The response of Irish consumers to behavioural interventions for autism has been very positive, when compared to the alternative interventions (Grey, Lynn and McClean 2010; Keenan, Dillenburger, Doherty, Byrne and Gallagher 2007) and evidence of these interventions’ effectiveness continues to accumulate (Virués-Ortega 2010). In spite of this, a great deal of misinformation exists regarding ABA (Department of Education and Science 2001) and, while many Irish professionals have embraced ABA, some continue to hold inaccurate or outdated views of behavioural interventions for people with autism (Ridge and Guerin 2011).
What is Applied Behaviour Analysis?
ABA is the applied arm of the science of behaviour. It is sometimes referred to as a method, but is better thought of as a scientific approach to solving problems of social significance. The treatment package that a behaviour analyst recommends for a client will most likely feature a range of evidenced-based behavioural techniques that are anchored in the philosophy of behaviourism. Behaviour analysts use the scientifically validated principles of learning to modify the environment in order to improve meaningful behavior, with a view to improving the quality of life of individuals, families and communities. Specific behavioural teaching procedures include precision teaching, video modelling, pivotal response training, discrete trial instruction, activity schedules, behaviour chaining, functional communication training, peer-mediated social skills training, self-management and natural environment teaching. These procedures have been employed to establish and improve behaviours related to communication (Bondy and Frost 2001), daily living skills (McClannahan, MacDuff and Krantz 2002) and academic skills (Wacker and Cooper 1996). Similarly, empirical studies have shown ABA interventions to be effective in treating many forms of problem behavior, including self-injurious behaviour (Iwata and Lewin 2002), aggression (Oliver, Oxener, Hearn and Hall 2001), and pica (Piazza, Roane, Keeney, Boney and Abt 2002). There have also been several studies examining the effectiveness of ABA teaching strategies with children and adults in Irish contexts (e.g. Murphy and Barnes-Holmes 2010; Lydon, Healy and Leader 2011; McDowell, Duffy and Kerr 2007).
Early Intensive Behavioural Intervention
ABA is closely associated with autism owing to the dramatic effects of early intensive behavioural intervention (EIBI) reported in some studies. In one of the first studies of EIBI, Lovaas (1987) found that 48% of children who received EIBI achieved normal functioning and progressed to mainstream schools. The study used matched control groups and multiple pre-treatment and follow-up measures. Lovaas (1987) reported average gains of 20 IQ points for participants who experienced 40 hours per week of behavioural intervention for two years or more. In contrast, those in two control groups failed to show similar gains. A follow-up study by McEachin and his colleagues (1993) determined that the intellectual and academic gains of the original EIBI group remained stable several years after treatment.
Since Lovaas’ original EIBI study, there have been several replications (including randomised control trials) that demonstrate the powerful effects of EIBI (Dawson et al 2010; Eldevik, Eikeseth, Jahr and Smith 2006; Howard, Sparkman, Cohen, Green and Stanislaw 2006; Remington et al. 2007). There have also been examinations of the effectiveness of EIBI in Irish contexts (Healy, Leader, O’Connor and Kenny 2008; O’Connor and Healy 2010). Reichlow (2011) examined 5 recent meta-analyses of EIBI for children with autism and found that it was a ‘powerful intervention capable of producing large gains in IQ and/or adaptive behaviour’. It has also been found to be an extremely cost.effective intervention (Chasson, Harris and Nealy 2007).
Is ABA autism-specific?
ABA is not an autism-specific therapy. ABA has also been shown as effective to use with a number of populations including schizophrenia (Wilder, Masuda, O’Connor and Baham 2001), attention deficit hyperactivity disorder (Northup et al. 1997) Down Syndrome (Dalton, Rubino and Hislop 1973), and feeding disorders (Piazza et al. 2003), as well as typical learners (Darrig et al. 2005). ABA is commonly associated with autism because of widespread coverage of its effectiveness for people with autism.
Who designs and implements the ABA programme?
ABA programmes have been successfully implemented by a variety of professionals and paraprofessionals including doctors, nurses, teachers, care workers, ABA tutors and special needs assistants. ABA programmes have also been proven effective when implemented by ABA professionals. However, it should be noted the internationally recognised Behaviorist Analyst Certification Board recommends that only Board-certified behaviour analysts are sufficiently qualified and experienced to design behavioural interventions (BACB 2004).
What does a behaviour analyst do?
When a behaviour analyst begins working with a person with special needs, they assess the individual’s current abilities and needs in order to select goals that will make a meaningful impact on the life of the learner in question. The assessment will typically involve examining contextual factors such as the room in which behaviour occurs; motivational factors such as hunger or thirst, verbal antecedent events and the consequences that result in changes in the probability that behaviour will occur in the future. Client, parental and caregiver input is crucial at this point of the intervention and the people who care for the client will later be taught how to help implement the programmes the behaviour analyst puts in place. When the behaviour analyst begins to teach the target skills to the individual, he or she typically begins by breaking a complex skill down into smaller steps and systematically provides praise or other rewards in response to the individual’s behaviour. Motivation is a crucial part of any behaviour analytic intervention and the therapist will frequently make alterations to the environment that increase the individual’s motivation to learn a particular skill.
