OPINIONS & PERSPECTIVES

None of the As in ABA stand for autism: Dispelling the myths*

KAROLA DILLENBURGER 1

& MICKEY KEENAN 2

1 Queen’s University Belfast, Ireland and

2 University of Ulster at Coleraine, Ireland

Keywords: applied behaviour analysis (ABA), autism spectrum disorder (ASD), misunderstanding

Introduction

Interventions that are based on scientific principles

of applied behaviour analysis (ABA) are recognised

as effective treatments for children with autism

spectrum disorder (ASD) by many governments

and professionals (Office of the Surgeon General,

2000; Ontario IBI Initiative, 2002). However, many

still view ABA as one of many treatments for

autism and contend that it should be part of an

eclectic mix of interventions. This paper addresses

this issue by outlining what ABA is and how ABA is

related to the array of treatments for ASD. With

approximately 1 in 100 children diagnosed with

ASD, it is important for professionals to understand

ABA accurately.

Getting it right

ABA is not a ‘‘therapy for autism’’ (Chiesa, 2005);

instead, it is the science on which a wide range of

techniques are based that have been used to help

people with a variety of behaviours and diagnoses,

autism being one of them.

Like most other sciences, behaviour analysis

encapsulates three distinct but related fields:

(1) Philosophy of the science: behaviourism.

(2) Basic experimental research: Experimental

analysis of behaviour.

(3) Applied research: Applied behaviour analysis

(ABA).

(1) Behaviourism: The philosophy of the science of

behaviour

Behaviourism defines behaviour as anything a person

does. Behaviour can have one or more dimensions,

such as frequency, duration, and/or latency; can be

overt (public) or covert (private); can be observed

and recorded by one (self) or more persons; and is

lawful, in as much as it is influenced by environ-

mental events.

The key point of behaviourism is that what people do

can be understood. Traditionally, both the layperson

and psychologist have tried to understand behaviour by

seeing it as an outcome of what we think, what we feel,

what we want, what we calculate, and etcetera. But we

don’t have to think about behavior that way. We could

look upon it as a process that occurs in its own right and

has its own causes. And those causes are very often

found in the external environment. (Cooper, Heron, &

Heward, 2007, p. 15)

One of the main advantages of defining behaviour

as ‘‘anything a person does,’’ apart from being

inherently a holistic perspective, is the way that it

permits ‘‘private behaviour’’ (e.g., thinking and

cognitions, and feelings and emotions) to be

considered when developing explanations. A child

who behaves in certain ways (e.g., makes no social

contact, engages in repetitive, self-stimulatory beha-

viour) is typically said to have ASD, and ASD is

referred to then as the reason (i.e., cause or

*This manuscript was accepted under the Editorship of Roger J. Stancliffe.

Correspondence: Dr Karola Dillenburger, School of Education, Queen’s University Belfast, 69/71 University Street, Belfast, BT7 1HL, Ireland.

E-mail: [email protected]

Journal of Intellectual & Developmental Disability, June 2009; 34(2): 193–195

ISSN 1366-8250 print/ISSN 1469-9532 online ª 2009 Australasian Society for the Study of Intellectual Disability Inc. DOI: 10.1080/13668250902845244

explanation) for the said behaviours; ‘‘he does this

because he has ASD.’’ In reality though, the term

ASD is merely a ‘‘summary label’’ (Grant & Evans,

1994) for the full range of the child’s behaviours, not

the cause of them.

The philosophical basis of modern behaviour

analysis stems from the early work of Skinner (e.g.,

Skinner, 1938) and sits in stark contrast to the earlier

methodological behaviourism, in which only publicly

observable behaviour was considered relevant to

psychology (Leigland, 1992). In contrast, today’s

behaviour analysts consider ‘‘everything a dead man

cannot do’’ as in the purview of analysis.

