Treatments For Autism - Applied Behavior Analysis (ABA)

DISCLAIMER – The Autism Resource Foundation provides general information to the autism community. The information comes from a variety of sources, and the Autism Resource Foundation does not independently verify any of it, nor does it necessarily reflect the views and/or opinions of the Autism Resource Foundation. Nothing on this website should be construed as medical advice. Always consult your doctor regarding the needs of your family.

Cambridge Center For Behavioral Studies

Applied Behavior Analysis (ABA) and Autism

Much publicity has recently surrounded the Applied Behavior Analysis approach to the treatment of Autism. But what exactly is ABA? How do you know if an intervention program works? How do you select a behavior analyst in the first place, making sure you don't inadvertently choose someone who is not properly trained in the ABA methodology? What rights do clients of these services have to effective treatment? Recognizing the confusing number of claims and choices which clients and parents of autistic children face, this CCBS Autism Section addresses these questions (and more) to give consumers of ABA services the information needed to choose wisely.

Frequently Asked Questions about ABA
Applied Behavior Analysis (ABA) is the most comprehensive and most effective approach to improving the lives of persons with autism and their families.

The following questions illustrate common misconceptions about the ABA approach to treating Autism:
Is ABA just a new fad?

ABA with persons with autism is not new and is not a fad

Research began in the early 1960s with the studies of Charles Ferster, Ivar Lovaas, Montrose Wolf and Todd Risley to name just the best known pioneers.

As long ago as 1981, applied behavior analysis was identified as the treatment of choice for autistic behavior. (See the literature review by Marion K. DeMyer, J. Hingtgen and R. Jackson.) Here are some references.

Recently, Johnny Matson and his colleagues counted more than 550 studies published in scientific journals showing the effectiveness of behavior analytic procedures with persons with autism.

Is ABA comprehensive?

ABA is comprehensive

ABA has been effective for teaching a vast range of skills to people with disabilities as well as to many other people in every setting in which people live, study and work

• in their own homes
• in shops, restaurants, public transport
• in recreation and sporting activities
• in regular and special preschools, primary schools and high schools; in colleges [For an exciting and challenging review, see Ed Anderson’s Education that works: The child is always right.]
• in business and industry
• in institutions, hospitals and correctional facilities.

Is ABA useful for managing anything other than "bad" behavior or severe behavior problems?

ABA is definitely not just useful for managing "bad" behavior or for people with severe behavior problems

Although ABA does provide the best methods for managing problem and aberrant behavior such as self-injurious, ritualistic, repetitive, aggressive and disruptive behavior, it does this through teaching alternative pro-social behavior.

Proper application of behavior principles and procedures also prevents behavior from becoming a problem.

Is ABA basically just early intervention?

ABA is much more than early intervention

The most successful early intervention programs to be documented are based on applied behavior analysis, but a great deal of work has been accomplished throughout the age span as well.

Is ABA an easy "miracle cure?"

ABA is not easy and not a "miracle cure"; there are NO cures – psychological or medical

ABA is not easy and not a “miracle cure”; there are NO cures – psychological or medical. Anyone who has tried to do ABA knows it is not easy. However, when done properly, progress can be seen very quickly. Positive results make the effort worthwhile.

You will not find a shred of scientifically acceptable evidence that treatments using psycho-dynamic psychotherapies or holding therapy are effective. The theory behind them has been discredited.
There are no medical treatments for autism itself. Persons with autism, of course, have medical needs for which pharmacological and other medical treatments are appropriate.

In a recent review of autism in the New England Journal of Medicine, Dr. Isabelle Rapin concluded: “No drug or other treatment cures autism, and many patients do not require medication. However, psychotropic drugs that target specific symptoms may help substantially.” She said further that: “The most important intervention in autism is early and intensive remedial education that addresses both behavioral and communication disorders.” (p. 102)

“Many other …(than educational/behavioral and medical)…interventions are available, but few, if any, scientific studies support their use. These therapies remain controversial and may or may not reduce a specific person's symptoms. Parents should use caution before subscribing to any particular treatment.

Counseling for the families of people with autism also may assist them in coping with the disorder.” (From NIMH Fact Sheet)

Is ABA a mechanical approach, which turns people into robots?

ABA is not mechanical

People are often told that behavior analysts are cold scientists who tell others what to do. In fact, behavior analysts know that successful programs require that they work collaboratively with all concerned. Being scientific means being guided by objective results and modifying procedures because other demands in the school or family must also be met and to make best use of the knowledge and skills of carers and the persons with autism as well.

