By Dr. Darren O’Reilly, Chartered Psychologist and Founder of AuDHD Psychiatry

In the first part of this series, we looked at why emotional regulation is harder for children with ADHD and how big feelings can seem to appear suddenly. This section builds on that by focusing on the early internal signs that emotions are rising, and how you can help your child notice what is happening in their body before those feelings spill over.

What Internal Cues Look Like

Internal cues are the signals inside the body that show a feeling is building. They can include changes in breathing, heart rate, muscle tension, or how a child experiences sound, light, or touch.

They are different from external triggers such as a noisy classroom or a sudden change of plan. The trigger is what happens around the child. The internal cue is what happens inside the child in response. Many children with ADHD move quickly from one moment to the next and do not pause to notice these signals.

One parent described her son this way: “He goes from fine to furious in seconds.” When they slowed things down together, they noticed that his hands tightened into fists and his breathing sped up just before he exploded. For families who are also wondering whether big emotional reactions and strong sensory responses might relate to autism as well as ADHD, a free autism test for children can sometimes be a gentle way to reflect on patterns before speaking with a professional.

Common internal cues include:

• fast or shallow breathing
• tight shoulders, jaw, or hands
• “wobbly” or tight feeling in the stomach
• sounds, lights, or touch suddenly feel “too much”

Why ADHD Makes Noticing Harder

Emotional regulation depends on attention, memory, and the ability to pause before responding. These are areas where children with ADHD often need extra support. They may react before they have processed what happened or before they can find the right words.

Children with ADHD also tend to focus strongly on what is happening around them and find it harder to tune in to what is happening inside. Emotions rise quickly, leaving less time to notice early signals.

Contributing factors include:

• fast emotional reactions that leave little time to pause
• attention pulled to the environment rather than the body
• difficulty remembering to “check in” when stressed
• internal cues that change quickly or feel hard to describe

Triggers and Situations to Watch For

Children may not yet be able to name what their body feels like, but you may notice that certain situations almost always lead to big feelings. A child might seem fine until homework starts, then quickly become restless or tearful. Another might manage a noisy birthday party but come home and collapse in tears.

Common triggers and situations include:

• just before or during transitions, such as leaving the house or stopping a favorite activity
• loud or busy spaces
• unclear or multi-step instructions
• rushed routines or unexpected changes to plans

Practical Ways Parents Can Support Noticing Internal Cues

Simple routines at home can help children learn to notice what is happening inside their bodies. Calm moments create space to practice this skill before emotions run high. Modeling is a helpful first step. You might say, “My shoulders feel tight, I think I need a small break,” or “My heart is beating fast, I am going to take a few slow breaths.”

Gentle prompts can then help children practice noticing for themselves. Questions such as “What does your tummy feel like right now?” or “Do your hands feel calm or fizzy?” give children words for their experiences. Visual supports, like a simple body outline or feelings thermometer, can make this easier. When children do notice and share a body signal, specific praise helps reinforce the skill.

Helpful strategies include:

• modeling your own internal cues out loud in everyday situations
• asking simple, choice-based questions about how the body feels
• using tools such as body maps, color scales, or feelings thermometers
• praising and gently reviewing early efforts to notice and share internal cues

More in this series

Read Part 1, Why Emotional Regulation is Difficult in ADHD

Be sure to watch for the next installment of this series, where we’ll talk about:

• Using external tools to make emotions easier to understand
• ABA alignment: using structured visual supports, consistent routines, and predictable cues that reduce ambiguity and increase successful responding.

About the Author

Dr Darren O’Reilly is a Chartered Psychologist and Founder of AuDHD Psychiatry. He writes about ADHD and autism with a focus on clear, practical guidance for families and adults.

By Dr. Darren O’Reilly

Many people notice traits like difficulty focusing, sensory sensitivities, or social challenges and wonder: Is this ADHD or autism? These two neurodevelopmental conditions often overlap, yet they affect thinking, attention, and communication in distinct ways.

The main difference between ADHD and autism lies in how each influences focus and social interaction. ADHD primarily affects attention, impulse control, and time management, while autism (or autism spectrum disorder) relates more to social communication, routine, and sensory processing. Still, the boundaries can blur, making professional assessment crucial for an accurate diagnosis.

Understanding these differences helps adults and families seek the right support, whether through ADHD assessments or autism evaluations. In this blog series, we’ll explore how ADHD and autism compare, where they overlap, and how recognizing their unique traits can lead to better self-understanding and tailored care.

What emotional regulation difficulties look like

Children with ADHD often experience emotions that rise quickly and settle slowly. This can make ordinary moments feel intense, especially when a task feels confusing or when the environment becomes overwhelming.

Parents may notice behaviors like sudden frustration, tearfulness, shouting, or a child walking away to escape a situation that feels too big.

These reactions are signs that the child has reached their limit. For example, a child may burst into tears when a game ends unexpectedly, yell during homework when the instructions feel unclear, or shut down when a sibling interrupts their play.

Common behaviors include:

• quick shifts from calm to upset
• raised voice or tearfulness
• walking away or withdrawing
• repeating the same concern

Why ADHD makes regulation harder

Emotional regulation depends on attention, memory, and the ability to pause before responding. These are areas where children with ADHD often need extra support. They may react before they have processed what happened or before they can find the right words.

Strategies they practiced earlier can be hard to recall once emotions rise. For parents trying to better understand these patterns, reading this guide to ADHD symptoms in girls can help explain why challenges with focus and emotional control are often overlooked in daily life.