(2) Experimental analysis of behaviour

The laboratory-based experimental analysis of beha-

viour has evolved from over 100 years of research and

has lead to the discovery of many principles of

behaviour; for example, respondent (or classical)

conditioning, operant conditioning, derived rela-

tional responding, and so forth (Sidman, 1994).

(3) Applied behaviour analysis (ABA)

Applied Behaviour Analysis is the science in which

tactics derived from the principles of behaviour are

applied systematically to improve socially significant

behaviour and experimentation is used to identify the

variables responsible for behaviour change. (Cooper et al.,

2007, p. 20)

ABA brings improvements and change in socially

relevant behaviours within the context of the

individual’s social environment; is conducted within

the scientific framework; focuses on functional

relationships and replicable procedures; is concep-

tually systematic and reflective; achieves measurable

changes in relevant target behaviours that last across

time and environments; is accountable, public,

doable, empowering, optimistic; and is more effec-

tive than eclectic treatments. Aversive methods are

avoided in favour of interventions based on func-

tional assessment and functional analysis and posi-

tive reinforcement.

Dispelling the myths about ABA and autism

The effectiveness of ABA-based intervention in ASDs

has been well documented through 5 decades of

research by using single-subject methodology and in

controlled studies of comprehensive early inten-

sive behavioural intervention programs in univer-

sity and community settings. (Myers & Johnson, 2007,

p. 1164)

Many lay people as well as professionals equate the

pioneering work of Lovaas (1987) with ABA.

However, behaviour analysts at the Princeton Child

Development Institute demonstrated the effective-

ness of early, comprehensive, intensive ABA 2 years

prior to the publication of Lovaas’s study (Ferster &

DeMyer, 1961). Since then, more than 19,000

papers have been published using ABA within a

variety of areas, including well over 500 studies

concentrating on children with ASD (Anderson &

Romanczyk, 1999).

When ABA is mistakenly categorised as a therapy

for autism, rather than as a science, it is listed

alongside a range of techniques such as Discrete Trial

Training (DTT), Picture Exchange Communication

System (PECS), Verbal Behavior Analysis (VBA),

Precision Teaching, generalisation and skill main-

tenance training, Pivotal Response Training (PRT),

prompting and prompt fading, imitation and

instruction, Aggression Replacement Training (ART),

shaping, Intensive Behavioural Intervention (IBI),

chaining, differential reinforcement, incidental teach-

ing, extinction, and others (Green, 1996). However,

it is the knowledge base gathered from the science of

ABA that underpins all of these techniques. For

practitioners, this means that learning specific tech-

niques is not the same as learning the science.

Training and professional certification

The Behavior Analyst Certification Board (BACB,

2007) certifies and regulates ABA professionals.

There are two levels of certification. Board Certified

Behavior Analysts (BCBA) must have at least Masters

degree level training in behaviour analysis as well as

1,500 hours supervised independent fieldwork ex-

perience prior to taking a rigorous 4-hour exam. At

present there are nearly 3,500 BCBAs worldwide.

Board Certified Associate Behavior Analysts (BCABA),

who since January 2009 are now termed Board

Certified assistant Behavior Analysts (BCaBA), must

have at least Bachelor degree level training in

behaviour analysis and 1,000 hours supervised

independent fieldwork experience prior to taking

the exam, and must be supervised by a BCBA

afterwards.

Discussion

In this paper we made three important points to

dispel the myths of the relationship between ABA

and autism treatment:

(1) ABA is an applied science that has evolved

from more than 100 years of research.

194 K. Dillenburger & M. Keenan

(2) This scientific research has produced a

wealth of evidence-based intervention proce-

dures, which are in turn derived from or

related to several more basic behavioural

principles.

(3) These procedures have been applied with

considerable success in the treatment of

autism. However, readers should not equate

ABA with any particular application or

program (e.g., Discrete Trial Training).

