trainings that are happening, but also they have a whole bank of videos and other training materials out there. And that actually helped me understand a lot about how the BCBAs work. We were fortunate that one of our ESDM trainers she’s a speech, she has a speech therapy background, which she’s also a BCBA.
And she is an ESDM trainer and so she was my supervisor. And I mean, just talking to her and finding out, you know, about her experiences as a dual certified professional in the field it helped us, you know, go such a long way in making our own practices more inclusive, I would say.
Yeah. I mean that is incredible, actually, that you have that multidisciplinary opportunity.
I’m sure they learned so much, yeah, just from working together on teams. They, you know, it’s more people where they’re not in a multidisciplinary environment, I guess, where you have to seek out some external. So, that’s great. Thank you for those resources though. That’s really helpful. So I can list that in the show notes.
So we chatted a little bit about, you know, what is evidence-based and I think the hard thing with that phrase is that it means something different to every field. You know, if you go to Google and like look at what that means in medicine versus occupational therapy versus behavioral analysis versus speech, you know, all these different fields, there’s different thresholds that each field has decided.
You know, first of all, their research base is different. You know, we use a lot of single subject research, design and behavior analysis, whereas others use randomized control trials. And so each has a number, we need X number of RCTs and then also X number of replications for it to be evidence-based or approaching evidence-based or whatever it may be.
So that’s very difficult to kind of pinpoint cuz you know, all these fields could be saying, this is evidence from our field, but the other may not see it that way. So I suppose, do you have any advice for when professionals are in tricky situations where maybe they’re in that situation where someone is saying, that’s not evidence-based. But then this might be more of a soft skills question, but yeah any ways to navigate those moments that can be kind of challenging?
Sure. We’ve actually just talking about something similar this morning. So I’ll use an example from a different field altogether here to give you an idea of, you know, how people think. So let’s say a person has a fever, right?
In my home, we’ll go to Tylenol or Advil. You have a fever, take Tylenol or Advil. I mean, I come from a background where, you know, in the family there are doctors and stuff, and that’s what we know how to do. My friend comes from a background of Ayurveda. And so in her family, if they have a fever, they’re not gonna go to Advil and Tylenol, they’re gonna take some Ayurvedic herb, which is gonna bring the temperature down, right?
Another person might believe in homeopathic medicine and they might take the homeopathic medicine to bring the fever down. The purpose is still the same to address the fever that is in the body, right? But allopathic medicine, homeopathic and Ayurvedic all have different research bases. They all have found things that would work.
It depends on what the individual believes in at that point. So like you said, we have very different ways of doing research between OTs and BCBAs or even speech therapists. Right? And so what is evidence-based to me as a BCBA may not be evidence-based to another person, as a OT may not be evidence-based to another person as, you know, a speech therapist.
So my recommendation or my you know, suggestion to people, especially when they’re new in the field and they don’t know how to navigate this, is to start with a feeling of trust. If the OT is telling you from their background, you know, their research background that this thing works, give them the benefit of doubt.
Don’t go out saying that this is not gonna work. And the same thing for OTs. If a behavior consultant is putting a behavior change program in place, they have research to back it. You know, they are not gonna just throw things out there at the child and assume that this will work. They have research that’s going back it.
So come with a feeling of trust to the table. You know, bring trust to the table and then go from there. If you have questions, you can still ask respectfully. You know, you can say that, Hey, you know, my literature says that this might work. Your literature is saying this. What shall we do? Try to come to a consensus.
I mean, even in our own team, though we are multidisciplinary, we have had it, you know, here. And there are odd cases where maybe the two are coming, the two professions are coming at the same child with different perspectives and different methods to apply. Now the question becomes, which method do we apply then?
Because we can’t apply both at the same time, especially if they’re going to be anti what the other one is doing. For example, with that kid, you know, that we were talking about escaping from the classroom because of the loud noise. If the BC is saying that, no, we are going to stop escape. And the OT is saying, let the child escape because the sense is too much for him. That’s not gonna work, right?
So then we have to find a midpoint. We have to find a place to, you know, compromise. No, compromise is not the right word there. But to come to a consensus about, you know, okay, what are we going to do? And if at the end of it, we still cannot come to a consensus there, get the parents involved. After all they’re working with the child. The parent is the final say into, you know, what they’re gonna do.
