improving quality of life through effective intervention
There are a lot of ideas and perceptions about ABA, and many prepackaged plans that ostensibly provide a family with an ABA program. It is critical to remember that there is no single program or plan that "is" ABA.
ABA, applied behavioral analysis, is simply the application of behavioral principles, to everyday situations, that will, over time, increase or decrease targeted behaviors. ABA has been used to help individuals acquire many different skills, such as language skills, self-help skills, and play skills; in addition, these principles can help to decrease maladaptive behaviors such as aggression, self-stimulatory behaviors, and self-injury. There are many providers of ABA services, many of whom are quite good. Frequently, a parent will choose a qualified provider with whom they share similar philosophical approaches in the application of intensive behavioral interventions.
This guide is provided to assist caregivers in their decision-making process.
Applied Behavior Analysis is the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior(1).
ABA is a discipline that employs objective data to drive decision-making about an individual’s program. That is, data is collected on responses made by the individual to determine if progress is being made or not; if there is no progress under a particular intervention, we need to reevaluate the program and change it so that the child begins to make progress.
The short answer is: almost anything. If it is a behavior, and it can be observed, ABA principles exist that can be used to either increase or decrease that behavior. As a discipline, ABA providers are charged with the improvement of socially significant behaviors. Socially significant behaviors include communication, social skills, academics, reading and adaptive living skills such as gross and fine motor skills, toileting, dressing, eating, personal self-care, domestic skills, and work skills.
This commonly asked question has no single answer. Research supports, at a minimum, 25 hours per week of intensive behavioral intervention for young children diagnosed with autism for 12 months a year (2). The original Lovaas studies showed that approximately half the children were able to achieve typical development with, on average, 40 hours per week over at least 2 years (3). There is no single study that can inform a parent of the optimal number for their child. But, frankly, ABA, like breathing and eating, should be incorporated into a family’s lifestyle. This does not mean doing flashcards all day long, or sitting at a desk for every waking hour. It does mean that the family should learn ABA principles and how to apply them in the context of daily activities.
Parents are indispensable in the child’s program. They play a necessary and critical role. Studies show that children whose parents are actively engaged in the process make measurable gains (4). First, no one knows the child better than the parent; the parent’s provide critical and insightful information that will help guide the ABA program. Second, parents are able to continue to prompt and reinforce the child through his and her various daily activities - an essential component to generalizing skills. Finally, parents are in a position to be able to record and track ABC data in the home and community setting. This information is vital in hypothesizing the function (the “why”) of specific behaviors as well as for determining what conditions encourage behaviors to occur.
Children need, and education law supports, the use of effective interventions for children with autism. Based on the National Autism Center’s National Standards Report,(note 3) the following components meet the criteria of research-based, effective interventions for children with autism:
Antecedent manipulation - modification of situational events that precede the target behavior. These alterations are designed to increase the likelihood of success of the targeted behavior. Examples include: prompt/fading procedures, behavioral momentum, contrived motivational operations, inter-trial intervals, incorporation special interests, etc.
Behavioral treatment -programs designed to decrease problem behaviors and to increase functional alternative behaviors. Examples include: functional communication training, chaining, discrete trial training, mand training, generalization training, reinforcement, shaping, etc.
Comprehensive intervention - low student to teacher ratio (1:1, or low as appropriate) in a variety of settings, including home school and community. Effective programs are based on a treatment manual, provide intensive treatment (25hrs/wk+), and include data-driven decision-making.
Joint attention intervention - programs designed to teach a child to respond to the social bids of another, or to initiate joint attention interactions. Examples include: pointing to objects, showing items, activities to another, and following eye gaze.
Modeling - adults or peers provide a demonstration of the target behavior; the student is expected to imitate. Thus, imitation skills are a necessary prerequisite to this type intervention. Modeling is often combined with prompting and reinforcement strategies which can assist the student to acquire imitation skills.
Naturalistic teaching strategies - use of child-initiated interactions to teach functional skills in the natural environment. This intervention requires providing a stimulating environment, modeling play, providing choices, encouraging conversation and rewarding reasonable attempts
Peer training - involves training peers without disabilities strategies for interacting (play and social) with children with autism. Some commonly known peer-training programs include: circle of friends, buddy skills, peer networks, etc.
