OAP Clinical Framework - Elements of Clinical Decision-Making

The following are recommended stages and critical elements of the clinical decision-making process. Good clinical decision-making is informed by multiple perspectives, making this process inherently complex. These stages are not necessarily linear and may occur in various sequences and sometimes simultaneously.

Understanding and Building the Story

To be able to provide high quality, family-centred personalized services, Rosenbaum and colleagues (1998) identified the following key service provider, behaviour-based components: supporting the family, using active listening skills, believing and trusting parents, promoting and facilitating parent decision-making, encouraging participation of all stakeholders, and ensuring clear and active communication. 9

Comprehensive Information Collection

Upon entry to the OAP, the OAP FSW gathers information to develop a comprehensive understanding of the strengths and needs of the child/youth, the family and the environment in which they live. Key information about the whole child or youth is collected, summarized, and initial needs and strengths are identified. Information gathering will be a continuous process as a child/family move through the OAP.

Information should be obtained from a variety of sources as indicated by the experiences, strengths and needs of the individual child/youth. This includes but is not limited to contexts in which a good deal of time is spent (e.g., in childcare, school), other involved therapies being given (e.g. motor speech development, Augmentative and Alternative Communication use), community-based programs and supports, and medical intervention. Other information that may be helpful includes:

The outputs of this information will be organized systematically, possibly through an administration of the Child and Adolescent Needs and Strengths (CANS) assessment, to establish from onset a method to both collect the same categories of information across the province and to provide a baseline for each child/youth. In some cases, where applicable, the OAP Behavioural Clinician may be involved in the early stages of information gathering.

Prior to the first meeting with the family, the OAP Behavioural Clinician reviews all relevant and available medical, educational and clinical community support documents about the child/youth that have been compiled to help inform their OAP Family Service Plan. This review includes the identification of any gaps in knowledge or relevant documentation. Appropriate means are then taken to fill in identified gaps (e.g., current education IEP), request additional information, and/or make needed referrals for other services.

Building the Story and the Family Service Plan

An initial meeting with the OAP FSW and the family/youth occurs to promote a shared understanding of the child/youth and to discuss OAP services and supports, including possible family supports. A comprehensive description is developed of the parents’/youth’s perspective on strengths, needs and areas of concern, and those requiring action. This includes reviewing the story or portrait of the child/youth, and identifying the child’s strengths and needs, possibly through the administration of a Child and Adolescent Needs and Strengths (CANS) assessment. The CANS is a tool used to ensure consistent attention is paid to key assessment outputs. It also provides a common practice approach to the assessment process that is applied systematically across all providers, allowing provincial comparisons of child and family characteristics and outcomes.

The OAP Family Service Plan is initiated at this point to begin services as quickly as possible. An OAP Behavioural Clinician will also become involved in this process.


Assessment, Goal Setting and Development of the Behaviour Plan

After initiation of the OAP Family Service Plan, the OAP Behaviour Plan is created. This plan is based on feedback from the family, a clear understanding of the parents’/youth’s expectations, capacities and which domains are priority areas to be addressed. Observations of the child and sometimes caregivers are included to better define behavioural intervention goals and strategies, and to establish a baseline for ongoing observations.

The OAP Behavioural Clinician will initiate assessment through informal and formal observations, which may take place in the child’s natural environment(s) and/or in a clinical setting. This will involve getting to know the family/youth, the child’s strengths, needs and interests, and open discussion of the family’s/youth’s highest areas of need and contextual/practical factors relevant to the behavioural assessment and intervention (e.g., language and cultural considerations, transportation, scheduling constraints, etc.) The OAP Behavioural Clinician will describe the behavioural service options, assessment process and plan, as developed in collaboration with the family, and answer the family’s questions. The OAP Behavioural Clinician will identify behavioural challenges, if any, and conduct formal assessments as needed.

Observations are a necessary component of the assessment phase and can be conducted in natural and/or structured settings. In line with Wong et al. (2014)10 and input from stakeholders, a review of the range of domains that require support for children/youth with ASD may include: social/interpersonal, communication, cognitive functions, school readiness skills, motor skills, personal responsibility/adaptive skills, play and leisure, self-regulation, vocational skills, and challenging behaviours.

Standardized tools (e.g., parent/school report, child/youth assessment tests such as the ABLLS curriculum, Social Skills Improvement System, etc.) may be useful to further direct the understanding of the child as they influence treatment decisions across the lifespan. Assessment processes are individualized to the age, abilities and interests of the child/youth. A formal developmental assessment and/or a functional assessment may be needed to further inform key decisions in the planning.

Once observations and formal assessments are completed, the OAP Behavioural Clinician will share the assessment results and discuss them with the family/youth. Together they will develop consensus on a common understanding of the child’s/youth’s priority goals and the plan for intervention. This may include both short- and long-term goals and priorities.