A series of papers by Montrose Wolf and his associates published between 1964 and 1967 illustrate these points very well. The articles describe how they worked first with “Dicky” when he was 3-1/2 years old in a hospital and made transitions from hospital to home and pre-school. Successful methods were developed in the hospital, the parents practiced them there, and then in stages Dicky returned home and was enrolled in a generic nursery school, where he acquired self-help, pre-academic and play skills. Many people were involved in planning and making those programs work.

Studies have shown that ABA programs are successful in generating spontaneous and creative behavior.

What are the key features of ABA?

• The person’s behavior is assessed through observations that focus on exactly what the person does, when the person does it, at what rate, and what happens before (antecedents) and what happens after behavior (consequences). Strengths and weaknesses are specified in this way.

• Skills that the person does not demonstrate are broken down into small steps.
• To teach each step:
• A – give a clear instruction, provide assistance in following the instruction (for example "prompt" by demonstration or physical guidance), and use materials that are at the person’s level.
• B – get a correct response.
• C – give a positive reinforcer (A consequence that will lead the person to do the behavior again in the future.)
• Many opportunities or trials are given repeatedly in structured teaching situations and in the course of everyday activities.
• Instruction emphasizes teaching a person how to learn -- to listen, to watch, to imitate.
• As the person progresses, guidance is systematically reduced so that the person is responding independently; prompts are faded out.
• As steps are acquired, the person is taught to combine them in more complex ways and to practice them in more situations.
• Problem behavior is not reinforced. The person is not allowed to escape from learning and is redirected to engage in appropriate behavior.
• The person’s responses during every lesson are recorded. These data are used to determine if he or she is progressing at an acceptable rate. If not, that part of the program needs changing.
• The “therapist’s” (teacher’s, parent’s) behavior is also observed continuously at first and then less frequently and as needed to ensure that procedures are being applied correctly and safely.
• Recording client and therapist behavior is essential because we need to SEE that the program is working as well as it can be. Even highly experienced behavior analysts need feedback in the form of detailed, rigorous performance data.
• Observing therapist behavior tells us that the procedures are being followed correctly and consistently.
• The information adds to our knowledge about the effectiveness of procedures and how to avoid and overcome problems that may arise in practice.

Guidelines for Selecting Behavior Analysts

The demand for behavior analysts far exceeds the number of persons with the expertise required to provide effective ABA programs. Enabling families to access affordable and competent behavior analysts is an urgent problem, because this is not an area in which “do-it-yourself” programming is advisable. Often, however, particularly for persons living far away from services, parents will have to assume major responsibility for their children’s intervention programs.

CCBS will not tell you who is, or who is not competent. Standards regarding the competent delivery of behavioral service have been identified, but they have not been fully implemented.

A useful starting point may be to view by state the Certificant Registry of those individuals credentialed as Board Certified Behavior Analysts or Board Certified Associate Behavior Analysts, maintained by the Behavior Analyst Certification Board.

Another valuable resource is the Directory of Graduate Training Programs in Behavior Analysis published by the Association for Behavior Analysis (ABA). ABA is the professional organization for the discipline. Although ABA does not accredit or certify individuals, it does accredit graduate training programs.

In addition, The Autism Special Interest Group of ABA has adopted guidelines for consumers of applied behavior analysis services to individuals with autism.

The Autism SIG of ABA's Guidelines for Consumers

The Autism Special Interest Group (SIG) of the Association for Behavior Analysis asserts that all children and adults with autism and related disorders have the right to effective education and treatment based on the best available scientific evidence. Research has clearly documented the effectiveness of applied behavior analysis (ABA) methods in the education and treatment of people with autism (e.g., Matson et al., 1996; Smith, 1996; New York Department of Health, 1999; U.S. Surgeon General, 1999).

Planning, directing, and monitoring effective ABA programs for individuals with autism requires specific competencies. Individuals with autism, their families, and other consumers have the right to know whether persons who claim to be qualified to direct ABA programs actually have the necessary competencies. All consumers also have the right to hold those individuals accountable for providing quality services (e.g., to ask them to show how they use objective data to plan, implement, and evaluate the effectiveness of the interventions they use). Because of the diversity of needs of individuals in the autism spectrum and the array of specific competencies amongst the pool of potential service providers, consumers also need to focus on the match between their needs and the specific competencies of a particular provider.