And let’s say if the parent decides one over the other, then support the other professional in implementing that program. So let’s say if the parent had said that, yes, noise canceling headphones, the BCBA has a very strong method of taking data. Take data and see whether that works or not. And if it doesn’t work, then come back to the drawing board, come up with other answers.
So I think that trust and respect for the other professional, if we can bring that to the table to our discussions, that would go a long way in understanding, you know, whether the other person, what they are saying when they’re saying that is evidence-based, how are they coming to that?
Being open-minded, being curious. You know, I read articles on, I’m not a speech therapist, but I like to read articles on AACs just to understand what’s happening in the field. You know, there’s so many new things coming up. So be curious, you know, be open-minded about that and learn from them.
Yeah, no, and I think all the professions, whether it is speech or BCBA or OTs, they have different educational backgrounds.
Based on that, where they are going for their education, they have their own research while they’re teaching. And there might be some researchers in OT as well as BCBA. They might have different ways of doing research. The other thing is depending on or contradicting each other, why don’t you collaborate and complement each other’s services?
Like say for example feeding. There might be lot of swallowing issues. There might be some tactile issues related to feeding. There might be some escape things from a behavior point of view. There are so many components in feeding. It is not under the purview of one particular professional to do everything.
So why don’t you divide the feeding into different components and see from different lenses of different professional background on education. And then come to a consensus that, oh, let’s try this first based on the priority, whether it might be tactile issues. A kid might not touch a food rather than putting it in the mouth where he might, again, have some oral issues.
Even if they put it in the mouth, there might be some swallowing issues, which might be taken care of by Speech Therapist so feeding itself has almost 32 components before even the kid starts taking the food in their mouth. It starts with the smell. There might be a issue with the food, like the smell, so that might be some sensory components.
So first, figure out those components, which are so many variables in feeding that one professional cannot take care of that. So we would rather collaborate with professionals who are specialized in that, rather than going into my particular professional’s research that, oh, this is not working. It will take tons of years to do that and that might not be productive for the kid.
That’s a great example. I really like that. And you know, in a sense, what I hear from that too is it kind of takes the pressure off. You know, like if you, we don’t need to, everybody doesn’t need to be the hero for every single behavior concern or that like is seemingly behavior related. Because not everything will be a hundred percent behavior related.
There will be other aspects and I think…
Oh, yeah. There are so many components and again, I like the term Activities of Daily Living. Starting from a kid getting up from the bed till he goes to the bed in the night. There are so many components starting from brushing, starting from dressing, starting from going to schools noise in the gym.
There might be social skills. They are all taken care of by different professionals, but you should have expertise in one particular component and leave the other one to the other professional. And see the child as a whole and work on their functions. So for example, dressing. There might be some textual issues of different kind of textures of the clothes.
There might be buttoning issues, there might be inside out challenges of the kid. They don’t know which one is inside, which one is outside. There might be a label in the collar which might be affecting the kid. But that whole component affects the function of the kid and it affects the self-regulatory part of the kid.
It affects the emotional regulation. All professionals can jump in and say, oh, this is what is our expertise, but will it help the kid in the long run? No, it will not. So you have to prioritize what is the goal. You have to have, you have to talk to the parent. Even you have to talk to the kid if they’re verbal and they can communicate what are the needs. And then decide what is the right fit.
Just to add to that I really like what you said earlier, Erika, about everybody not having to be the hero for every single child. Because like, you know, something that we often do and we do it at Symbiosis, but I’m sure people can do it, you know, outside as well.
Whether they have a multidisciplinary practice or not, is reaching out to other professionals when you’re stuck. Going back to this example of feeding that we are talking earlier, we have OTs who are trained in feeding. We have speech therapists who are trained in feeding. So we had a OT talking to a behavior consultant recently at our clinic saying that this kid came to us because he was gagging at food.
And so we’ve come to that point where, well, now he can take textures, but he’s still not eating, you know, a meal with his family, so we don’t really know what’s happening. And then the BCBA came in and figured out, well, it’s more of, you know, that habit development that the child knows he can get away with eating chicken nuggets and fried fish every day.
