29

3Applied behAviorAl AnAlysis

Mallory l. dimler and elisabeth hollister sandberg

WhAt is Applied behAviorAl AnAlysis? Applied Behavioral Analysis (ABA) is a comprehensive, behavioral treatment program designed to increase positive skills and behaviors, and to decrease problematic behaviors in children with ASD. ABA involves having trained therapists make careful observations of specific behaviors and the factors that trigger these behaviors. Positive reinforcement is then used to shape behavior into new pro- social skills. Problematic behaviors are addressed by not providing reinforcement for them. ABA is implemented in both structured (e.g., school-based ABA program) and unstructured (e.g., at home) environments, so that the child can learn how to generalize behavior changes across settings.

The term “Early Intensive Behavioral Intervention” (EIBI) refers to programs of 25 or more hours per week of one- on-one ABA therapy for very young children (ages two to six). The term EIBI, for all intents and purposes, is the same thing as “ABA program” when referring to interventions with young children.

C o p y r i g h t 2 0 1 2 . J e s s i c a K i n g s l e y P u b l i s h e r s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing : eBook Academic Collection (EBSCOhost) – printed on 9/16/2023 1:32 PM via UNIVERSITY OF MASSACHUSETTS – GLOBAL AN: 499253 ; Elisabeth Hollister Sandberg, Becky L. Spritz.; A Brief Guide to Autism Treatments Account: ns253283.main.eds

A Brief Guide to Autism Treatments30

hoW does Applied behAviorAl AnAlysis supposedly Work As A treAtment For Asd? The development of ABA was influenced by the Young Autism Project (YAP), a highly structured behavioral program for children with ASD created by O. Ivar Lovaas in 1970. This program was designed to provide individualized, one-to-one behavioral training in the child’s home.

ABA is based on the principles of behaviorism, a psychological learning theory that explains how people learn and behave. Behaviorism asserts that an individual’s actions are neither random nor unpredictable; all behaviors have a purpose. According to this theory, behaviors that are reinforced (for which a positive consequence occurs) are more likely to be repeated. Although this seems to be a straightforward idea, reinforcement can be a subtle and extremely complicated thing. Our tendency is to view reinforcement as a transparent positive event (such as receiving praise for doing something right). When looking at the behaviors of ASD the notion of reinforcement goes much deeper than simply receiving parental approval or disapproval in response to a behavior. If a child with ASD regularly engages in an undesirable behavior, that behavior is occurring because the consequences of the behavior are in some way rewarding for the child. The central goal of ABA is for the child with ASD to learn specific skills that will increase the likelihood of becoming as independent and successful as possible in the future—skills such as being able to greet people politely, request things, stand in line and button a coat.

The first step in initiating ABA therapy is for a licensed ABA therapist to conduct a Functional Behavioral Analysis. During a Functional Behavioral Analysis, positive and negative behavior patterns—patterns that promote or

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Applied Behavioral Analysis 31

interfere with functioning within the family or classroom— are identified. Building on the principles of learning theory and behaviorism, the ABA therapist formulates theories about what triggers various behaviors and how those behaviors are reinforced. With input from parents and teachers, an individualized plan is developed to specifically address targeted behaviors. Specific intervention techniques (usually in the form of small and immediately gratifying rewards, which are called “positive reinforcers”) are used to assist the child in producing and maintaining desired, socially meaningful behaviors. Problematic behaviors are purposely redirected or not reinforced (e.g., not responding to a child’s screaming if it has been identified that the goal of screaming is to obtain a parent’s attention). Continual monitoring and observation gives the therapist feedback regarding the child’s progress so that treatment plans can be adjusted.

Within the field of ABA, there are two dominant intervention methods that are used to when treating ASD: discrete-trial teaching (DT) and pivotal response training (PRT).

discrete-trial teaching Discrete-trial teaching, also known as the Lovaas method, is what most people are referring to when they say “ABA.” It is comprised of formal one-on-one training sessions between a child and an ABA therapist. Within each training session, one particular skill is practiced through repeated trials (attempts). The term “discrete” means that each trial is separate from the next. Trials are designed to be brief and are broken down into four parts: an instruction from the therapist, a response from the child, an immediate consequence for the response, and a short interval of down-time before starting the next trial.