Formal credentialing of professional behavior analysts through the Behavior Analyst Certification Board (BACB) can provide some safeguards for consumers, including a means of screening potential providers, and some recourse if incompetent or unethical practices are encountered. Unfortunately, there continues to exist a tremendous gap between the supply of qualified behavior analysts and the demand for ABA services. Nonetheless, as with any other credentialed professionals, consumers should exercise caution when working with individuals who have, or claim to have, credentials in behavior analysis. Although a formal credential in behavior analysis is evidence that a professional has met minimum competency standards, it does not guarantee that the individual has specific expertise in autism, nor that s/he can produce optimal treatment outcomes. Furthermore, the credentialing of professional behavior analysts has only been in place on an international level since 2000 and there may be some competent service providers who are still in the process of applying for BACB certification.

The Autism SIG recommends that consumers seek to determine if those who claim to be qualified to direct ABA programs for people with autism meet the following minimum standards:

• Certification by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst (BCBA), or documented evidence of equivalent education, professional training, and supervised experience in applied behavior analysis.

Standards for certification as a BCBA, which can be found at www.BACB.com (Consumer Information Section), include: at least a master's degree in behavior analysis or a related area; 225 hours of graduate level coursework in specific behavior analytic content areas (as of the deadline for Spring 2005 applications); 18 months of mentored experience or 9 months of supervised experience in designing and implementing applied behavior analysis interventions; and a passing score on a standardized examination. Consumers are urged to check the BACB website as these requirements may change from time to time. An individual's BACB certification status may be verified by going to www.BACB.com, clicking on "Consumer Information," and then clicking "Registry."

Note that there is also a lower level of BACB certification, Board Certified Associate Behavior Analyst (BCABA), for individuals who have a bachelor's degree, 135 hours of classroom instruction in behavior analysis (effective for Spring 2005 applications), 12 months of mentored experience or 6 months of supervised experience in implementing applied behavior analysis interventions, and a passing score on a standardized examination.

A complete list of skills and knowledge covered on the Behavior Analyst Certification Board examinations is available at www.BACB.com. Both BCBAs and BCABAs must renew their BACB certification annually, participate in continuing education activities that must meet BACB standards, and adhere to the BACB's Guidelines for Responsible Conduct (also available at www.BACB.com).

With respect to BCABAs, the Behavior Analyst Certification Board explicitly states that:

The BCABA designs and oversees interventions in familiar cases (e.g., similar to those encountered during their training) that are consistent with the dimensions of applied behavior analysis. The BCABA obtains technical direction from a BCBA for unfamiliar situations. The BCABA is able to teach others to carry out interventions once the BCABA has demonstrated competency with the procedures involved under the direct supervision of a BCBA. The BCABA may assist a BCBA with the design and delivery of introductory level instruction in behavior analysis. It is strongly recommended that the BCABA practice under the supervision of a BCBA, and that those governmental entities regulating BCABAs require this supervision.

The Autism SIG does not consider BCABAs, or individuals with equivalent or less training and experience, to be qualified to independently design, direct, and guide behavior analytic programming for individuals with autism. They may deliver behavior analytic intervention, and may assist with program design, but should be adequately supervised by BCBAs or the equivalent. The Autism Special Interest Group encourages consumers to request the name and contact information of the BCABA's supervisor and check to see that the supervisor is a BCBA or equivalent, as well as the information about the amount and type of supervision he/she provides.

The Autism SIG asserts that certification as a BCBA or documented equivalent training and experience is a necessary but not sufficient qualification to direct programming for individuals with autism. Consumers should be aware that the discipline of applied behavior analysis is broad and varied, and that many individuals who hold certification as a BCBA have little to no experience directing or delivering ABA programming to individuals with autism. Therefore, the Autism SIG considers the following training and experience, in addition to certification as a BCBA or the equivalent, to be necessary to competently direct ABA programming for individuals with autism:

IIa. At least one full calendar year (full-time equivalent of 1000 clock hours [25 hrs/wk for 40 weeks]) of hands-on training in providing ABA services directly to children and/or adults with autism under the supervision of a Board Certified Behavior Analyst or the equivalent with at least 5 years of experience in ABA programming for individuals with autism.