Pivotal response training - program designed to target specific, “pivotal,” behaviors that lead to improvement across a broad range of behaviors. These pivotal behaviors include: motivation to engage in social communication, self-initiation, self-management, responsiveness to multiple cues, etc.
Schedules - teaching a student to follow a task list (picture- or word-based) through a series of activities or steps in order to complete a specific activity. Schedules are accompanied by other behavioral interventions, including reinforcement.
Self-management - this treatment intervention teaches a student to regulate his or her behavior by recording the occurrence or non-occurrence of the target behavior, and secure reinforcement for doing so.
Story-based interventions - involves a written description of the situations under which specific behaviors are expected to occur. The stories seek to teach the: who, what, when, where and why of social interactions to improve perspective taking. The most well-known of these interventions is Carol Gray’s “Social Stories.”
Note (3) National Standards Report. (2009). National Autism Center. Retrieved from http://www.nationalautismcenter.org/pdf/NAC%20Standards%20Report.pdf
The first step for parents wanting to start an ABA program is to get an assessment of their child’s current skill level. There are a number of assessments available, and parents should try to get an assessment that is as comprehensive as possible. This could include:
Solid assessments provide a baseline upon which to begin building an ABA program. In addition, the assessment outcomes can provide year-to-year objective markers of progress (or lack thereof) of the interventions chosen. The American Academy of Neurology and the Child Neurology Society (6) has released guidance on appropriate assessments for professionals working with children with autism. (see: http://www.aan.com/professionals/practice/pdfs/gl0063.pdf ) (5)
Second, parents will need to find a qualified provider of ABA services. There is a formal credentialing within the profession of behavior analysts coordinated by the Behavior Analyst Certification Board (http://bacb.com). Certification under this process provides parents with some safeguards with respect to the services of the professional. It assures the parent that the professional has undergone specific training and supervision by qualified Behavior Analysts and has completed specific coursework related to behavioral analysis and interventions. However, parents need to understand that a BCBA certification does not guarantee that the professional has any training or experience specific to autism or that that individual has the skills necessary to produce optimal treatment outcomes. Thus, a parent should always ask about the individual professionals’ specific experience and training in the implementation and training of ABA programs for individuals with autism. Finally, since the BCBA certification process is relatively new, there are a number of professionals who have actively been working in the field for many years and who are in the later stages of their career who are not BCBAs. If you interested in working with a non-certified professional, parents are urged to request information relating to their qualifications and experience.
Third, parents will need to find therapists to implement the ABA program designed by the consultant. Some ABA providers can provide parents with trained therapists; others rely on parents to find and hire therapists which the consultant subsequently trains. Costs for programs vary tremendously. Comprehensive programs (where therapists are provided to the families) can run between $60,000 to $120,000 per year. Programs where parents find and hire their own therapists can run substantially less than comprehensive programs, and yet remain financially burdensome (between $20,000-$35,000 per year).
Costs can be alleviated by securing ABA services through early intervention services or through the school system. Federal law requires that individuals with disabilities be provided individualized and appropriate education that is research-based and effective (see http://idea.ed.gov/ ). ABA is the only intervention that passes such standard; thus schools and early intervention providers are required to utilize such interventions with students with autism.
Another avenue that parents can pursue for financial assistance is through their insurance plan. Insurance coverage will vary depending on your state of residence, and whether your plan is self-funded or fully funded.
For residents of Texas, H.B.451 requires that fully funded plans governed by the Texas Department of Insurance must provide coverage for children with autism up to the age of 10. FEAT-Houston has put together an informative page on autism insurance coverage (found here: http://www.feathouston.org/resources/how-do-i-access-aba/insurance/ ).
In Connecticut, S.B. 301 requires that each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the diagnosis and treatment of autism spectrum disorders, as set forth in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders.” Policies must cover (given certain prerequisites) behavioral therapy. Dr. Olive currently accepts some insurance. Contact her for additional information.
If you reside outside of Texas or Connecticut, you are urged to find out your state’s laws on insurance coverage for ABA therapy.
(4) Johnson, C.R., et al. 2007. "Development of a Parent Training Program for Children with Pervasive Developmental Disorders." Behavioral Interventions 22(3):201-221
(6) Filipek, P.A., MD et al (2000), “Practice Parameter: Screening and Diagnosis of Autism.” Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society.