Contributing factors include:

• fast emotional reactions
• difficulty pausing before responding
• trouble remembering coping steps
• feeling overwhelmed by multi step tasks
  

Triggers and environmental factors to watch for

Strong emotional reactions often follow repeating patterns. Rushed routines, loud environments, unclear instructions, or sudden transitions can make regulation harder. Many parents notice that reactions happen in predictable moments.

For example, a child might become upset when asked to stop a favorite activity, struggle in busy supermarkets, or feel overwhelmed if the morning routine changes without warning. Tracking what happens before the reaction can help parents adjust the environment to reduce stress.

Common triggers and environmental factors include:

• loud or busy spaces
• unclear or multi-step instructions
• rushed transitions
• unexpected changes to plans
  

Practical ways parents can support regulation

Simple adjustments at home can make emotional moments easier to manage. Clear routines, short instructions, and predictable transitions help create a sense of safety. Practicing calming steps during relaxed moments makes them easier to remember when emotions rise.

Visual reminders or simple phrases like I need a minute can give a child a way to pause before reacting. Families often find improvements when they break homework into smaller parts, give a short pause before moving to the next activity, or offer a gentle heads up before leaving places like the playground.

Helpful strategies include:

• breaking tasks into smaller steps
• offering short pauses during challenges
• giving advance notice before transitions
• reviewing triggers together after the moment has passed

More in this series

Be sure to read Part 2 of this series, Helping Children Notice Internal Cues, where we’ll talk about:

• How to help learners notice internal cues
• ABA alignment: breaking skills into components, modelling, prompting, and reinforcing early identification of body signals and sensory cues

About the Author

Dr Darren O’Reilly is a Chartered Psychologist and Founder of AuDHD Psychiatry. He writes about ADHD and autism with a focus on clear, practical guidance for families and adults.

By Nahoma Presberg, MS BCBA NYS-LBA

If you’ve ever reviewed an ABA treatment plan, you’ve probably seen a program about emotion identification…and for good reason! Understanding our emotions and the emotions of other people is an incredibly important aspect of navigating the world around us. But not all emotion ID programming is created equal. Let’s talk a little bit about the specific benefits that emotion identification can serve when navigating stressful situations and how to make your programming specifically address these elements.

1. In order to identify your emotions, you first have to pause and assess what’s going on for you. By doing this, have to step outside of the feeling long enough to observe it. This step is the first step to regulating those emotions! Remember– emotions are value neutral. It’s important to let people label a wide variety of emotions without judgement. We can be quick to redirect or focus more on positive emotions but practice facing more challenging emotions without judgement.
2. When you can effectively name what you’re feeling, it gives the people around you more information about how to help you. Labeling emotions can be a first step in accessing co-regulation.
3. Once we’ve placed a label on our emotion, we can start to assess the strategies we might need to take to regulate it. We can map emotions onto various coping strategies so that once you label your emotions, you can quickly assess for what to do next.
4. Learning to identify your emotions is also the first step in building resilience skills. As we mentioned before, in order to label an emotion, we have to step out of it for a moment. This can also be a helpful moment in identifying and remembering that feelings are temporary. It is a lot easier to cope with a difficult emotion knowing that it will end. Sometimes in stressful situations it can feel like the things we are experiencing are going to last forever. Once we label it and take a step back, we are more able to remind ourselves that this isn’t true.
5. Accurately identifying how you’re feeling also helps people to make better decisions. Since we make so many decisions based on feelings, when we are clear about how we’re feeling, we are less likely to make impulsive choices that we are later going to regret once that emotion settles down.

Remember, when teaching emotion identification skills, keep the utility at the forefront of your mind. Build in mindfulness and compassion into the process. It’s difficult to face negative emotions but getting comfortable with being uncomfortable is a super power that will support our clients for the long-haul.

About the Author

Nahoma Presberg, MS BCBA NYS-LBA, is a Board Certified Behavior Analyst. Nahoma obtained their master’s degree at the University of Rochester in Human Development. They have been working with clients in their homes for the past 6 years but has over a decade of experience supporting children with developmental disabilities. Nahoma is passionate about neurodiversity affirming care and thoughtful programming that helps every client thrive.

For more information about Nahoma, you can visit their website at https://www.nahomapresberg.com/.

This week’s article comes to us from Ash (Ashleigh) O’Connor, MEd (ABA), BCBA, CBA, BSP, Clinical Director and founder, Mosaic Early Intervention, and Executive Director David Celiberti, PhD, BCBA-D, Association for Science in Autism Treatment. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

I am the parent of a newly diagnosed boy with ASD. He is my third child and is verbal, presents with some behavioral challenges along with many neat qualities as well. How can I explain autism to friends and family and ultimately to my son?

Thank you for asking this question, as it’s an important inquiry with many layers. If you’ve recently learned that your child has autism spectrum disorder (ASD), you may be experiencing a mix of emotions, wondering about the significance of this new diagnosis, what it might involve, and how to explain autism to your child and his siblings. When presented with the task of explaining the diagnosis to others, you might find yourself worrying about the best timing for sharing it with your child, family, and friends.

In this article, we will explore some concerns commonly shared by parents during this phase (Crane et al., 2012) and provide guidance drawn from our experience in supporting families through this transition. As you will read, cultivating empathy, promoting open communication, learning from trusted sources, and building a strong support network for both you and your child can be beneficial. It could also serve as common threads that run through how you approach the when, how, and why in your conversations about autism. Our aim is to provide practical advice and strategies to help you navigate the diagnosis effectively. You will also find links to a wide array of ASAT’s resources below that will help you learn more about autism.

