Twenty hours a week is a part-time job. Nobody ever said it that way to me, and I did not do the arithmetic until much later.
My son was at 20 plus hours. Add the driving, the getting ready, the recovery afterwards, and there was not a great deal of week left over. What got squeezed was not therapy time. It was everything else.
The part that does not appear on any form
When a provider recommends a number of hours, the number is presented as a clinical quantity. What it actually is, from where you are sitting, is a shape imposed on your family’s week.
Nobody in the process is responsible for that part. The clinic measures the session. The insurer counts the authorisation. The person absorbing the difference is you, and there is no box on any form for it.
It is worth writing down what the real cost is, because it is easy to carry it without naming it:
- The hours themselves, plus travel, plus the time either side.
- What your child has left afterwards. If they are spent by four in the afternoon, that is time gone too.
- Unstructured play, which is not a luxury and is where a good deal of development actually happens.
- Your other children, and how much of you they get.
- Your work, and what accommodating the schedule has cost your income or your career.
- The parts of family life that quietly stop, because there is no slot left for them.
Why this is a fair thing to weigh
For a long time I would not have let myself put family life on the scale against my son’s therapy. It felt like choosing my convenience over his development, and I do not think I was the only parent who has felt that.
What changed my mind was learning that the number itself is not as solid as it is presented. A 2024 meta-analysis in JAMA Pediatrics covering 144 studies and 9,038 autistic children tested three separate measures of how much intervention a child received. None showed a significant positive association with outcomes. The authors’ conclusion was that the findings “do not support the assertion that intervention effects increase with increasing amounts of intervention.”
That does not mean therapy is useless. It means the specific tradeoff I thought I was making, more hours bought at the cost of family life, may not have been the trade it appeared to be. I was paying a real price for a benefit the evidence does not clearly show.
And the incentives around the number do not point toward restraint.
Where the hours wanted to expand into
It always felt like there was pressure for more hours, and it is worth being specific about what that actually sounded like, because it was not one conversation. It was a standing set of suggestions.
- Skip school and come to us.
- Come straight after school.
- Do evening sessions.
- Come at the weekend.
Read that as a list and you can see the shape of it. School time, after school, evenings, weekends. There is no part of a child’s week that is not being proposed as available.
The first one still stops me. Skip school and come to ABA. That is a provider suggesting a child miss his education in order to receive more of their service.
The thing I would not give up
My son did karate at a local place, and a rock climbing class. I would not agree to stop either of them, because I wanted him exposed to more things rather than fewer.
I do not think I could have justified that with evidence at the time. It was closer to an instinct that a childhood made entirely of appointments is not a childhood, and that whatever he was getting from climbing a wall on a Saturday was not nothing just because nobody was recording it on a data sheet.
If you are being asked to clear space in your week, it is worth asking what is being cleared. Not the abstract hours, the actual things. Which class, whose birthday party, which afternoon in the park, and whether anyone has weighed those against the thing replacing them.
Reducing hours is a decision you are allowed to make
You do not need a professional’s permission to consider it, though you will want their input. What helped me was framing it as a specific, reversible experiment rather than a refusal.
- Ask what would be lost, specifically, at a lower number, and how you would both know.
- Propose a time-limited trial with a review date, rather than a permanent cut. Almost nobody refuses a trial.
- Ask to reallocate rather than remove. Moving hours to speech or OT is a different conversation from wanting less therapy.
- Track what happens at home during the trial. Sleep, eating, mood, whether your child has anything left in the afternoon.
- If cost is what is holding the schedule in place, the options may be wider than you think. I wrote up what I learned about that.
What I would say to the version of me who was afraid to ask
I did eventually say no to more hours and asked for occupational therapy and speech instead. It was not comfortable. The clinic pushed back and insurance stalled, and I felt shaky about it for months.
What I did not expect was how much of the improvement afterwards came from the shape of the week rather than from the therapy in it. A child who is not spent by mid-afternoon is a different child.
Family life is not the thing you sacrifice to make room for the treatment. For a lot of children, it is part of the treatment, and it is the only part nobody is billing you for.