The training and supervision should assure competency in the following areas:

• Experience in assuming the lead role in designing and implementing comprehensive ABA programming for individuals with autism. The experience should involve designing and implementing individualized programs to build skills and promote independent functioning in each of the following areas: "learning to learn" (e.g., observing, listening, following instructions, imitating); communication (vocal and nonvocal); social interaction; self-care; school readiness; academics; self-preservation; motor; play and leisure; community living; self-monitoring; and pre-vocational and vocational skills.
• Providing ABA programming to at least 8 individuals with autism spectrum disorders who represent a range of repertoires and ages.
• Employing an array of scientifically validated behavior analytic teaching procedures, including (but not limited to) discrete trial instruction, modeling, incidental teaching and other "naturalistic" teaching methods, small group instruction, activity-embedded instruction, task analysis, and chaining.
• Incorporating the following techniques into skill-building programs: prompting; error correction; reinforcement and manipulation of motivational variables; stimulus control (including discrimination training); preference assessments; and choice procedures.
• Employing a wide array of strategies to program for and assess both skill acquisition and skill generalization.
• Modifying instructional programs based on frequent, systematic evaluation of direct observational data.
• Conducting functional assessments (including functional analyses) of challenging behavior and becoming familiar with the array of considerations that would indicate certain assessment methods over others.
• Designing and implementing programs to reduce stereotypic, disruptive, and destructive behavior based on systematic analysis of the variables that cause and maintain the behavior and matching treatment to the determined function(s) of the behavior.
• Incorporating differential reinforcement of appropriate alternative responses into behavior reduction programs and efforts to teach replacement skills, based on the best available research evidence.
• Modifying behavior reduction programs based on frequent, systematic evaluation of direct observational data.
• Providing training in ABA methods and other support services to the families of at least 8 individuals with autism.
• Providing training and supervision to at least 5 professionals, paraprofessionals, or college students providing ABA services to individuals with autism.
• Collaborating effectively with professionals from other disciplines and with family members to promote consistent intervention and to maximize outcomes.

IIb. Additional training in directing and supervising ABA programs for individuals with autism that involves:

• Formal training and/or self-study to develop knowledge of the best available scientific evidence about the characteristics of autism and related disorders, and implications of those characteristics for designing and implementing educational and treatment programs, including their impact on family and community life.
• Formal training and/or self-study to develop knowledge of at least one curriculum for learners with autism consisting of: (a) a scope and sequence of skills based on normal developmental milestones, broken down into component skills based on research on teaching individuals with autism and related disorders; (b) prototype programs for teaching each skill in the curriculum, using behavior analytic methods; (c) data recording and tracking systems; and (d) accompanying materials.
• Formal training and/or self-study to develop skills in using scientifically validated methods to assess and build vocal-verbal and nonverbal communication repertoires in people with autism, consistent with the principles and practices of behavior analysis. This includes augmentative and alternative communication systems for individuals with limited vocal repertoires that are matched to the individual needs of the learner.
• Accrual of continuing education in the best available research from behavior analysis and other scientific disciplines as it informs autism treatment. The Autism SIG encourages consumers to ask prospective directors of ABA services for evidence that they have participated recently in continuing education activities relevant to the treatment of individuals with autism like those they will be serving (e.g., preschoolers, adults, individuals with limited vocal-verbal repertoires, etc.).

The Autism SIG urges consumers to ask prospective directors of ABA services (including those who use titles such as "consultant") to provide evidence of their qualifications in the form of:

• Certification as a Board Certified Behavior Analyst (BCBA), or documented equivalent qualifications;
• Information about the amount and type of supervision they provide to all those who deliver intervention directly to individuals with autism and monitoring of the level of involvement/responsibilities and certification status of their supervisees (i.e., BCABAs are not qualified to independently design, direct, and oversee programming);
• Membership in the Association for Behavior Analysis (ABA);
• Membership in an affiliated chapter of ABA (e.g., CalABA, NYSABA, TxABA, FABA, NJABA);
• Undergraduate, graduate, and post-graduate training in behavior analysis specifically, as differentiated from non-behavior analytic study in psychology, special education, education, or other disciplines;
• Letters of reference from employment supervisors and/or families for whom they have directed ABA programming for similar individuals with autism (with appropriate safeguards taken to ensure privacy and confidentiality); and
• Publications of behavior analytic research in peer-reviewed professional journals.

Consumers should be aware of the following:

• Attending or giving some workshops, taking some courses, or getting brief hands-on experiences does NOT qualify an individual to practice applied behavior analysis effectively and ethically. Unfortunately, there may be some individuals who misrepresent themselves when describing their skills and experiences to consumers.