The scientific method applied to the study of

individual’s behaviours was pioneered by ABA. It is

not autism specific, but it guides the development of

techniques that address any socially relevant beha-

viour. When applied to children who display autistic

behaviours, ABA is method driven only in the sense

that the scientific method guides decision making

with respect to data collected. By responding to the

specific needs of each individual within their social

context, ABA offers a holistic and comprehensive

alternative to an eclectic mixture of techniques

that are not anchored in a science of behaviour

(Howard, Sparkman, Cohen, Green, & Stanislaw,

2005; Zachor, Ben-Itzchak, Rabinovich, & Lahat,

2007).

References

Anderson, S. R., & Romanczyk, R. G. (1999). Early intervention

for young children with autism: Continuum-based behavioral

models. Journal of the Association for Persons with Severe

Handicaps, 24, 162–173.

Behavior Analyst Certification Board (BACB). (2007). Retrieved

10 October 2007 from http://www.bacb.com

Chiesa, M. (2005). ABA is not ‘a therapy for autism’. In M.

Keenan, M. Henderson, P.K. Kerr, & K. Dillenburger (Eds.),

Applied behaviour analysis and autism: Building a future together

(pp. 225–240). London: Jessica Kingsley.

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied

behavior analysis (2nd ed.). Upper Saddle River, NJ: Prentice

Hall.

Ferster, C. B., & DeMyer, M. K. (1961). The development of

performances in autistic children in an automatically con-

trolled environment. Journal of Chronic Disease, 13, 312–345.

Grant, L., & Evans, A. (1994). Principles of behavior analysis.

New York: HarperCollins.

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does research tell us? In C. Maurice, G. Green, & S. C. Luce

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manual for parents and professionals (pp. 29–44). Austin, TX:

Pro-Ed.

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Stanislaw, H. (2005). A comparison of intensive behavior

analytic and eclectic treatments for young children with autism.

Research in Developmental Disabilities, 26, 359–383.

Leigland, S. (Ed.). (1992). Radical behaviorism: Willard Day on

psychology and philosophy. Reno, NV: Context Press.

Lovaas, O. I. (1987). Behavioral treatment and normal educa-

tional and intellectual functioning in young autistic children.

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Myers, S. M., & Johnson, C. P. (2007). Management of

children with Autism Spectrum Disorders. Pediatrics, 120,

1162–1182.

Ontario IBI Initiative. (2002). Retrieved 10 October 2008 from

http://www.bbbautism.com/ont_new_funding.htm

Sidman, M. (1994). Equivalence relations and behavior: A research

story. Boston: Authors Cooperative.

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analysis. New York: Appleton-Century.

Office of the Surgeon General (OSG). (2000). Mental health: A

report of the Surgeon General. Retrieved 10 December 2008 from

http://www.surgeongeneral.gov/library/mentalhealth

Zachor, D. A., Ben-Itzchak, E., Rabinovich, A.-L., & Lahat, E.

(2007). Change in autism core symptoms with intervention.

Research in Autism Spectrum Disorders, 1, 304–317.

Opinions & Perspectives: Applied behaviour analysis 195

ANRV407-CP06-18 ARI 22 February 2010 15:48

Behavioral Treatments in Autism Spectrum Disorder: What Do We Know? Laurie A. Vismara and Sally J. Rogers M.I.N.D. Institute, University of California, Davis, Sacramento, California 95817; email: [email protected]

Annu. Rev. Clin. Psychol. 2010. 6:447–68

First published online as a Review in Advance on January 4, 2010

The Annual Review of Clinical Psychology is online at clinpsy.annualreviews.org

This article’s doi: 10.1146/annurev.clinpsy.121208.131151

Copyright c© 2010 by Annual Reviews. All rights reserved

1548-5943/10/0427-0447$20.00

Key Words

applied behavior analysis, autism spectrum disorder, intervention, discrete trial training, naturalistic behavioral teaching

Abstract Although there are a large and growing number of scientifically ques- tionable treatments available for children with autism spectrum disorder (ASD), intervention programs applying the scientific teaching principles of applied behavior analysis (ABA) have been identified as the treatment of choice. The following article provides a selective review of ABA in- tervention approaches, some of which are designed as comprehensive programs that aim to address all developmental areas of need, whereas others are skills based or directed toward a more circumscribed, specific set of goals. However, both types of approaches have been shown to be effective in improving communication, social skills, and management of problem behavior for children with ASD. Implications of these findings are discussed in relation to critical areas of research that have yet to be fully explored.