Process the Diagnosis Yourself First if Necessary

Receiving an ASD diagnosis for your child can be unexpected and overwhelming. One of the initial steps you can take is to allow yourself some time for the news to settle in before discussing it broadly with others. Coming to terms with the diagnosis may involve various actions, such as seeking accurate, high-quality information and resources to gain a deeper understanding of what it entails. Consulting with a healthcare specialist knowledgeable about autism and evidence-based practices can provide valuable guidance. In addition, make space for processing your emotions, which could include sharing your feelings and thoughts with a close family member, friend, counsellor, or another parent of a child with ASD. For some parents, engaging in activities like walks or other stress-relief techniques can help manage this newly learned information. Deciding when — or if — to share the diagnosis is a highly personal choice that can differ from one family to another, depending on individual circumstances. Take the time you need.

Understand the Basics of ASD

Before sharing the diagnosis with family and friends, it may be helpful to develop a greater understanding of ASD. This includes learning about common areas of difficulty, such as social and communication challenges, repetitive behaviors, and sensory sensitivities. It’s also important to recognize that certain situations or environmental factors—often referred to as “triggers”—can lead to distress or behavioral responses in children with autism. Understanding what these triggers may be, if any, can help in anticipating and managing them effectively. In addition, it’s valuable to learn about strategies that support children with autism in developing essential coping and communication skills and overcoming obstacles, become a discerning consumer amid the wide range of treatment options (many of which, unfortunately, lack scientific support), and become familiar with the roles of different professionals on a multidisciplinary team.

At this stage, you may not have all the details about how the diagnosis specifically impacts your child now and in the future. However, developing a general understanding of ASD will be foundational to talking about autism with others. One of the most important things to share is that ASD manifests differently in every individual, with significant variations in symptoms and severity. Sharing this point sets the stage for discussing your son’s unique experience.

Share Information Specific to Your Son’s ASD Diagnosis

Once you feel more knowledgeable about ASD, you will be better positioned to discuss how ASD specifically affects your son. This discussion can include highlighting his strengths, discussing areas where he may face challenges, and celebrating his individuality. For example, you might explain how certain triggers, sensory sensitivities, or communication difficulties impact his daily life, while also sharing his unique talents or interests. Striking that balance is key.

As you learn more about the specialized support that would be beneficial to your son, such as early intervention services, applied behavior analysis, speech therapy, or occupational therapy, you can talk with loved ones about these services and resources. Sharing recommendations from your healthcare practitioner or other trusted sources can also help family and friends better understand autism and how they can support you and your son. It is important to keep in mind that you need not share everything in a single conversation, nor does everyone you speak with about your child’s diagnosis need in-depth information.

Share Suggested Ways to Interact with Your Son

When discussing your child’s diagnosis with others, it would be helpful to share information about meaningful and effective ways to interact with your son. This explanation might include important information about his routines, goals, and what you are working on, as well as his interests and strengths. Suggestions on how to establish rapport could also be very helpful.

In some instances, you may also like to mention any dos and don’ts when it comes to interacting with your son (e.g., he may find physical contact aversive until he becomes more comfortable; he loves everything related to jungle animals; loud noise scares him, including gum chewing; and bring your sneakers, he loves soccer). Of course, as will be discussed later in this article, the suggestions and examples provided would vary from person to person (e.g., grandma, next-door neighbor, sibling). Again, think of these as a series of small conversations. We have no doubt that your son has many wonderful qualities, so be sure to help others see that as well.

Explaining Autism to Your Son

Your question, albeit brief, brings up several points to consider. Although we do not know your son in depth or his age, you noted that he has some verbal language skills. When discussing ASD with your child, the approach may vary depending on his age, abilities, and overall level of understanding. A great way to begin is by balancing the conversation by incorporating positive aspects of his diagnosis. Highlight unique traits and strengths that make him special. You can also share stories to illustrate his uniqueness, mentioning that these traits are common in individuals with ASD. If you, as a parent or caregiver, also have ASD, sharing your positive experiences can be helpful for your child’s understanding. It’s all about framing the autism diagnosis in a positive way so he doesn’t feel fearful or concerned. It’s important to gently introduce the areas where your child might need extra support. You can explain that he may need help from various specialists and providers, which can make him feel more comfortable with the idea.

The timing for discussing the ASD diagnosis with your child depends on various factors, such as his age, readiness to comprehend the diagnosis, self-awareness, and other individual personality traits. In the case of a young child, you might opt to wait until they’re older and better equipped to comprehend it. Alternatively, you might choose to introduce the topic in a simplified and more limited way, focusing on clear and recurring behaviors, like difficulty sharing or staying calm when upset, that your child can easily recognize in themselves. Understanding ASD may require multiple conversations, as your child may have many questions. It’s advisable to explore resources to gain a solid understanding of the basics so that you can effectively share this information with your child if needed. Hopefully, trusted professionals will also be available to support you and address any questions you may have.