This consensus-based planning process continues throughout the child’s treatment experience.

Development of the Behaviour Plan

Despite the individualized nature of ABA service decision-making and delivery, there are common processes that underlie most ABA case preparation, assessment, and intervention decisions. Below is a list of elements that are generally required for each step of behavioural service planning, depending on the child’s needs. (Note that given the diversity of OAP clients, there likely will be reasonable exceptions and/or additions to these elements.)

  1. Recommendations regarding the amount and modality of needed behavioural service

    Based on information from all previous elements (above), and the evidence from the literature, the OAP Behavioural Clinician and the family/youth will develop a plan for recommended behavioural service (this is called the Behaviour Plan). The Behaviour Plan will include a description of the proposed intervention and a summary of the discussion between the clinician and family about the proposed intervention, information about the amount, scheduling, and anticipated duration of the intervention. The plan will include details about how progress will be measured and assessed, and how next steps will be determined.

    The OAP Behavioural Clinician together with the family/youth will determine involvement of the family and other supports (as available) in the recommended intervention.

  2. Development of the Behaviour Plan

    The OAP Behavioural Clinician will write up the Behaviour Plan as developed in collaboration with the family/youth and with the involvement of other professionals, as needed, and document his/her clinical decision-making process, including the rationale for the recommended intervention.

    The OAP Behavioural Clinician will explain the Behaviour Plan to the family/youth, and will document both the plan and parental/youth consent to proceed with plan.

Written Behaviour Plans will include the following components:

  1. brief summary of the behavioural observations/assessment and rationale for the Behaviour Plan;
  2. description of domain(s) to be addressed;
  3. definitions of skills to be increased;
  4. definitions of behaviours to be decreased (if needed);
  5. description of planned intervention approach (e.g., discrete trial, naturalistic, 1:1, small group, parent training, etc.), with recognition that this will need to be flexible based on child’s learning;
  6. measurable, relevant and realistic behavioural goals (i.e., for behaviours defined in c. and d. above), with mastery criteria and approximate time frames (e.g., a family and Behavioural Clinician may agree that reviews at 3, 6, and 12 months would be helpful) to achieve mastery (or meaningful reduction of problem behaviour) for each skill/behaviour identified;
  7. therapeutic expectations including anticipated risks and benefits;
  8. description of generalization and maintenance strategies;
  9. roles and responsibilities of relevant parties;
  10. outline of a review plan. Note that intervention goals and strategies can be changed, as needed; and
  11. a summary of the OAP Behavioural Clinician’s rationale for the elements of the plan and how they were discussed with the family.

Once the Behaviour Plan has been developed, the Behavioural Clinician will discuss with the family/youth and provide a written follow-up, which will include, but not be limited to:

The OAP Behavioural Clinician must document any necessary parental consent and, as appropriate, child/youth consent, to proceed with the plan.


Delivery of Behavioural Intervention

Once the Behaviour Plan has been developed and consensus is reached between the family and the OAP Behavioural Clinician, intervention is delivered as discussed with the family/youth.

Behavioural services support children, youth and their families throughout OAP, varying in form and intensity as needed. The OAP provides a continuum of behavioural interventions. Children’s needs change over time and as those needs change, children and youth with ASD move between different levels and forms of interventions/treatments. The child/youth may, according to priority goals and needs, receive 1:1, small group or consultation supports. Learning new skills and the generalization and maintenance of skills are integrated components of each child/youth’s OAP Behaviour Plan.

To promote the child/youth’s learning, including the transfer and retention of new skill(s) to home and community, parents of children receiving intervention should be actively involved in the child’s behavioural services. This could include parents receiving consultation support and/or training and coaching in the clinic, at home and/or in other community settings. When a child or youth is receiving behavioural assessments or behavioural intervention for skill development and/or behaviour changes/reduction and their generalization, parents and caregivers will be offered parent/caregiver training and education.

As a child or youth is achieving the goals outlined in the OAP Behaviour Plan, the focus will include consolidating and/or maintaining the skill(s) recently acquired and using it flexibly and in new ways, in new environments and with new people. Goals may also focus on increasing the capacity of the people around the child to maintain and/or extend those skills in the child/youth’s natural environments.

Family and Family Team Intervention Support

As a child/youth is achieving the goals outlined in the OAP Behaviour Plan, the parents and the Family Worker and Team, including the OAP Behavioural Clinician, will meet to consider how they can best support the child/youth’s learning. This process may involve updating the OAP Behaviour Plan. The family will be involved in any modifications to the Behaviour Plan, including the identification of new goals. The OAP Family Support Worker/Team will also modify the broader OAP Family Service Plan (FSP), identifying a new set of goals related to the real-life generalization and flexible use of the new skill(s).