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A Brief Guide to Autism Treatments32

Once the basic skills of a behavior have been mastered, complex skills (skills identified as important for the child to improve or increase) are broken down into smaller sets of basic subskills. Subskills are taught and reinforced through repeated trials of instruction, response and consequence, with trials repeated until a positive result is obtained consistently. For example, a family might decide that it is important for their four-year-old son with ASD to respond appropriately when greeted by another person. This is a complex skill. Subskills within this complex behavior include making eye contact, saying “Hi” back, and adding the name of the person. Initially the child will receive reinforcement for executing small parts of the desired response. Consider the following sample intervention:

Therapist Nancy is working with four-year-old Alex on responding appropriately to greetings. Nancy and Alex sit down facing each other (usually across a desk or table). Alex is not paying attention to Nancy. Nancy will brightly and loudly say, “Hi, Alex!” The tone of her voice will induce Alex to look at her. Nancy will immediately say, “Good looking!” while giving Alex a small reward (such as a pretzel or a raisin). There will be a brief period of inactivity (the interval) before Nancy repeats this exchange, which represents a behavioral sequence. When Alex learns that rewards are received for looking, he will be more likely to make eye contact when Nancy says, “Hi.” Eventually Nancy will be able to reduce her tone to a more normal level.

Building on these skills, Nancy may then target getting consistent eye contact from Alex in response to her greeting. She models the desired behavior for him. When she says, “Hi, Alex!” Alex makes eye contact but says nothing while waiting for his treat. Nancy holds the treat up and says, “Say hi.” She will repeat this until Alex at least makes the tiniest approximation of saying “Hi”—for which he will receive

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Applied Behavioral Analysis 33

praise and his reward. Future trials will require making eye contact as well as saying “Hi” in order to earn a reward. By breaking down skills like this, behavior is shaped into the complete desired response.

pivotal response training Pivotal response training is a procedure that focuses on reinforcing and shaping pivotal behaviors that are essential for social, emotional and intellectual functioning. In contrast to DT, PRT is more loosely structured and uses naturally occurring teaching opportunities that spontaneously arise in the child’s interactions with others. Strategies used in PRT include organizing the environment to include the child’s preferred toys and activities that, through behavior initiated by the child, can be used to reinforce positive pivotal behaviors.

For example, nonverbal six-year-old Lindsay is playing in the toy area in her preschool. Lindsay reaches out for a block to add to her tower. Therapist Nancy holds the block back, looks at Lindsay and says, “Block.” Lindsay says “Blah,” and then is given the block as a reward for her verbal request. Over time, the requesting skill can be built up into clearly saying “Block,” and eventually, “I want the block.”

WhAt Will you reAd on the internet About Applied behAviorAl AnAlysis As A treAtment For Asd? There are common, persistent myths about ABA on the internet. Some will refer to ABA as a “philosophy,” implying that it reflects the basic belief systems of its proponents (in other words, they say that people who believe in ABA as an effective treatment must believe that children can be reduced to a collection of trained behaviors). ABA is not a philosophy,

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A Brief Guide to Autism Treatments34

however: it is an evidence-based scientific technique that uses the methods of experimentation (e.g., careful observation, measurement, manipulation of environment) to identify factors responsible for behavioral change. Critics will also argue that ABA produces “robot children” who are trained to perform certain tasks on demand and who can execute those skills only in artificially constructed environments and situations. Advocates defend the skill acquisition process by saying that a skill that does not come naturally must be artificially learned and practiced before it can be generalized to more natural settings.

Be alert for the use of strong language in online discussions of ABA, many of which contain misrepresentations and inaccurate information. Some media sources claim that ABA can help a child “overcome ASD” or “lose an ASD diagnosis.”1 Although ABA effectively increases pro- social behaviors and decreases problematic behaviors for children with ASD, it does not cure autism. One will also read claims that ABA is “torture,” will “traumatize your child,” and “causes much harm.” Although ABA requires diligent effort and may be challenging and stressful for both parents and children, scientific research indicates that ABA is not dangerous or harmful for children and that the procedures are safe. Notably, ABA no longer uses aversive consequences, or punishments, when children engage in problematic behaviors (e.g., slapping; shocking). Prior to the 1980s there were extreme programs that did employ aversive consequences, but any claims that ABA uses such techniques are inaccurate.

