Autism Therapy: applied behavior analysis (ABA)

What is it?

The Applied Behavior Analysis (ABA) approach teaches social, motor, and verbal behaviors as well as reasoning skills ⁽¹⁾. ABA treatment is especially useful in teaching behaviors to children with autism who may otherwise not "pick up" these behaviors on their own as other children would. The ABA approach can be used by a parent, counselor, or certified behavior analyst.

ABA uses careful behavioral observation and positive reinforcement or prompting to teach each step of a behavior ⁽²⁾. A child’s behavior is reinforced with a reward when he or she performs each of the steps correctly. Undesirable behaviors, or those that interfere with learning and social skills, are watched closely. The goal is to determine what happens to trigger a behavior, and what happens after that behavior that seems to reinforce the behavior. The idea is to remove these triggers and reinforcers from the child’s environment. New reinforcers are then used to teach the child a different behavior in response to the same trigger ⁽³⁾.

ABA treatment can include any of several established teaching tools: discrete trial training, incidental teaching, pivotal response training, fluency building, and verbal behavior (VB).

In discrete trial training, an ABA practitioner gives a clear instruction about a desired behavior (e.g., “Pick up the paper.”); if the child responds correctly, the behavior is reinforced (e.g., “Great job! Have a sticker.”). If the child doesn’t respond correctly, the practitioner gives a gentle prompt (e.g., places child’s hand over the paper). The hope is that the child will eventually learn to generalize the correct response ^(4,5).

Pivotal response training uses ABA techniques to target crucial skills that are important (or pivotal) for many other skills. Thus, if the child improves on one of these pivotal skills, improvements are seen in a wide variety of behaviors that were not specifically trained. The idea is that this approach can help the child generalize behaviors from a therapy setting to everyday settings ^{(4, 6, 7)}.

Incidental teaching uses the same ideas as discrete trial training, except the goal is to teach behaviors and concepts throughout a child’s day-to-day experience, rather than focusing on a specific behavior ^{(1, 7)}.

In fluency building, the practitioner helps the child build up a complex behavior by teaching each element of that behavior until it is automatic or "fluent," using the ABA approach of behavioral observation, reinforcement, and prompting. Then, the more complex behavior can be built from each of these fluent elements ^{(8, 9)}.

Finally, an ABA-related approach for teaching language and communication is called "verbal behavior" or VB for short ⁽¹⁰⁾. In VB, the practitioner analyzes the child’s language skills, then teaches and reinforces more useful and complex language skills ⁽¹¹⁾.

What's it like?

Through ABA training, parents and other caretakers can learn to see the natural triggers and reinforcers in the child’s environment. For example, by keeping a chart of the times and events both before and after Sammy’s tantrums, a parent might discover that Sammy always throws a tantrum right after the lights go on at night without warning. Looking deeper at the behavior, Sammy’s mother might also notice that her most natural response is to cuddle Sammy in order to get him to calm down. In effect, even though she is doing something completely natural, the cuddling is reinforcing Sammy’s tantrum. According to the ABA approach, both the trigger (lights going on at night without a warning) and the reinforcer (cuddling) must be stopped. Then a more appropriate set of behaviors (like leaving the room or dimming the lights) can be taught to Sammy, each one being reinforced or prompted as needed. Eventually, the hope is that this kind of approach will lead to a time when the lights can go on without warning and Sammy still does not throw a tantrum.

What is the theory behind it?

Many experts believe that children with autism are less likely than other children to learn from the everyday environment ⁽¹²⁾. The ABA approach attempts to fill this gap by providing teaching tools that focus on simplified instructional steps and consistent reinforcement. At best, the ABA approach can help children with autism lead more independent and socially active lives ⁽¹²⁾. Research suggests that this positive outcome is more common for children who have received early intervention. This may be due to critical brain development that occurs during the preschool years and can be affected by training ^{(3, 13)}.

Does it work?

ABA is considered by many researchers and clinicians to be the most effective evidence-based therapeutic approach demonstrated thus far for children with autism ⁽¹⁴⁾. The U.S. Surgeon General states that thirty years of research on the ABA approach have shown very positive outcomes when ABA is used as an early intervention tool for autism ⁽¹⁵⁾. This research includes several landmark studies showing that about 50% of children with autism who were treated with the ABA approach before the age of four had significant increases in IQ, verbal ability, and/or social functioning. Even those who did not show these dramatic improvements had significantly better improvement than matched children in the control groups. In addition, some children who received ABA therapy were eventually able to attend classes with their peers ^{(12, 16, 17)}.

Parents are often trained in ABA therapy, and several single-subject studies have shown that parental training helps children with autism who receive ABA therapy ⁽¹⁸⁾. Larger controlled studies looking at this issue are underway ⁽¹⁹⁾. Studies of parental satisfaction with ABA indicate that parents believe the approach is effective ⁽²⁰⁾. Parents also report that they experience less stress as a result of applying ABA ⁽²¹⁾.

