When I first began working in the field, autism interventions were primarily offered in clinic and research-based settings. As those therapies and the scientific understanding of autism evolved and as the demand for services has grown, a market for home-based and community-based services emerged. Services are expanding and the availability of funding is increasing, resulting in massive growth in this sector of the behavioral health market—with more services being offered in homes, schools, and centers nationwide. It is encouraging to see increased access to intervention and broader service offerings for individuals diagnosed with autism and their families. More treatment setting options result in reaching more people in need.
While school-based intervention exists to aid children in their ability to learn and interact in their school environment, center and home-based care focus on skills for success and independence at home and in the community. These types of intervention also teach other critical life skills. Often, the setting in which a child receives services is determined by the funding source or the availability of services in the community in which they live.
There has been much debate around whether services delivered in a center are better than services delivered in the home and vice versa. Some research suggests that an ideal program may be a hybrid mix of both home-based and center-based services. Studies have shown that children made great developmental gains in gross motor, fine motor, and language skills in center-based programs. Conversely, children made great gains in self-help and social skills by participating in home-based programs. While some service providers promote only one specific setting for intervention, research has demonstrated benefits to both. The critical variables that determine outcomes are the quality of treatment and the involvement of others, as well as a variety of other factors.
The Pros and Cons of Home-Based vs. Center-Based Services
The biggest benefit to home-based intervention is that it allows children to learn skills in their home environment where they feel comfortable and secure, and where they naturally spend their time at a very young age. This intervention also lends itself to the involvement of caregivers. Essential daily living skills, like hygiene or personal care, eating, and bathing, are typically easier to teach in the environment in which those activities occur.
Many states and payers advocate specifically for services to occur in the home. However, living situations, work schedules, availability of services, and other variables may preclude some families and individuals from home-based services as a primary treatment option.
Due to this challenge, the preference of some providers, and other issues, center-based programs are the subject of increased advocacy and popularity. Center-based therapies can be extremely effective because the environment provides structure and control. While a child may have some structure in a home environment, the staff at centers have the ability to create and enforce a structured routine using the clinical setting. They can control the environment, control distractions, and create mock situations to teach skills—like paying attention, taking turns, and following instructions. They can enforce the skills while familiarizing the child with the environment and routine of specific tasks.
Environments can also be manufactured in center-based intervention to expose children to specific situations and teach critical skills. For example, if a child is preparing to attend school, staff can create an environment that mimics the classroom and help the child learn the basic skills, like following directions and participating in a group environment.
There is considerable discussion in the literature about the generalization of skills which is a critical component of skill acquisition and development. Individuals with autism often experience challenges with generalizing a skill that was learned in one environment and moving it to another environment or another person. For example, if a child learns to respond to a request delivered by a specific interventionist in a specific room, the child may not respond to the same request when delivered by a different interventionist or in a different setting. Historically, research has demonstrated that generalization of skills is compromised when services occur in a center-based setting. More recent research focusing on parent behavior has shown that parents who participated in a center-based training program focused on facilitating generalization of skills in their children at home implemented the program successfully. Their children maintained their skills acquisition in multiple environments.
Providing intensive center-based services to children under the age of 5 presents considerations that need to be accounted for. For example, most children under 5 need to nap during the day. Maintaining a routine of appropriate nap time is critical for the development and growth of young toddlers’ and children’s’ bodies and brains. This complicates service delivery because of space requirements and noise restrictions, as well as the costs of maintaining staff during these activities. Some centers fail to meet this need. One can also question whether it is appropriate for a young child to be receiving intervention in a center for 8 hours per day.
Regardless of whether the program is based in-home or at a center, service providers should emphasize the importance of parental or caregiver involvement. When the parents or caregivers are included in the treatment program and learn the skills and strategies to continue the program on their own, the child can be completely immersed in the intervention. This establishes a system of contingencies and reinforcements that continues consistently at home and at the center—twenty-four hours a day, seven days a week.
Service providers should work with parents or caregivers to help define goals. The goals should be small at first to help facilitate the parents’ or caregivers’ participation and confidence as “teachers.” It is also important that the goals be relevant to family life, such as eating and sleeping habits, and that they are tailored to fit into the natural routines of each family.
Specialists providing home-based services face the unique challenge of having to provide intervention within an existing family dynamic. Sometimes that dynamic can be very challenging. The ideal situation utilizes caregiver or parental support. However, in some cases, this kind of support is not possible. That’s why it is particularly important that additional options be made available to the market; whether they be center-based, or even hybrid in nature.
As autism prevalence increases and more children with autism prepare for adulthood, the autism services industry needs to advance with the growing need. Early intervention and therapies that teach important life skills are increasingly important. Center-based intervention with caregiver involvement can be a very valuable option. But whether a child’s best program is home-based, center-based, or a combination, there is room for advancement and enhancement of current programs, services, and outcomes.