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Autism spectrum disorder (ASD): a group of neurobiological disorders characterized by impaired social interaction and communication and by restricted and repetitive behavior

Applied behavior analysis (ABA): an applied science devoted to understanding the laws by which the environment affects behavior in order to address socially significant problems for individuals with disabilities

Contents

INTRODUCTION . . . . . . . . . . . . . . . . . . 448 COMPREHENSIVE-BASED

ABA MODELS . . . . . . . . . . . . . . . . . . . . 449 SKILLS-BASED APPLIED

BEHAVIOR ANALYSIS MODELS 455 SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . 459

INTRODUCTION

Autism spectrum disorder (ASD) is a group of neurobiological disorders with long-term im- plications for the individuals concerned, their families, and for the provision of education and habilitative services. In recent years, there has been a dramatic increase in the number of in- dividuals, of all ages and all levels of ability and severity, seeking treatment services for autism (Kogan et al. 2008). It is now widely acknowl- edged that the forms of treatment with the most empirical validation for effectiveness with indi- viduals with ASD are those treatments based on a behavioral model (Natl. Res. Counc. 2001). A defining characteristic of these treatments is their foundation in the experimental anal- ysis of behavior, which is a science devoted to understanding the laws by which environ- mental events influence and change behavior. The clinically applied field from this science is known as applied behavior analysis (ABA), and the development of the behavioral treatments of autism is largely the result of this field of science (Schreibman 2000).

ABA requires careful assessment of how environmental events interact to influence an individual’s behavior. The assessment consists of contextual factors such as the setting in which a behavior occurs; motivational variables such as the need to attain something; antecedent events leading to the occurrence of a behavior, such as a request to do something or a question from another person; and consequences or events following the behavior that dictate whether the behavior is likely to occur again. A detailed assessment of how the environment

and the individual’s behavior interact is crucial because the information resulting from this as- sessment leads to the design, implementation, and additional evaluation of environmental interventions intended to change behaviors. For individuals with ASD, these behaviors typically include language and communication, social and play skills, cognitive and academic skills, motor skills, independent living skills, and problem behavior (Smith et al. 2007). Progress in achieving the desired behavior change is typically determined by direct observations that occur on multiple occasions with the same individual over time. An equally important measurement is the acceptability of the interventions and outcomes to the treated individual, as well as the impact on caregivers and other family members (Wolf 1978).

Initial evidence of the effectiveness of ABA treatment models appeared in the 1960s with papers by Wolf, Risley, and Lovaas, who used highly structured operant learning paradigms to build behavioral repertoires and improve maladaptive behaviors of children with autism (e.g., Baer et al. 1968; Lovaas et al. 1966, 1967; Risley 1968). These behavioral programs led to increased language, social, play, and academic skills and reduced some of the severe behavioral problems often associated with the disorder. These studies were seminal in that they were the first to demonstrate empirically validated gains in children with autism. However, in addition to these promising results, data concerning maintenance and generalization indicated some limitations to their effectiveness (e.g., Lovaas et al. 1973). Subsequent research has addressed these problems, leading to enhanced effectiveness of ABA treatments for communi- cation (Cohen et al. 2006, Sallows & Graupner 2005), social skills (McConnell 2002), and management of problem behavior (Horner et al. 2002). As demonstrated in these studies, ABA approaches have evolved and broadened to include comprehensive behavioral packages designed to address all developmental areas of need and applied across all (or an extended part) of the child’s day, as well as behavioral strategies that focus on a narrow response

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pattern or set of skills; both of which result in widespread and durable treatment outcomes.