Support is growing for increased use of ABA in the classroom ⁽²²⁾. One study found that ABA therapy was as effective, and sometimes more effective, than other special education intervention programs ^{(23, 24)}. High-intensity ABA therapy (for example, the Lovaas method) during preschool can be more effective than special education techniques ⁽²³⁾.

There are, however, some controversies surrounding the ABA approach ⁽¹⁴⁾. Early ABA practice (in the 1980s and early 1990s) included the use of aversive techniques such as yelling at or restraining a child. Most ABA practitioners no longer consider aversive techniques to be acceptable, and the current ABA approach is equally effective without these techniques ⁽²⁵⁾.

Experts also disagree as to whether the ABA approach should be used alone or along with other treatment methods. While there are varied opinions ⁽¹⁴⁾, most practitioners agree upon the importance of early intervention, intensive treatment for as much time as possible each day (in the range of 25 to 40 hours per week), well-trained practitioners, and consistent application of the ABA approach within and outside of school ⁽³⁾.

A crucial element of the ABA approach that is especially important for children with autism is finding appropriate reinforcement for each child. Because praise may not be rewarding for these children, careful analysis of each child's behavior can help reveal more effective reinforcement tools ⁽²⁶⁾. Examples of successful reinforcers may include access to a favorite toy or chair.

Is it harmful?

There are no known negative effects of the ABA approach. This is especially the case if gentle prompting is used rather than aversive techniques.

Cost

Although autism is a condition covered under the Individuals with Disabilities Education Act (IDEA) of 2004, whether IDEA covers intensive ABA treatment is still being considered by the courts. For legal information about IDEA, go to http://www.wrightslaw.com/.

In order to effectively implement ABA, both parents and other major caretakers are usually trained in ABA ⁽¹⁹⁾. Workshops covering the basics of ABA treatment can last from 2 to 7 days, and cost between $175 to $1,000 per person. Online ABA courses are especially useful for parents who do not live in a large city.

Children can also be enrolled in schools and clinics that specialize in ABA treatment. These can be found in most major cities and university towns. The cost of such schools can be quite high; tuition ranges from $16,000 to $25,000 per year. However, some schools offer scholarships to parents in need.

It is possible to set up ABA treatment at home using therapists in training or college students who have taken a workshop in the ABA approach. This can also be expensive ($5,000 to $20,000/year), and requires a great deal of time organizing and structuring the program.

A qualified, full-time (30 hours/week or more) ABA therapist devoted to your child costs approximately $30,000 to $50,000 per year. Because of the success of ABA and the evidence indicating that training should be intensive (25 to 40 hours/week), there is very high demand for ABA-trained therapists, and it may be difficult to find one who is available (see Resources).

Resources

Healing Thresholds has partnered with Rethink Autism. Rethink Autism offers a Web-based autism treatment program that is based upon ABA. It makes ABA treatment accessible to many people who would otherwise have no access to ABA.

Healing Thresholds has also partnered with Natural Learning Concepts. They have many tools that will make it easier to do an ABA program in your own home.

Autism is a condition covered under the IDEA of 2004. Services covered by IDEA include early identification and assessment by an occupational therapist. This law protects the rights of patients with autism and provides guidelines to assist in their education. It covers children from birth to age 21 (U.S. Department of Education).

Pediatricians can provide contact information for the state early intervention program (for children 0 to 3 years old). School districts can coordinate special services for children 3 to 21 years old. For some additional coverage information in the U.S. go to: http://www.asha.org/public/coverage/autism.htm. In addition, there is a listing on this Web site for state early intervention centers.

Several books that might be useful:

Applied Behaviour Analysis And Autism: Building a Future Together by M. Keenan, M. Henderson, K.P. Kerr, and K Dillenburger (Eds.). 2005. Jessica Kingsley Publishers.

Understanding Applied Behavior Anaylsis: An Introduction to ABA for Parents, Teachers, and Other Professionals by A.J. Kearney. 2007. Jessica Kingsley Publishers.

The Verbal Behavior Approach: How to Teach Children with Autism and Related Disorders [VERBAL BEHAVIOR APPROACH -OS] by M. Barbera and T. Rasmussen. 2007. Jessica Kingsley Publishers.

Psychosocial Treatments For Child And Adolescent Disorders: Empirically Based Strategies For Clinical Practice (2nd Edition) by E. D. Hibbs & P. S. Jensen (Eds.). 2005. American Psychological Association.

Applied Behavior Analysis (2nd Edition) by J.O. Cooper, T.E. Heron, and W.L. Heward. 2007. Prentice Hall.

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References

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