ABA therapists are either Board Certified Behavioral Analysts (BCBAs) or Board Certified Associate Behavior Analysts (BCABAs).2 To become a BCBA, one must receive advanced formal training and at least a Master’s degree, participate in supervised work designing and conducting ABA

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Applied Behavioral Analysis 35

interventions, and pass the Behavior Analyst Certification Board examination. BCABAs have fewer qualifications, including undergraduate-level coursework in behavioral analysis, supervised work conducting ABA interventions, and passing the BCABA examination. BCABAs practice under the supervision of BCBAs. Other professionals may have completed training in ABA before the BCBA certification program was developed and still others have participated in training workshops (e.g., as a part of teacher development courses). The Autism Special Interest Group of the Association of Behavior Analysis International urges parents to ask for documented credentials when hiring an ABA therapist.3

The internet is inundated with anecdotal reports about the use of ABA for ASD. Many parents discuss the improvements their children have experienced as a result of ABA while other stories highlight the challenges that parents may experience with learning ABA and the stress associated with implementing it at home. Some parents report negative experiences with ABA therapists and programs that do not follow ABA procedures appropriately. Other parents report frustration because they know ABA is a scientifically supported treatment for ASD but they cannot access or afford ABA services. Parents seeking help on this issue frequently receive tips and suggestions from other parents, including advice for accessing ABA treatment.

WhAt do scientists sAy About Applied behAviorAl AnAlysis? Although research supports ABA as being successful in improving core deficits in ASD, like any other treatment, it is not a cure. Some of the earliest high quality scientific support for ABA was Lovaas’ 1987 Early Intervention Project.

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A Brief Guide to Autism Treatments36

Dr. O. Ivar Lovaas studied 38 children with ASD who were under four years old.4 Half of the children participated in one- on-one intensive behavioral treatment, mostly discrete-trial training, for approximately 40 hours a week. The remaining children served as a control group, and received ten hours or fewer of the same one-on-one behavioral treatment. Children who participated in the intensive treatment for two or more years experienced significant improvements in IQ, social and school functioning. The inclusion of a control group and the use of a homogeneous sample of children gives strength to these conclusions.

Since then, additional research has pointed to the increased likelihood of achieving success with ABA if interventions are started at a young age (before the age of five years). One particular research team examined 34 studies that had been conducted on the effects of ABA programs for young children with ASD. Generally, children with ASD who participated in Early Intensive Behavioral Intervention across these studies experienced improvements in IQ , communication and social skills, and daily living skills. The evidence, though compelling, is not perfect. Only nine of the studies included a treatment group and a control group for comparison. Also, when comparing EIBI with any other intervention, one needs to establish that the effects are due to the behavioral intervention itself, and do not simply stem from spending 30 hours per week with a highly educated, attentive adult. Studies are needed in which EIBI is compared to other interventions conducted with similar intensiveness and by comparably trained adults.

Because of its behavioral focus, ABA is one of the most widely researched treatments for ASD. Moreover, the research on ABA is most consistent with the scientific standards for evaluating effective treatments (see Chapter 2 on Science and Scientific Vocabulary). In fact, in 2012, researchers

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Applied Behavioral Analysis 37

reviewed the cumulative body of evidence on ABA through an examination of five different meta-analyses.5 This collective evidence definitively indicates that early intensive ABA programs can be powerful interventions that produce large gains in IQ and adaptive behaviors among children with ASD.

In conclusion, ABA has been recognized as a primary, scientifically supported treatment for ASD by the US Surgeon General and the American Academy of Pediatrics.6, 7 ABA treatment methods were also recognized in 2009 as “established treatments” for ASD by the National Autism Center’s National Standards Project, indicating that there is sufficient compelling scientific evidence to conclude that ABA is an effective ASD intervention.8 Currently researchers are working on designing ABA programs that balance a structured format and natural settings, to increase the likelihood of rapid skill attainment and generalization across settings.