As described above, individualized goals within an OAP Behaviour Plan are developed with the family/youth, and progress information is shared regularly through informal updates (i.e., Touch Points) with the family and their Family Team. The OAP Behavioural Clinician is responsible for monitoring, communicating and evaluating the OAP Behaviour Plan. A written progress summary is provided to the family and to the Family Team at meetings as required at least every six months.

Parents/caregivers may receive education, training and/or consultation support. Consultation to the child or youth’s school or primary learning environment(s), from OAP clinicians or other Family Team members may also be provided according to needs. As needed, the OAP Behavioural Clinician can provide consultation and support to reinforce and support maintenance of newly learned skills. Generalization and maintenance is coordinated with the Family Team members. This can occur in a variety of places in which the child/youth spends considerable time. For example, early years or school ABA staff could assist staff in helping a child/youth to use their newly achieved self-help skill(s) in childcare, after school care and/or in school. In other situations, a youth may be supported to use new conversation skills with his friends at soccer practice by the Family Team SLP. In another instance, a child may be supported to maintain her toileting skills at home and at her grandparent’s home by an Early Interventionist. The OAP Behavioural Clinician may provide consultation to staff of a child and youth community-based mental health provider in managing a youth’s challenging behaviour. This collaborative partnership work is coordinated at the Family Team level.

At the next Family Team meeting, individualized goals and data tracking are developed, and the OAP Family Service Plan is updated. The OAP Behavioural Clinician is a member of the Family Team and provides consultation as required. Again, although frequency and type of communication are individually determined, a re-evaluation meeting must be held at least every six months or earlier as needed. Communication expectations are also confirmed, including when and how the family and the Family Team will be updated with Touch Points and/or Progress Review (full team) meetings. Clinicians are responsible for the ongoing monitoring and evaluation of their assigned responsibilities and the Family Team Lead ensures this is reviewed on a regular basis. The parent/youth may decide that next steps be determined either at that meeting or following that meeting with support from the OAP Behavioural Clinician. The next steps are determined based on an individual’s needs and can include an updated Behaviour Plan with continued or new goals.

Note: An updated behavioural assessment and/or other required assessments may be required when there is a marked change in needs, priorities and/or intervention goals.

Monitoring and Evaluating the Behaviour Plan

As a child/youth is receiving behavioural intervention, progress information is shared regularly through informal updates (Touch Points) with the family and their Family Team.

Behaviour plans are not static and should be monitored and evaluated on an ongoing basis to ensure a child’s/youth’s continuous progress. Monitoring and evaluation of the Behaviour Plan is the responsibility of the OAP Behavioural Clinician. The Behavioural Clinician will also examine the effectiveness of programming and treatment fidelity. On an ongoing basis, the Behavioural Clinician will monitor the child’s response to treatment. If a child is not making progress, the Behavioural Clinician will examine what has been done or could be done to refine the Behaviour Plan.

The OAP Behavioural Clinician writes a progress summary every six months or sooner if needed. The progress summary will include the target skills/behaviours, the behavioural goals, a brief description of the intervention, the results to date (based on data), and recommendations for next steps. The OAP Behavioural Clinician reviews the summary with the family/youth and Family Team and provides them with a copy of the summary.


Progress Reviews and Updates to the Story

Communication between each family and their OAP Behavioural Clinician is individualized and determined with the family/youth as part of the OAP Behaviour Plan. A progress summary will be provided to the family and Family Team at least every six months.

There is an expectation that Touch Points will occur between the OAP Behavioural Clinician and the family/youth and Family Team, on an ongoing basis as needed (i.e., in response to significant changes to goals or strategies). An update of the child’s overarching needs and strengths is conducted every six months or sooner as needed.

In addition to the regular progress reviews, there will be a clear, mutual understanding of the Touch Points (e.g., updating conversations, emails, etc.) that will occur in between progress reviews. The Touch Points will be determined collaboratively with the family/youth.

Progress reviews with the Family Team will occur at least every six months. They will “build on the story” developed at intake and involve:

If there are changes to the behaviour plan (e.g., significant changes to goals and/or methods) this information is conveyed through an agreed upon form of communication (e.g., written, telephone, meeting) to parents and Family Team members. All verbal communication is documented in written form by the Behavioural Clinician.

As the goals outlined in the OAP Behaviour Plan are met, the OAP Behavioural Clinician initiates a family team meeting, as appropriate, to determine next steps and plan for a transition to the next intervention. Transition decisions are individualized based on the achievement of goals, and are made by the family/youth and the behavioural clinician based on the current profile of strengths and needs of the child/youth and their family.

This image describes the critical elements of clinical-decision making: building or updating the story, develop/update a behaviour plan, delivery of behavioral intervention, and touch points and progress review.

Figure 3: Critical Elements of Clinical Decision-Making