What and how to tell your son about autism is deeply personal. Here are a few things you might like to consider when discussing the diagnosis with him:

• Start with the basics, emphasizing how your son’s autism manifests and that there is help available, particularly if those services and supports are already in place.
• Use positive language in a relaxed and warm tone so that your son has a more positive experience, not just around the content but also the flow of the conversation. For example, instead of using words like ‘deficit’ or ‘lacking,’ you could say ‘challenge’ or ‘rough patch.’ It may be helpful for your son to hear that you, too, experience things that are hard (like meeting new people or a fear of dogs).
• Highlight the positive aspects or traits, whether it’s simply pointing them out, telling a story, or providing an example of his strengths. In a related vein, it would be fine to share some of your own unique qualities as well.
• As mentioned above, describe what help or services you may seek out for your child, so they understand there will be extra support on hand. Frame this help with hopefulness and with a reminder that the providers are on his side (e.g., “Miss Amy, your OT, is like a coach who knows a lot about helping kids learn to write. Just like your older sister has to go to soccer practice three days a week, practice writing also helps you as well.”).
• Reading children’s books can also be a valuable way to explain what ASD is and how it can affect different children. It offers a unique approach to helping your child understand this new information. As mentioned in our introduction, you will find many helpful resources hyperlinked below.
• You may like to discuss other people that you know who have autism, or even some famous celebrities. When talking about other individuals with autism, it may be helpful to emphasize that no two individuals with autism are the same.
• Some parents might say things like the diagnosis makes the child a little bit like a superhero, highlighting the positives of their diagnosis rather than the challenges, while also emphasizing that even a superhero can run into some rough patches.
• Invite questions and check in for understanding. Clarify any messages that may not have landed as you intended and revisit at a later time as needed.

Who Tells/Where to Tell

You may want to tell your child about their diagnosis when they are at home or somewhere familiar, so they feel comfortable. It’s best to choose a time when you are both relaxed and calm. Creating a comfortable and safe environment for the conversation will help your child feel more confident in hearing about their diagnosis.

As a parent, you might choose to be the one to inform your child, or you could involve one of your providers in the discussion. The benefit of having a professional present is their expertise, which allows them to address any questions that may arise and offer additional information as needed. Ultimately, the decision should be based on what you believe will be most effective for your son.

Who Else Needs to Know

You mentioned that you have at least two other children and we encourage you to think carefully about how you talk about autism with them as well as about autism in their presence. Keep in mind that your phone conversations are often in earshot of siblings who may pick up on some of your concerns and worries. We want to share a quick and related story. The second author’s grandmother passed away in his home when he was five years old. He overheard his mother tell other family members and neighbors that the grandmother died after having prunes for lunch. For a few years, he harbored a fear that prunes were the cause of his grandmother’s death and frequently hid them from his father, and even on a few occasions threw out the box of prunes behind his parents’ backs. The takeaway is that the narratives you share with others may be easily overheard and misunderstood or misperceived by other children in the home. Aside from talking with your other children directly about autism, we also encourage you to ask them what they may already think about autism (if that term is familiar to them) or if they have any questions. Lastly, consider if the siblings may misuse some of the information shared (e.g., bring it up during conflicts with your son, overshare with others).

If your child is at daycare or school, you may wish to discuss the diagnosis with their educator or teacher to determine if any changes need to be made to accommodate their learning. Although we do not know the age of your son, for older children in particular, discussing who may need to know about their diagnosis is important for several reasons. First and foremost, it empowers the child to have agency over their own story and fosters a sense of control in a situation that may otherwise feel overwhelming. Additionally, by respecting their opinion and preferences, you build trust and open communication channels, allowing them to express their fears or concerns about potential negative reactions from peers. This consideration ensures that the child’s emotional well-being and self-esteem are protected, ultimately contributing to a more positive and supportive environment.

In one of the first author’s early professional experiences, a parent mentioned their child’s diagnosis to another parent in front of the child and their peers. The child became upset and asked their parent not to share their diagnosis with anyone else. In this instance, it was essential that everyone respect the child’s choice and continue to support them as they navigated their diagnosis. Doing so gave them control over who to share this information with and when.

Conclusion

Navigating your son’s autism diagnosis is a journey that comes with many unique challenges, but also opportunities for resilience and connection. Please remember that how you and your family choose to talk about ASD is deeply personal and evolves over time—there is no single “right” way to proceed. As you move forward, please peruse both our resources and those of other trusted organizations and forge connections with professionals and other parents who understand and support your path. By equipping yourself with knowledge, fostering empathy, and cultivating a strong support network, you are taking important steps toward empowering both yourself and your son to better experience and navigate the chapters that lie ahead.

Reference cited above:

Crane, L., Liu, L., Davies, J., & Pellicano, E. (2021). Autistic parents’ view and experiences of talking about autism with their autistic children. Autism, 25(4) 1161-1167. https://doi.org/10.1177/1362361320981317

Reference for this article:

O’Connor, A., & Celiberti, D. (2025). Clinical Corner: How can I explain autism to my child, family, and friends? Science in Autism Treatment, (22)6.