WhAt Are the costs oF Applied behAviorAl AnAlysis? ABA treatment programs are frequently school based, and thus free of charge to qualifying families. School funding and resources may vary, though, and systems are seldom able to provide a full-time (30–40 hours per week) ABA program. Private ABA therapy is extremely expensive. Cost estimates for a full-time private ABA program range from $30,000 to $50,000 a year. Because of the strong scientific support for the effectiveness of ABA as a treatment for ASD, insurance coverage for ABA services is improving, but blanket coverage is still not the norm.

Parental and familial involvement and skilled ABA therapists increase treatment effectiveness and generalization.

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A Brief Guide to Autism Treatments38

Parents can be taught to implement ABA teaching plans, but regular professional consultation with an ABA therapist is required—not only to conduct the Functional Behavioral Analysis but also to evaluate data and update teaching plans accordingly. Licensed ABA therapists usually charge at least $50 per hour, though this varies widely by region and level of experience. An ABA program requires a large time commitment and a great deal of consistent effort.

Applied behAviorAl AnAlysis (AbA)

Ages most effective in young children

Anecdotal parental support

not much mixed positive

scientific evidence

weak moderate strong

Availability limited moderate wide

cost (time and money)

minimal moderate high

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Professional Practice

Identifying Evidence- Based Special Education Interventions From Single-Subject Research Jennifer Freeman and George Sugai

Special educators are aware of the

need to use evidence-based academic

and behavioral interventions in their

classrooms. Using research to guide

decision making in the classroom—

whether at the program, school, or dis-

trict level—can help ensure students

are effectively served. A second-grade

resource room teacher, Mark, struggles

with managing the behavior of several

students who have trouble staying on

task and completing work. Cindy, a

middle school special education

teacher, teaches a self-contained pro-

gram and is looking for a way to teach

writing skills to a seventh-grade stu-

dent with a learning disability. How

can Mark and Cindy find out about

best practices, and read reviews or

summaries of recent studies? Cur-

rently, there is no rigorous and com-

prehensive database to support educa-

tors. It also can be difficult for teach-

ers, schools, and policy makers to

interpret the results of research. Des-

pite the limitations in currently avail-

able resources, there are ways for spe-

cial education teachers and administra-

tors to identify evidence-based prac-

tices that fit their specific contexts.

6 COUNCIL FOR EXCEPTIONAL CHILDREN

The most recent authorizations of the Individuals With Disabilities Education Act (IDEA, 2006) and the No Child Left Behind Act of 2001 (2006] provide a mandate for the use of evidence-based practices (EBPs) in the areas of aca- demic and behavioral education (20 U.S.C. § 1414[b][6][B], 20 U.S.C. § 7801 [37]). However, the lack of a clear understanding of what EBPs are and the difficulty finding EBPs that address the specific needs of students can be frustrating for many teachers and administrators. In response, education- al researchers have attempted to evalu- ate the current research base and to define clear criteria for determining

and evaluating EBPs without clear criteria.

In order to address this issue, the U.S. Department of Education created the What Works Clearinghouse (WWC) as a resource for teachers. In addition, several other agencies, such as the Council for Exceptional Children (CEC), the American Psychological Association (APA), and the Promising Practices Network (PPN), also have attempted to bring together research results in a concise, user-friendly way for educators. Each organization has developed criteria for determining EBPs, and their web sites provide quick and easy access to EBPs for spe-

The body of educational research in special education is extremely

varied in both methodology and quality, often leaving special education teachers with the very difficult task of identifying and evaluating

[evidence based practices] without clear criteria.

EBPs (Odom et a l , 2005). However, the body of educational research in special education is extremely varied in both methodology and quality, often leaving special education teachers with the very difficult task of identifying

cific categories of students. However, differing criteria, a mismatch between current research practices and EBP standards, and limited access to specific research studies limit the use- fulness of these resources for special

education teachers. In particular, prior to 2010 the WWC prioritized random- ized group design studies and excluded from consideration the results of stud- ies using single-subject designs. This practice was particularly problematic for special educators due to the preva- lence of single-subject designs in spe- cial education research (Horner et a l , 2005).

In 2010, the WWC announced stan- dards that included criteria for identify- ing EBPs through the use of single-sub- ject research (Kratochwill et a l , 2010), and both the CEC and APA have also developed standards. However, the WWC standards do not yet align with the current standard of practice in the field of special education. Conse- quently, few special education prac- tices meet both WWC design and evi- dence standards.