Typically, ABA interventions provide multiple opportunities for a learner to practise and master a skill in order to maximise the number of opportunities for the learner to experience success. Similarly, individuals with autism sometimes struggle to generalize, therefore behaviour analysts take care to teach skills in a way that will lead to generalisation to new settings, conditions and people.
In making judgments about a client’s progress, behaviour analysts avoid the use of subjective opinion and instead focus on carefully collected and objectively described data. These data are then carefully analysed and used to optimise the effectiveness of the programme for the client.
ABA with older children and adults
EIBI was developed for young children with autism, and as such it may not be appropriate for older children and adults with autism; however, there are alternative approaches that cater to the needs of older individuals (McClannahan, MacDuff and Krantz 2002; Palmen, Didden and Lang 2012). ABA interventions for older learners can take place in a variety of settings including schools, residences, or workplaces. In comparison to EIBI, these interventions focus more on developing group participation skills and independent daily living skills. Research indicates that these interventions can be effective in teaching older children and adults with autism a variety of new skills (McClannahan et al. 2002).
How do behaviour analysts deal with challenging behaviour?
Behaviour analysts are frequently called into schools, hospitals, homes and residential service settings to deal with challenging behaviours such as self-injury and physical assaults. The main tool that behaviour analysts use to decrease challenging behaviour is the Functional Behaviour Assessment (FBA). Using an FBA involves an examination of how the individual interacts with their environment, and aims to discover specifically when, where and why problematic behaviour arises. It is not always easy to recognise the cause of any particular behaviour and it can be particularly difficult to identify the function of challenging behaviour in people with special needs, because they may also have difficulties in communicating. The benefit of the FBA is that it helps us to learn more about the causes or functions of challenging behaviour and this knowledge can then be used to formulate an individualised effective treatment for a particular individual’s challenging behaviour.
There are two main types of FBA: descriptive assessment and indirect assessment. Descriptive assessments involve the direct observation of the behaviour in a natural setting. The ABC sheet can be used in direct observations, or there are alternatives such as scatterplots, or specially designed data collection forms. Indirect assessments get their name from the fact that the data they provide is based on recollections of the behavior, rather than direct observations. Indirect assessments are generally used in conjunction with forms of descriptive assessment. There are many interviews, checklists and rating scales that have been specially designed for functional assessments that can be carried out with parents, siblings, teachers or other significant people in the life of the individual, which can be used to guide direct observations. The most precise form of functional assessment is known as a functional analysis. While very powerful, a functional analysis is the most difficult form of functional assessment to conduct properly and should only be attempted by a board.certified behaviour analyst with relevant experience.
The functions of behaviour can be divided into those that are used to obtain positive reinforcement and those that are used to obtain negative reinforcement. Positive reinforcement involves obtaining something. For example, the function of a self-injurious behaviour might be to obtain attention from a parent, or it might be an inappropriate way of accessing a preferred toy, activity or snack. It could also be automatically reinforced by the release of endorphins within the body which cause pleasant physical sensations. Negative reinforcement typically involves stopping, avoiding or postponing some negative condition. For instance, a child might run away to escape a barking dog, or they might scratch their skin to remove an itch.
Once a behaviour analyst has enough information about the circumstances in which the challenging behaviour occurs, he or she can form a hypothesis about its function and put in place an intervention designed to decrease its frequency. Some challenging behaviours have single functions, while others may have multiple functions and any intervention will be individualised to the needs and capabilities of a particular individual. As a result, every intervention will be different. However all behavioural interventions will pay particular attention to the function of a challenging behaviour and will seek to teach replacement behaviours that match its function where possible.
Have any expert groups recommended ABA?
ABA has been recommended as a treatment for autism by respected organisations such as the US Surgeon General, the American Academy of Paediatrics and the New York State Department of Health. A recent report by Ireland’s National Council of Special Education (NCSE 2011) found behavioural approaches to be among the most effective for treating students with emotional and behavioural difficulties, including students with autism. The National Standards Project (2009) conducted the largest review of the subject of autism intervention and concluded that the overwhelming majority of effective treatments for autism were developed from ABA.
Eclectic versus ABA
In Ireland, autism treatment frequently involves the use of an ‘eclectic’ treatment model; however, the research indicates that ABA is generally more effective than an eclectic approach. Howard et al. (2005) compared 4 months of EIBI for children with autism , with two other intervention groups. The first group received an intensive, ‘eclectic’ autism treatment that included the use of the TEACCH methodology, sensory integrative therapy and a limited amount of ABA therapy. This treatment was delivered for 30 hours per week during 1:1 or 2:1 instruction sessions. The second group received non-intensive public special education. Participants were carefully matched to groups and, although the groups showed no significant differences on pre-treatment measures, the EIBI group demonstrated an average increase of 31 IQ points, while participants in the other two treatment groups demonstrated an average increase of just nine points. Similarly, Remington and colleagues (2007) found EIBI to be more effective than standard educational services or eclectic services.
It is important to note that adopting an eclectic approach is not the same thing as working in a multidisciplinary team. It is common for behaviour analysts to work with other professionals, such as occupational therapists, speech therapists, doctors and physiotherapists, when designing EIBI programmes similar to those described in the empirical record.