COMPREHENSIVE-BASED ABA MODELS

Perhaps the most well-known of the behavioral approaches is discrete trial training (DTT; Lo- vaas 1981), also referred to as early intensive be- havioral intervention (EIBI) if delivered before age 5 years. DTT involves breaking down com- plex skills and teaching each subskill through a series of highly adult-structured, massed teach- ing trials. Each trial or learning opportunity consists of a concise and consistent instruction for a response, typically the imitation of the therapist’s model or compliance with a verbal request, and acquisition occurs through the use of explicit prompting and shaping techniques with systematic reinforcement contingent upon the child’s production of the target response. Teaching trials are typically delivered in blocks over the course of 20–40 hours per week for two or more years, with skill emphasis in communi- cation, social skills, cognition, and preacademic skills (e.g., letter and number concepts, match- ing) (Leaf & McEachin 1999).

In the most well known study of this method, Lovaas (1987) reported an average gain of 20 IQ points for 19 young children with autism receiving 40 hours per week of EIBI for two years or more. Initially, the treatment occurred in children’s homes in order to provide highly structured one-on-one teaching. As children improved, instruction extended to facilitating social interaction and transitioning to typical preschools and other community settings. Re- sults revealed that nine children from the EIBI group (47%) achieved average intellectual func- tioning (IQ over 75) and attended general ed- ucation classrooms. The two other matched control groups, in which one group received only 10 hours of behavioral intervention and the other group received other types of in- tervention, showed virtually no changes in IQ scores. In fact, only 1 child out of the 40 com- parison children was reported to have intel- lectual functioning in the normal range. In a

Discrete trial training (DTT): an intervention approach that teaches behaviors by breaking down complex skills and teaching each subskill through a series of highly adult- structured, massed teaching trials

EIBI: early intensive behavioral intervention

follow-up study, McEachin et al. (1993) found that the intellectual and academic gains of the original EIBI group remained consistent sev- eral years after treatment, with an average of up to 13 years of age. Additional studies have attempted to replicate the original findings re- ported by Lovaas (1987), including one study using a randomized controlled design (Bibby et al. 2002; Cohen et al. 2006; Eikeseth et al. 2002; Howard et al. 2005; Luiselli et al. 2000; Sallows & Graupner 2005; Smith et al. 2000a,b; Takeuchi et al. 2002).

In examining findings from studies of Lovaas’s treatment approach, two important points stand out. First, three groups—Cohen et al. (2006), Howard et al. (2005), and Sallows & Graupner (2005)—reported findings of best outcome status in approximately half of their groups of treated children, thus supporting Lovaas’s (1987) original findings that “recov- ery,” defined as IQs in the normal range and educational placement in typical age-level class- rooms without supports, may occur for a signif- icant subgroup of children with autism treated early enough and intensively enough. Second is that DTT delivered to young children at a high level of intensity and supervised by experienced therapists with rigorous levels of training and supervision results in marked group increases in standardized test scores. Nonetheless, chil- dren may continue to show significant deficits in intellectual, language, social, and adaptive functioning, and as many as 50% of the chil- dren who receive DTT may show no substantial change in symptoms or test scores after exten- sive, intensive intervention. The few compara- tive studies (Eikeseth et al. 2002, Howard et al. 2005) to examine effects of Lovaas’s approach compared to eclectic approaches demonstrated statistically significant differences in test scores in favor of Lovaas’s treatment. Thus, intensity of treatment without consistently applied ABA strategies and techniques was not sufficient for treatment effectiveness.