About the Authors

Ash (Ashleigh) O’Connor, MEd (ABA), BCBA, CBA, BSP is the Clinical Director and founder of Mosaic Early Intervention, a Sydney, Australia-based service that provides individualised, evidence-based support for young children with developmental delays and disabilities. Mosaic is known for its warm, neurodiversity-affirming approach and its commitment to compassionate, ethical care that helps children thrive in their everyday environments. Ash’s passion for supporting children and families began early in life and led her to study Speech and Hearing Sciences at Macquarie University, followed by a Graduate Diploma in Autism Studies (Griffith University) and a Master of Education in Applied Behaviour Analysis (Monash University). She is a Board Certified Behaviour Analyst (BCBA), Certified Behaviour Analyst (CBA) through ABA Australia, and a registered Behaviour Support Practitioner. After years of commuting across Sydney to deliver therapy, Ash founded Mosaic in the Sutherland Shire to meet the growing need for accessible, high-quality services in her local community. What began as a solo practice has grown into a thriving team of 25 professionals, many of whom Ash has supported to become board certified behaviour analysts themselves. Ash is deeply committed to neurodiversity, family-centred care, and strengths-based practice. She believes in helping children grow through meaningful, everyday experiences, and in fostering workplaces that prioritise the wellbeing and ongoing development of clinicians. At the heart of her work is a belief in ethical practice, collaboration, and making a genuine difference in the lives of the children and families she supports.

David Celiberti, PhD, BCBA-D, is the Executive Director of ASAT and Past-President, a role he served from 2006 to 2012. He is the Editor of ASAT’s monthly publication, Science in Autism Treatment. He received his PhD in clinical psychology from Rutgers University in 1993 and his certification in behavior analysis in 2000. Dr. Celiberti has served on a number of advisory boards and special interest groups in the field of autism, applied behavior analysis (ABA), and early childhood education. He works in private practice and provides consultation to public and private schools and agencies in underserved areas. He has authored several articles in professional journals and presents frequently at regional, national, and international conferences. In prior positions, Dr. Celiberti taught courses related to ABA at both undergraduate and graduate levels, supervised individuals pursuing BCBA certifications, and conducted research in the areas of ABA, family intervention, and autism.

By Nahoma Presberg, MS BCBA NYS-LBA

For such a seemingly simple thing, small talk is quite complex. It serves a number of social functions that facilitate relationship development. Good small talk is a skill that comes naturally to some and not naturally to others. For people for whom small talk does not come naturally, it can feel foreign, awkward, and stressful. But the good news is we can teach small talk skills much like we teach anything else.

In order to teach it well, we need to get specific about the purpose of small talk. So let’s get clear about what small talk is and what it isn’t.

What small talk is: a social ice breaker in search of common interest, a professional networking tool, an emotional regulation tool as an opening to a more serious conversation.

What small talk is not: a relationship substitute, universal, efficient communication, or authentic self-expression.

Keeping these things in mind is important when we develop programming to support teaching small talk.

How To Teach Small Talk Skills

Start out by doing a little bit of self-reflection. Identify some ways that small talk serves you well in your life, and think about when it’s felt difficult or uncomfortable. Have a conversation with your client about your experiences with small talk, what it is, and some reasons to learn about it. Work together with your client to identify some goals related to small talk that will have immediate and positive benefits in their life.

Let’s say you’re working with a high school student who just moved to a new school. They’ll need some small talk skills to be able to start to make friends at school. In this case, small talk conversation topics can (and probably should) include some of your client’s interests. This will be a way for them to quickly find people who have things in common as a building block for friendship. Help your client identify some things they like to do and what they like to talk about. Then build a list of questions that they can ask in a conversation related to these topics. Bingo! You’re already doing small talk.

Practice and Adaptation

But good small talk is nuanced, right? It requires reading social cues, understanding the social context of the environment, recognizing emotions in others, thinking on your feet, just to name a few.

As you’re practicing concrete small talk skills with your client, work together to identify other aspects of this skill that they’re struggling with. You may be able to observe some challenges and your client might be able to tell you a bit about what’s feeling uncomfortable. These insights will help to identify additional goals you can work on to continue to shape the skill.

Learning small talk can be an awkward process. But it can also be really silly and fun! Let your programming be fluid and meet the needs of the environment and the learner, and remember that we’re all learning new things about this skill all the time.

About the Author

Nahoma Presberg, MS BCBA NYS-LBA, is a Board Certified Behavior Analyst. Nahoma obtained their master’s degree at the University of Rochester in Human Development. They have been working with clients in their homes for the past 6 years but has over a decade of experience supporting children with developmental disabilities. Nahoma is passionate about neurodiversity affirming care and thoughtful programming that helps every client thrive.

For more information about Nahoma, you can visit their website at https://www.nahomapresberg.com/.

By Anika Hoybjerg, PhD, EdS, BCBA-D, LBA and Casey Barron, BCBA, LBA

Last week, we shared a blog about how to work with insurance companies and advocate for medical necessity in ABA. This week, let’s take a closer look at how you can work with insurance companies when using our newest assessment, the MOTAS.

For many clinicians working in Applied Behavior Analysis, submitting treatment plans and reporting client progress is a large part of the job. Navigating insurance requirements and aligning goals with the criteria set by payors can be a daunting task. With the Meaningful Outcomes Treatment and Assessment Scale (MOTAS) being a newer assessment, many practitioners are asking about the approval of utilizing this assessment in submitting treatment plans to insurance companies. Up to this point, the MOTAS has been submitted to several insurance companies and treatment plans have been approved. While we cannot guarantee that insurance will accept a particular assessment, several different strategies have been used to gain approval, including understanding medical necessity, providing justification for treatment, aligning goals with the DSM-5 criteria for autism, and pairing the MOTAS with other assessments.

Understanding “Medical Necessity” and Core Characteristics

In many cases, insurance companies approve treatment plans based on whether they are deemed “medically necessary” and if the goals selected relate to the core deficits of autism, as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The MOTAS was intentionally designed to align with these core characteristics, making it an excellent tool for establishing medical necessity in treatment plans. The entirety of the DSM-5 criteria for Autism Spectrum Disorder (ASD) has been printed, with special permission from the American Psychiatric Association (APA), in the MOTAS. This allows practitioners to be familiar with the characteristics of autism and align treatment goals to address the needs of their clients.