Why would he want to eat vegetables and rice? Right? So you have to slowly introduce, you know, the other foods back. And so it was more of a behavior component there, but the child was used to a particular way of doing things and didn’t want to change. You know, it had no motivation to change. The parents had no motivation to change at that point because it was easy, you know, not to get into a fight about food every and let the child eat, you know, what, whatever they’re used to eating.
But if we hadn’t enrolled the behavior consultant there, the OT would’ve been thinking, well, I’ve done my job. In my session, the child is eating. But when he goes back home, he’s not eating. Now I don’t know what to do. That would’ve been like a failure for the child because he’s not succeeding, you know, in, in reaching his goal.
But having the behavior consultant involved there helped to transition that piece to the home environment and make sure that the child actually got the nutrition that the child needed. It’s really important to, you know, bank on each other’s strengths over there. See how the two can help each other rather than trying to either pull each other down or not, you know, not trusting what we are seeing them.
I would just like to add something like when we are talking of behavior or function lot of it depends on the context and the environment. Lot like we are fortunate that we are doing clinic based as well as community based. A lot of BCBAs might only have access to the client’s house or client’s school.
There are a lot of environmental factors, lot of environmental variables. There might be other factors which might be affecting the kids’ function that particular day. So if I see from a BC point of view, we do that ABA, APC analysis, which the OT might not be well trained to do that. They might be thinking from sensory motor perspective or they might be thinking from sensory lenses.
But tapping on each other’s strength is very useful. And again, if the BCBA is going for a community-based or a home-based setting, then they can always give a feedback to the OT who is only doing the intervention in a clinic setting. That, oh, this is working in the clinic, or may not work in the clinic, but at home the behavior is totally different.
The function is totally different. It might be feeding. The kid might not be eating sitting on a table, but the kid might be doing something, say for example, watching something or sitting with their friends to eat and they’re totally fine. So, environmental context is very much important. So, and again, the other flip side that the BCBA is seeing something at home because the kid is the boss at home and one find that the kid doesn’t want to do anything, and there might be some escape behavior or something. But in the clinic, because they cannot control the whole environment, they’re performing well.
So sometimes you have to see where, like what is the context and where that behavior is happening. So that is looking at the bigger picture and even communicating. Communication among all professionals is very important. Whether it is professionals, whether it is teachers, even the BI behavior interventionists, even the therapy assistant. OT might be more knowledgeable, but maybe the person who is the kid is working better with the therapy assistant.
So therapy assistant might give a lot of insight of what is happening during the, on a day-to-day basis. Or the BI, the BC might BCBA might make a plan, but the intervention is carried forward by a BI. So getting to know the BI, what is their feedback. So it is more of a team approach, is very important to figure out what is the issue.
So again, it is not conflicting among professionals ethics research. It’s more about what works for the kid and the family. And we work towards that as a team. That is what we would like to tell all the audience of your podcast.
Yeah. I love that. Just like that individual focus, like it needs to be so individualized. And in some cases someone will take more of a lead or have more insight because it’s relevant to the case. Another case, someone might have more insight there. Because I wonder in OT, in your training, well, I guess what I should say first is I think sometimes in behavior analysis training, we are taught that, you know, behavior is behavior.
You can treat any behavior, and I don’t know if that’s explicitly said, I can’t say for certain, you know, every program is different. But I think there’s this undertone there that like, you should now be ready to treat anything. And you know, of course if you’re going like way out of your competency into something totally new, you need supervision and such, like that is taught as well.
But do you get that undertone in OT that like you should be able to do it all?
They do, but do it all in terms of the OT areas, so, right. You know, when you say occupational therapy, we are talking about a person’s occupation. So whether it is their work, whether it is their play or it is, you know, their activities of daily living.
So as long as it is something skill-based, yeah, OTs are expected to do. But like, for example, we can talk about, I have been in the pediatrics field for so many years, and my focus has primarily been the early elementary kids. So if you ask me to work with a 17, 18 year old kid, I would probably have to get some extra training or, you know, refer them elsewhere.