Identilying Evidence-Based Practices

Table 1 provides a comparison of sev- eral web-based resources to assist spe- cial educators looking for EBPs. How- ever, to benefit from these resources, educators must be critical consumers; the sites use varying criteria to evalu- ate the design standards and effects of

single-subject research. In order to be able to evaluate practices based on sin- gle-subject research, educators must be fluent with the purpose and character- istics of single-subject research designs and the guidelines for evaluation and interpretation of that research.

Recognizing Well Designed Single-Subject Research

To judge the usefulness and strength of the results and implications from sin- gle-subject research, educators must understand the specific methods used, the strengths, and the limitations of single-subject research designs. Single- subject design studies are distinguished by several key characteristics:

• The individual case (individual or group of individuals), rather than a group, is the unit of analysis.

• The individual case serves as his or her own control.

• The researcher conducts frequent and repeated observations and measures outcomes over time to assess changes in level, trend, vari- ability, and immediacy of the inter- vention effect across differing condi- tions (e.g., participants, settings).

Despite the strengths of single-sub- ject research for special education (see box, "Strengths of Single-Subject Research"), determining what is and is not an EBP based on single-subject research can be difficult, because there is no standardized method for synthe- sizing results (Conroy, Dunlap, Clarke, & Alter, 2005; Mooney, Epstein, Reid & Nelson, 2003). Single-subject research designs identify causal relationships between an intervention and an observed effect in a specific setting and context and with a specific individual. Generalizable statements to larger pop- ulations of individuals are difficult to make from single-subject research.

Systematic and repeated demon- stration of the effect of the interven- tion is a key requirement for establish- ing a causal relationship between an intervention and an observed effect. In single-subject research these replica- tions occur across individual students, settings, or conditions. Common single- subject designs include ABAB, alternat- ing treatment, or multiple baseline designs. The goal is to control and account for internal threats to validity such as practice effects or an outside event that may affect the outcomes.

TEACHING EXCEPTIONAL CHILDREN | MAY/JUNE 2013 7

Table 1 . Web Resources for Identifying Evidence-Based Practices

Features

Design standards for SSR published and available

Design standards matched to current research practices

Evidence standards for SSR published and available

Provides links to intervention descriptions

Provides links or references to research used for determinations

Fee required

ft

What Works Clearinghouse

http://ies.ed.gov/ncee/wwc/

X

X

X

X

Resource iiMiiM|iMi[MimM

Council for Exceptional Children http://www.cec.sped.org

X

X

X

X

only includes research

commissioned by CEC

X

American Psychological Association

Iittp://www.apa.org/education/kl2/index.aspx

X

X

X

Promising

Practices Network

http://www.promisingpractices.net/

group designs only

group designs only

X

Note. SSR = single-subject research.

Traditionally, the effects of single- subject research are evaluated using visual analysis. Researchers graph and evaluate outcome data for changes in trend (direction), level (mean/median level), and variability (fluctuation) within and across phases. Because decision rules have not been sufflcient- ly tested and established to guide visu- al analysis and interpretation of single- subject research data, inaccurate, inconsistent, or limited interpretations can result.

In addition to visual analysis, sin- gle-subject researchers often calculate an effect size, typically reported in standardized units that make compar- isons of effect easier across studies and participants. The most prevalent reported effect size involves an exami- nation of non-overlapping data points (54.65%) followed by a calculation of the standardized mean difference (18.6%; Maggin, 2011). There is cur- rently no agreed-upon method for cal-

culating an effect size in single-subject research, which makes it difflcult to synthesize research results.

In sum, single-subject research designs have a number of strengths and useful characteristics that make them appealing to conducting studies that identify EBPs in special education. However, because of (a) a reliance on visual analysis procedures, (b) a lack of an effect size metric and methodolo- gy, and (c) a need for standardized cri- teria for effective implementation and interpretation, special educators also need guidance on how to systematical- ly evaluate the existing research evi- dence base.

Evaluating and Interpreting Research

Given the signiflcant but insufflcient advances associated with using single- subject research methodologies to iden- tify EBPs, teachers and administrators require additional guidance as they

attempt to interpret research and judge

practices that are examined with sin-

gle-subject research methods. Table 2

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