Pairing MOTAS with Other Assessments

Because the MOTAS is still gaining recognition, pairing it with assessments already accepted by insurance companies may be a practical strategy. Some commonly approved assessments include:

• VB-MAPP (Verbal Behavior Milestones Assessment and Placement Program)
• ABLLS-R (Assessment of Basic Language and Learning Skills-Revised)
• AFLS (Assessment of Functional Living Skills)
• EFL (Essentials for Living)
• Vineland Adaptive Behavior Scales
• PEAK Relational Training System

A clinician may complete one of these more commonly recognized assessments, and select 1-3 domains from the MOTAS to supplement these goals, and only score the applicable domains and subdomains. Alternatively, the clinician may find the MOTAS goals are more appropriate for their learner and complete several MOTAS domains and largely feature MOTAS goals in their treatment plan, but also complete an assessment grid for a more commonly recognized assessment. These techniques have been successful when submitting to payors.

Payors may also request a rationale or justification for using the MOTAS as the skills assessment. Highlighting features of the MOTAS that align with medical necessity and the core characteristics will help individuals unfamiliar with the assessment learn how it can be useful. Some of these features include skill domains relevant to the core characteristics of autism (including social behavior, perspective taking, relationships, transitions, and communication), scoring that tracks progress across multiple environments to evaluate for generalization and maintenance, and an accompanying interview for caregivers to help guide treatment and ensure they are part of treatment from the onset of services and continually throughout.

By incorporating the MOTAS alongside one or more of these assessments, practitioners can highlight how the MOTAS addresses gaps in traditional assessments, particularly in Self-Awareness, Relationships, Perspective Taking, and Flexibility—areas that are crucial for meaningful skill acquisition and which directly address core characteristics of autism in ways that are medically necessary.

Writing a Strong Treatment Plan Using the MOTAS for Insurance Approval

Here is a summary of things to consider when writing a treatment plan using the MOTAS when submitting to an insurance company.

1. Identify the Core Deficits: Use the MOTAS to link goals directly to the DSM-5 criteria for ASD. Clearly state how each goal addresses deficits in social communication (expressive and receptive communication, social communication and interactions) , restrictive and repetitive behaviors (including rigidity in routines), or adaptive functioning.
2. Include Results for Selected Domains: Present MOTAS results and if necessary, do it alongside other assessments that the insurance company will recognize to strengthen the case for medical necessity.
3. Describe Functional Impact: Demonstrate how the proposed interventions will decrease interfering behaviors and improve daily living, social participation, and overall independence.
4. Use Objective Data: Since the MOTAS features a consistent 0-5 rating scale, this data-driven approach can illustrate progress and justify continued treatment.
5. Align Goals with Insurance Terminology: Use language that directly ties the need for treatment to medical necessity, emphasizing how therapy will address impairments that limit functioning in home, school, or community settings.

Further Reading

Learn more about the MOTAS in our ongoing blog series:

• Introducing the Meaningful Outcomes Treatment and Assessment Scale
• Using the MOTAS and LOOP: Selecting Meaningful Goals
• Why the MOTAS Was Created

About the Authors

Anika Hoybjerg, PhD, EdS, BCBA-D, LBA
Dr. Hoybjerg is the CEO, founder, and owner of Autism & Behavioral Intervention (ABI) (a clinic-based ABA center in Draper, UT), ABA Education Center, and Integrity Billing. In addition to founding and leading these companies, Anika has worked in public schools and in private sectors with children and families for over 20 years. Anika is a Doctoral level Board Certified Behavior Analyst (BCBA-D) and a Licensed School Psychologist. Anika has a Bachelor’s degree in Human Development, a Master’s Degree in Curriculum and Instruction with an Emphasis in Autism, a Master’s degree in Human Exceptionality, an Ed.S in School Psychology, and a Ph.D. in Applied Behavior Analysis. Anika is currently pursuing a Master’s degree in Neuroscience and Trauma. Anika has presented at regional, national, and international conferences on a variety of topics relating to kindness in ABA services, autism, collaboration, and assessments.

Casey Barron, BCBA, LBA
Casey is a practicing Board Certified Behavior Analyst in Salt Lake City, Utah. She has been working in ABA since early 2015, spending several years first working as an RBT then as a BCBA in academic, home, and clinical settings. In addition to her work as a practicing BCBA, Casey works as the clinical director of an ABA center that has supported hundreds of children and where she oversees and trains staff members and future BCBAs. Since becoming a BCBA, Casey has presented at regional and international conferences on case studies from her own clinical practice.

By Ashleigh Evans, MS, BCBA

In the early 2000s, advocacy efforts pushed forward a medical model of ABA. This model gained momentum as states began passing autism insurance mandates. In 2014, the Centers for Medicare & Medicaid Services (CMS) published a bulletin clarifying that Medicaid programs must provide autism services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. This set in motion plans across all 50 states for Medicaid programs to provide ABA and other services to Medicaid recipients. As of today, every US state also has insurance mandates requiring ABA therapy coverage, fully integrating ABA into the healthcare system.

The shift to a medical model of Applied Behavior Analysis (ABA) has brought benefits to the field, including increased access to care. However, with it also came increased treatment plan scrutiny from payors. Most payors now require BCBAs to demonstrate that a client meets medical necessity to authorize services. Let’s explore the concept of medical necessity and consider how clinicians can advocate for their learners.