Yes, as a BCBA, I’m expected to work with everybody, but I don’t have. And same as a OT, you know, I mean, I, because I don’t work with the, with that particular population so much, my expertise may not be in that area. But yeah, when we come out from school, we are expected to know because the training is such that we are trained in, you know, the, like someone was saying, the anatomy, the physiology, you know, the biomechanics part.
Every single disorder could be out there. We are trained in all these aspects, right? Like from physiology to anatomy, to biomechanics, et cetera. Now, whether you are working with a let’s say if you’re talking about a motor concept, whether you’re working with a adult with a fractured hand or a child with a fractured hand, the therapy is gonna be the same, or at least along the similar lines.
The function is different because it affects adults’ work, whereas it affects a child’s ability to write and play, right? So the activities you might use, so the expectation is that an OT who’s graduating out of school should be able to work with any population. The reality is that when they get into jobs, they get a lot of on-job supervision, a lot of on-job training.
So that, let’s say if somebody comes to our clinic, they will be specializing in pediatrics, you know, while they’re with us. If they’re working with adult, you know, say elderly home, the residential homes, they will be trained more in, you know, doing work with them, with that particular population, whether it’s the transfers, whether it’s skill training, whether it’s, you know, equipment recommendations and stuff.
Right? But just like with the BCBAs, the expectation is that you have your BCBAs certificate, now go, you know, you’re out there and you can do anything. Same with the OTs as well.
Again, I think the component is when you come out from the school or when you get a BCBA certification, you get training in all the components.
But eventually, once you’re in the field as an OT or as a BCBA, you should have some specialized training, some certification based on what is your niche or what you want to be expertise in. You don’t want to dig or put hands in each and everything, but you don’t master anything. And again, alls OTs might not be trained in sensory integration, but it is expectation from the general public or from other professionals that because he’s a OT, he might have specialized in sensory integration or he might be an expert in handwriting, but that is not the case.
You should dig into more into the training and even their expertise, what the OT specializes in. And then you approach that OT. All OTs are not in sensory integration. All OTs are not experts. Same as BCBAs. All BCBAs might not be able to do toilet training. All BCBAs are in British Columbia.
All behavior consultants are not BCBAs. They might only have some experience doing behavior consultation, but they might not be certified. So the code of ethics for these behavior consultants in general in British Columbia might not be applicable what is applicable to a board certified behavior analyst.
So there are components which the parent have to do their own homework of who is the right fit for the kid. And all kids with autism doesn’t have the similar challenges. So you have to see what is the challenge my kid is facing. And based on that, you do your own research. It might take time because it might, all BCBAs may promote that they specialize in this particular field, but the parent have to do their own due diligence. And then get in and get the services from that particular professions, whether it is speech specialist, whether it is feeding, whether it is toileting.
So they have to dig more into the professional qualification and the skills of the BCBAs or OTs or even speech therapists.
And just to add to that a little bit. So, I was at this autism conference in Pennsylvania when I was doing my master’s in education from there. And I had the honor of meeting Dr. Iwata there. He is like very well known, right? I mean, so many research articles. So much research design happening there. And he said something which resonated with me so much. He encouraged everybody in that auditorium to go to the DSM-5. I mean, we still have the DSM-5 at that time, the DSM-4, 5.
Yeah. And he’s like, go in there. And every single diagnosis of BCBA should be able to work. We should, that should be the goal for the profession as a whole. That every single diagnosis in the DSM-5, which talks about, you know, all the psychiatric, psychological issues. A BCBA should be able to work.
You know, there should be a BCBA associated, that there should be research for. I was like, that’s a huge lofty goal for the profession as a whole to be able to work with every single diagnosis. It’s a beautiful goal to have. As an individual, we have to recognize our limitations there. Just because the BCBA field says that working, they can work with inmates in prisons doesn’t mean me at Symbiosis, I have the qualification or the experience to be able to work with inmates in prisons, right, and similarly.
And that reflects on the OT profession as well. Sending us out there with a masters in occupational therapy saying that, okay, you are certified, you have your license, go and work… is not enough. We need to constantly keep developing our skills and understand our limitations as well. This is, if this is the area where maybe I’m not so strong at, what can I do to get better at it? Either I improve or I refer where, you know, we can’t give half big services to the clients. That’s just not acceptable. Yes. Yeah.