Although DTT has been successful for im- parting important behaviors to children with autism, it has been criticized for several rea- sons. First, the adult-directed nature of the

www.annualreviews.org • Behavioral Treatments in Autism Spectrum Disorder 449

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PRT: pivotal response training

instruction and strict stimulus control can limit the spontaneous use of skills (Schreibman 1997a). Second, the highly structured teaching environment (Lovaas 1977) and use of artifi- cial or unrelated reinforcers (Koegel et al. 1987) can prevent generalization to the natural envi- ronment and lead to cue dependency and rote responding (Horner et al. 1988, Schreibman 1997b). Concerns have also been noted in some applied settings with respect to the level of expertise and amount of staff time that are required in order for correct implementa- tion of the intensive teaching procedures in- volved. Moreover, the use of punitive pro- cedures following inaccurate responses may contradict other teaching philosophies (i.e., positive behavior support) adopted by many facilities.

In response to some of the difficulties asso- ciated with DTT, new behavioral interventions have been developed that include more natural- istic, spontaneous types of learning situations that embed the child’s interest into teaching op- portunities. These include incidental teaching (e.g., Hart & Risley 1980, McGee et al. 1991), natural language paradigm or pivotal response training (PRT; e.g., Koegel et al. 1987, Laski et al. 1988, Schreibman & Koegel 1996), and milieu teaching (Alpert & Kaiser 1992, Kaiser & Hester 1996). These treatment approaches share commonalities in terms of embedding teaching opportunities within naturally oc- curring events (e.g., play routines, mealtime, dressing, bath time), following the child’s lead in initiating learning events, explicit prompting, reinforcing attempts, and natural reinforce- ment. These approaches also draw from the developmental literature, such as contingent imitation and linguistic mapping (Warren et al. 1993). Research suggests that these naturalistic approaches can address a variety of commu- nicative functions, such as preverbal com- munication (e.g., eye contact, joint attention) (Hwang & Hughes 2000), spontaneous produc- tions (Charlop & Walsh 1986), social amenities (e.g., please, thank you, hello) (Matson et al. 1993), peer interactions (McGee et al. 1992), answers to “Where is ?” (McGee et al.

1985), phoneme production (R.L. Koegel et al. 1998a), and increased talking (Laski et al. 1988).

However, there are mixed results on whether naturalistic behavioral approaches are superior to DTT for facilitating greater and sustain- able child changes (Goldstein 2002). Naturalis- tic teaching procedures can be more easily em- bedded into everyday activities and reduce the need to program for generalization. As a result, a number of studies have found increased spon- taneity and generalization of language gains to natural contexts and for improving effi- ciency in teaching acquisition and generaliza- tion simultaneously (e.g., L.K. Koegel et al. 1998b, McGee et al. 1985, Schreibman 1997a, Schreibman & Koegel 1996). In contrast to DTT, naturalistic behavioral approaches have also been reported as less aversive to children with autism and their treatment providers (e.g., parents), as evidenced by higher levels of pos- itive affect (Koegel & Egel 1979, Schreibman et al. 1991). Children have been shown to emit fewer disruptive behaviors and to make greater improvements in verbal attempts, word approx- imations, word production, and word combi- nations during naturalistic teaching conditions compared to the discrete trial format (R.L. Koegel et al. 1992b).

An additional benefit of naturalistic inter- ventions is the ease with which others can be taught to embed the strategies into already ex- isting activities across multiple settings, such as the home, the classroom, and the commu- nity. Schopler & Reichler (1971) highlighted the importance of including parents of chil- dren with autism as intervention agents, with- out whom gains were unlikely to be maintained (Lovaas et al. 1973). Although most ABA inter- vention approaches include a parent education program, naturalistic interventions programs are specifically designed to fit into a family’s lifestyle and routine so that teaching can oc- cur on a regular, constant basis throughout the day in natural settings. The importance of im- parting skills and knowledge to parents cannot be understated given the lack of preparation, assistance, and support parents may experience when caring for their child with autism (Koegel

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