What is Medical Necessity in ABA?

Medical necessity is a concept used within the healthcare field. It refers to treatment that is necessary to diagnose, treat, cure, or alleviate symptoms of a particular condition. When we look at medical necessity in ABA, we have to consider whether the therapy modality and specific individualized goals will realistically help relieve the symptoms of autism that are interfering with the learner’s quality of life.

Each payor has different medical necessity criteria. Generally speaking, to determine medical necessity, funders consider the type of care, frequency and duration, location where care will be provided, whether the treatment is research-backed, and whether it would be considered effective for the individual patient.

How to Demonstrate Medical Necessity

Behavior analysts are responsible for advocating for their clients–this includes advocating for medical necessity to enable their learners to receive medically necessary care. Here are some recommendations for navigating this requirement.

1.    Understand the payor’s medical necessity criterion.
First, make sure you understand each payor’s criteria for medical necessity. Most major insurance providers publish medical necessity guidelines online under their Behavioral Health or Medical Policies. You can also access medical necessity criteria in your provider manual. If you can’t locate medical necessity criteria, reach out to your provider rep for guidance.

2. Ensure up-to-date diagnostic assessments.
   
   One component of medical necessity is typically a recent autism diagnosis. Most payors require comprehensive diagnostic evaluations every 3-5 years to verify the individual’s diagnosis. Keep an eye on the dates of diagnostic assessments and inform your clients when they’ll need a reassessment soon. Many providers have lengthy waitlists, so try to be proactive in urging families to get these scheduled.
   
   Tip: If your client is due for a reauthorization but is overdue for a diagnostic re-evaluation, encourage the family to at least get it scheduled before you submit the authorization request. Many funders will recognize that diagnosticians have schedules that book out for months or even years, so the client may not be able to access a re-evaluation by the required date, but they at least want to see that it’s scheduled.
   
   
3. Conduct insurance-approved assessments at least every 6 months.
   
   Make sure you have an updated and accurate assessment on file. Certain payors only accept specific assessment tools, so be sure to verify which assessments are accepted by the funder.

4. Add a rationale for each goal.
   
   In your treatment plan, add a justification for each treatment goal. This justification should tie back to the diagnostic criteria of autism spectrum disorder (ASD). In other words, specifically, how will targeting the goal alleviate the symptoms of ASD? Per the DSM-5, diagnostic criteria for autism include:
   

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
   
   
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
   
   
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
   
   
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).
   
   
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).
   
   
4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

Here’s an example of a justification statement for an ABA treatment goal:

Goal: Client will independently mand for preferred items in 80% of opportunities, across 10 consecutive sessions, by 10/09/2025.

Rationale: To remediate the deficits in social communication that limit the client’s ability to get their needs and wants met.

5. Make sure the hours you’re requesting match the learner’s needs.

Lastly, ensure the hours of ABA you are requesting match the learner’s needs. If the individual has minimal needs or if you aren’t effective in communicating the full scale of their needs within the treatment plan, the funder may deem that services at the requested level are not medically necessary. Consider the whole picture of the learner’s abilities, needs, other services, and school supports to determine clinical need.

Main Takeaways

Behavior analysts are responsible for advocating for their clients’ best interests. While navigating the complexities of insurance and Medicaid can be challenging, it can be done effectively. Take time to understand each payor’s criteria and create a comprehensive treatment plan that directly addresses the funder’s requirements for demonstrating medical necessity.

About the Author

Ashleigh Evans, MS, BCBA, is a Board Certified Behavior Analyst. She has been practicing in the behavior analysis field for over 13 years and opened her own independent practice in early 2022. Her experience has been vast across different age groups, diagnoses, and needs. She is passionate about improving the field through education, reformative action, and better supervisory practices, leading her to create content and resources for families and ABA professionals which can be found on her website, www.abaresourcecenter.com

By Patrick Faga, MS, Creator of the FirstWork App

Tablets have become common tools in education, but their impact in special education, especially within the framework of Applied Behavior Analysis (ABA), deserves special attention. For many students—particularly those with autism—tablets can offer lightning-fast feedback that is both immediate and consistent. When someone taps a tablet, it registers the input in as little as 1 to 10 milliseconds, faster than the human eye can detect. That kind of speed, paired with the tablet’s reliable response, can make a world of difference for learners who depend on quick reinforcement to build new skills.

A Brief Recap of DTT/DTI

Discrete Trial Training (DTT), also known as Discrete Trial Instruction (DTI), is a highly structured teaching method often used in ABA therapy. It typically involves three main steps: a clear, concise instruction or question (the “discriminative stimulus”), the learner’s response, and an immediate consequence—either positive reinforcement for correct answers or gentle correction for errors. Because it focuses on repeated practice and immediate feedback, DTT has been particularly effective for children with autism and other developmental disabilities. However, the success of DTT hinges on providing quick and predictable responses to each learner action.

Why Faster, More Consistent Feedback Matters

Research published in the Journal of Applied Behavior Analysis highlights the importance of minimizing the delay between a learner’s action and the educator’s response. The less time between response and consequence, the more robust the learning connection becomes. Yet in busy classrooms or therapy sessions, even well-trained professionals can experience natural variations in how quickly or consistently they deliver feedback. Human factors—like fatigue, changes in tone of voice, or distractions—can cause slight delays that might interrupt the smooth flow of reinforcement.