Like even with OTs, there are some specialization, like some OTs might be better equipped to work in a center for child development or some might be only, only can provide services to school-aged kids. Some might be working in ICU that unit in intensive care unit. Some might be able to work with in BC Children’s especially in acute care settings.
So if they want to transition, they should have that particular training to do that. So, for example, a kid who is working BC Children’s and they switch their jobs to work in a school district, they have to have appropriate training to do that and see the kids. Because the work environment, the work facility, even the working model is different.
Some might be intensive therapy, some might be just a consultative therapy and some might be just maintenance. So depending on what the OT wants to do, they should have good training in that. And that applies to BCBAs too, depending on what setting they’re working.
Yeah, that’s helpful to know about the kind of the messaging in OT as well. It’s the same model of, you know, supervision to expand your competence.
Is there discussion within, I guess the last thing I’ll say is, you know, in behavior analysis right now there’s talk about subspecialties. And making that a little more official and certifications within that. Even talk of a more medical model when you’re in school training, you’re doing like in med school rotations in different areas.
Is there any discussion or how is it in OT? Like, is, do you have that medical model where you do a rotation in feeding or rotation in?
Yeah, there are clinical placements. So for example, in all the universities like we, we accept some cases from some to study students for their field work from UBC University of British Columbia.
And that is all across the world. They have to do some clinical placements where they get the theoretical aspects from the university or from the school they’re graduating. But the practical experts, they go to the clinics or a community setting, where they get mentorship from experienced OTs, and they see hands on how the treatment is being done.
Yeah. So, so the way it is set across, at least in Canada, is that you have from Level 1 to Level 3 placements and Level 12 placement is like somebody’s just into the OT school and they send them out for a couple of weeks. You know, either two hospitals, or clinics, or you know, wherever OTs are basically.
And they will reach out and put them there to see how OTs work in that particular setting. Whereas as, and then you go up to level one, level two, level three B, the last placement is where they are almost independent. So, well, technically they cannot be independent because they’re not OT yet, so they have a OT supervising them, but they are doing the assessments.
They’re running the programs under the supervision of a qualified OT so that when they get out, then they’ve already learned all these things. So they do have, you know, a rotations. And most students like to get placements, like, it’s not mandatory, but most students like to get placements in different aspects.
So they might get one in a, you know, working with the adults population. They might get one with the kids. They might get one in acute care, one in community kind of thing, out of the four, five placements that they have. Just so that they can get a broader experience of, you know, what is happening out in the OT field.
So then they can make their decision about which line they want to, you know, specialize in or work in where they’re passion lies, right? You compare that with the behavior analysts feel. At least the way we have, the way we have junior behavior consultants, you know, who are working towards a BCBA certification or, you know, becoming board certified behavior analysts if they’re working with kids, all their thousands of experience with only kids, right?
So I think, I mean, moving to that kind of a model where BCs, the behavior consultants have more exposure to different things would probably help. I feel that at least they could see what other things are happening out there, right? There’s OBM or there’s, you know, other things which we learn theoretically, but we never have chances to implement unless somebody takes a job in that area and then goes into that.
Yeah I totally agree with you. And I think that would actually allow, that would probably provide a better foundation for multidisciplinary collaboration. Because chances are, if you’re doing six rotations, shorter maybe than, you know, what we would do with our fields are, you know, 2000 hours of field work now. Short, but maybe more intensive.
And that variety I think could be so, so good. Cuz if you do your, all your 2000 hours or even two placements between the 2000 hours, you may not rub shoulders with other professionals very much. Or only one type of professional that entire time versus doing, you know, a few hundred hours in many areas. So that’s interesting.
Because right now for our field as behavior consultants it’s left to us to decide how we want to structure those 2000 hours. So I do have you know, interns at Symbiosis where they’re working towards their, you know, BCBA qualifications and they’re occurring all these experience hours, but they may not be doing all of it with us.
So they might be doing 50% with us, and then they’re doing the other 50% at a school, you know, in a school setting. So they’re learning to work with teachers and parents and other things over there. Or they might be doing a little bit in, in a different setting where at least they get some other exposure apart from just children with autism.