Tablets bypass many of these challenges. The moment a learner taps the screen, an on-screen prompt or sound can tell them right away if they’re correct or if they should try again. That instantaneous feedback helps learners form stronger associations between their response and the outcome, reinforcing correct behavior and guiding error correction more effectively.

Benefits for Learners with Autism

Many individuals with autism thrive on consistency and predictability. Knowing exactly what will happen when they touch the screen can reduce anxiety, encourage engagement, and help them persist with challenging tasks. A tablet’s consistent, automated feedback is less likely to vary because of human mood or environment, making it an invaluable tool for reinforcing positive behaviors or prompting self-correction. Over time, learners often show increased independence and confidence when they can anticipate the same quick response every time.

Generalization Through Digital Presentation

Another major advantage of digital DTT/DTI is the built-in capacity to present multiple examples or “exemplars” of a single concept. Generalization—being able to apply a skill across different settings, stimuli, or people—is a critical goal in ABA and special education. When using a tablet, it’s easy to display various images or sounds in rapid succession, exposing learners to different contexts without having to gather real-life objects or shuffle through physical flashcards. This variety helps learners transfer what they’ve mastered to the broader world, ensuring the skill doesn’t remain “locked” in a single context.

Keeping it Simple for Teachers and Therapists

Of course, the human element remains essential. Educators and therapists are still the guiding force, shaping each learner’s progress and providing the warmth, understanding, and personal connection no device can replicate. However, certain digital platforms strive to make it easier for professionals to leverage tablets in DTT/DTI. One such example is FirstWork, which offers a wide range of images and straightforward data-tracking features, streamlining session prep and progress monitoring. By automating some of the rote tasks—like collecting response times and instantly providing feedback—tools like FirstWork allow educators to focus on what really matters: helping learners succeed.

In short, tablets represent a powerful ally in delivering more immediate, consistent feedback in DTT/DTI programs. Their speed, reliability, and versatility in presenting varied content help learners, including those with autism, stay engaged and acquire skills that transfer smoothly into everyday life. When paired with thoughtful strategies and a caring educator, tablet-based DTT can turn each tap of the screen into a stepping stone toward independence and growth.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).

Criterion B2 for Autism Spectrum Disorder lists “insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or non-verbal behavior”—underscoring a clinical preference for predictable, consistent environments.

Goris, J., Brass, M., Cambier, C., Delplanque, J., Wiersema, J. R., & Braem, S. (2020). The relation between preference for predictability and autistic traits. Autism Research, 13(7), 1144-1154.PubMed

This empirical study found that higher autistic-trait scores correlate with stronger preferences for predictable music, images, and reward schedules, providing experimental evidence for a drive toward predictability.

About the Author

Patrick Faga, MS, is a behavior scientist and technologist. Patrick obtained his masters in Behavior and Decision science from the University of Pennsylvania. He has experience as an ABA technician, working directly with learners on the spectrum. Patrick’s passion is applying science based principles into technology systems to create new avenues for learning and skill development. 

By Nahoma Presberg, MS BCBA NYS-LBA

Behavior analysis can support the improvement of an individual’s quality of life in a wide variety of ways. We can teach language and functional skills as well as help clients find replacements and alternatives for unsafe behaviors. We can also help clients develop a wider repertoire of leisure skills that can support the enjoyment of free time and broader access to the world around them.

There’s no better feeling than when you can see someone getting more comfortable and curious to explore and try new things. Introducing new interests really has the power to change someone’s life in a meaningful way. However, this task can be extremely complex and requires a lot of intentionality from the therapists.

So, what are some things to keep in mind when you’re working with a client on developing new interests?

1. Be patient. Familiarity often leads to enjoyment. When we’re more comfortable with an activity, it’s easier to relax into it and have it be a true leisure skill. One of the characteristics of autism is preferring to stay within routines and familiarity. This means that it can be difficult to try new things. It may evoke feelings of anxiety or nervousness in our clients (and probably ourselves too!) Take your time, it will be worth it.
2. Abandon expectations. There are endless things that people find interesting in this world. Some are more popular, while others might be more niche. While we know that shared interests can help facilitate social skills and make developing friendships easier, it’s important that we listen to our clients about what is genuinely interesting. From there, we can help them tap into various social communities that share these interests. The same can’t be said in reverse order.
3. Get creative. You never know what’s going to click. Get comfortable exploring the process with your client and have fun with it!
4. Respect autonomy. New interests is a great opportunity to let your learner take the lead more than they might get to otherwise. This is an opportunity to understand how they approach things and what gets them excited.
5. Get curious. You never know what might work!
6. Be careful about what you’re reinforcing: When you’re introducing new activities, materials, etc. towards the intent of supporting the development of new interests, it can be easy to want to reinforce compliance behaviors or task completion behaviors. However, finding new interests is often about the process and we want to make sure that we’re reinforcing willingness to try, flexibility, curiosity and other behaviors that support the client’s ability to engage with you. Remember, it’s about the process and the process should be fun!

About the Author

Nahoma Presberg, MS BCBA NYS-LBA, is a Board Certified Behavior Analyst. Nahoma obtained their master’s degree at the University of Rochester in Human Development. They have been working with clients in their homes for the past 6 years but has over a decade of experience supporting children with developmental disabilities. Nahoma is passionate about neurodiversity affirming care and thoughtful programming that helps every client thrive.

For more information about Nahoma, you can visit their website at https://www.nahomapresberg.com/.