But also, I mean, since we are talking about the Lower Mainland and British Columbia, the way the funding is here most BCBAs work with children with autism. We don’t really have BCBAs working with children with, let’s say ADHD or Down Syndrome or anywhere else where they might have behavior issues, but there is no funding for those kinds of services.
And so because the work eventually is in the field where you’re linked with children with autism is why a lot of people are doing their, you know, supervision hours, their experience hours in the field work with children with autism as well.
There a lot of BCBAs who are working in school districts, not in all school districts.
Yeah. So that is where some things needs to, yeah, all school districts should hire BCBAs. Or even, even OTs and SLPs. Yeah. We need more in the workforce. That is the place where the kid is spending most of their time.
And, and that is where you also do end up working outside of the field of autism. Like you get everything that, or, you know, some of our organizations like possibilities or sources. You might get some referrals outside of autism. But yeah, you’re right. It’s not as common, that’s for sure.
The last thing I wanted to ask is, do you just have any final, like parting advice for BCBAs or OTs when working together?
I mean we’ve touched about that before. But just to reiterate, because that’s such a, the thing which is really close to my heart about the communication and the trust between the professions, you know, just respecting each other. I did my masters in education from Penn State, like I said, and nowhere in the course did they put any other profession down.
So when we come out and start practicing, we shouldn’t be doing that. Same thing with my my degree in OT. I mean, I have my degrees, both my degrees in OT from India, but anywhere in that coursework, they did not say that, oh, a speech therapist is not working, or a BC is not working and you are the best.
You are not the hero. So when we are taught to respect other people, somewhere down the line when we are working, that starts disappearing. Yeah. It could be because of the funding models. It could be because of that feeling that we really want to do the best for our kids, and we believe so strongly in our way of working that it’s not leaving us open to other ideas.
So maybe just opening up your mind a little bit, giving the other person a chance and listening, actively listening to what they’re saying. And if that helps your child, then let’s advocate for that. You know, if a parent is not convinced that a BCBA is required, but the OT feels that they are, let’s work with the parents and help them, you know, encourage them to get that service in.
And same way for the others. You know, where if a BC is working with the child and they feel that a OT is required, let’s advocate with the parents to get the OT involved and get those services going. Rather than thinking that, Nope, it’s okay, we’ll just handle everything at our end. It’s just gonna become too much.
You know, no one person can do everything, so let’s work together.
That, that is why our company’s name is Symbiosis Pediatric Therapy, where we have to work together to, and our main focus should be the kids and the family, rather than different professional research or expertise or skills. We have to see who is the right fit, which professionals should work with the kid based on what challenges the kid is facing.
And then let them take the lead and collaborate with other professionals who can always give the input. So that is where you have to come together and help the kid who is having lot of difficulties in day-to-day life. Once we see the bigger picture, I think things will be more clearer rather than having a micromanaging perspective of what is.
And again, all professionals have limitations, all professionals have strengths. So why not tap on each other’s strength and see who is, like BCBAs do lot of research, lot of data taking. OTs might have some expertise or better equipped to do sensory motor assessments. There might be optometrist who might be expertise in visual motor skills.
There might be audiologists who are focusing on auditory processing. There might be lot of other even medical professionals. Why not collaborate with them and see there might be some medical background based on the behavior issues. So my takeaway word is collaborate and look at the bigger picture. And then you’ll see the kid as a whole.
I love that. Thank you so much. I really appreciate your insights. That is just so, yeah, great to hear from you two working in both fields, working with outside of your fields, with other professionals and just the wealth of knowledge and experience that you have. I think this has been such a valuable conversation for me and I really hope it is the same for the audience listening for both occupational therapists and behavior analysts.
So thank you again, Shalini and Sumanta.
Yeah, sure. Thank you for having us and I hope we can provide more insight to the bigger community as a BCBA and OT. And yeah, just to make life easier for the kids and the family.
Yeah. Thanks Erika. Thanks for your time and thanks for having us today.
The comments and views expressed in this podcast do not constitute or replace contractual behavior, analytic consultation, or professional advice. Views express are solely the perspective of the speaker and do not represent the views or position of their colleagues, employer, or other associates. Please seek out a behavior analyst through BACB website if you’d like to receive further behavior consultation.