• Evidence of attendance and active participation in professional meetings and conferences in behavior analysis (e.g., the annual meeting of the Association for Behavior Analysis) is certainly desirable. Such activities by themselves, however, do not constitute training in behavior analysis, and conference presentations are not equivalent to publications in peer-reviewed professional journals because conference presentations typically are not reviewed carefully by a number of other behavior analysts, and do not have to meet scientific standards. Therefore, it is important for consumers to differentiate presentations at conferences and workshops from publications in peer-reviewed journals.

• Consumers who have concerns about the ethical behavior of individuals providing ABA services are strongly encouraged to contact the Behavior Analyst Certification Board in the case of a BCBA or BCABA, and discipline-specific licensing boards in the case of those holding professional licensure (such as psychologists, speech-language pathologists, physicians, social workers).

DISCLAIMER: This document suggests guidelines for consumers to use in determining who may be qualified to direct applied behavior analysis programs for individuals with autism, as recommended by the Autism Special Interest Group of the Association for Behavior Analysis International. It does not represent the official policy, position, or opinions of the Association for Behavior Analysis, its members, or its Executive Council.

Evaluating Intervention Programs

Gina Green has written an excellent chapter by that name in Maurice, Green and Luce (1996, Chapter 2). She describes types of evidence and explains why subjective evidence – testimonials, anecdotes and personal accounts – are not reliable.

Testimonials alone are simply too ambiguous to be the basis for making critical decisions about which treatment program to choose. Resources and time are too scarce to be wasted on treatments that have not been shown to be effective.

Now, we have a substantial body of controlled quantitative research on programs of treatment for autism. Now there has been ample time to properly investigate currently popular treatments, but most of these programs have not been. Advocates of treatments should be asked to:

• Describe the exact purposes of the treatment – what is it intended to achieve?
• Describe exactly how the treatment is conducted – there should be no mystery or secrecy about the methods and procedures being used.
• Describe how treatment effects were measured – what numerical data were collected and how were they collected?
• Show before and after data collected by independent – unbiased – evaluators;. and
• Show follow up data – do the persons maintain gains? do they continue to improve? do they regress?

Only applied behavior analysis is able to answer those questions convincingly. Gina Green argues the case in the next chapter entitled "Early Behavioral Intervention for Autism: What Does Research Tell Us?" Then, in Chapter 4, Tristram Smith answers the question, “Are Other Treatments Effective?” His conclusions are:

“Nonbehavioral special education classes, individual therapies, and biological interventions (except major tranquilizers) have not been established as effective treatments for children with autism. Some treatments, especially Facilitated Communication and psychoanalysis, are quite harmful and definitely should be avoided. Major tranquillizers offer an alternative to behavioral treatment for managing disruptive behavior, but they can cause major side-effects and therefore are a last resort rather than a first-line intervention. Several other biological treatments (Prozac, Anafranil, naltrexone, and B6 with magnesium) may be effective but require further research.

In short, behavioral treatment has much more scientific support than any other intervention for children with autism. Consequently, if behavioral treatment is available, or if families are in a position to set up their own behavioral treatment program, the best initial course of action may be to concentrate exclusively on carrying out behavioral treatment as well as possible, rather than looking for ways to supplement it with other treatments.” (Maurice, Green & Luce, 1996, Page 56).

In a paper just published, [Smith T. (1999). Outcome of early intervention for children with autism. Clinical Psychology: Research and Practice, 6, 33-49], Tris Smith has carefully studied peer-reviewed outcome investigations of ABA programs, Project TEACCH, and Colorado Health Sciences. He found that the latter two programs have shown little improvements for most of the children, but some subgroups may have benefited.
In contrast, he found convincing evidence that ABA programs increase adaptive behavior and reduce maladaptive behavior. He also noted that these programs may substantially raise IQ and other standardized test scores, while reducing the need for special services. However, he cautioned that the quality of the research on IQ, other test scores, and school placement does not permit firm conclusions; replications of this research are needed.

Rights of Clients
A committee of behavior analysts have prepared a position paper that has been adopted by the Association for Behavior Analysis. [See Van Houten et al. The right to effective behavioral treatment. Journal of Applied Behavior Analysis, 1988, vol. 21, pp. 381-384. This document is also available from the Association for Behavior Analysis.]

The position paper asserts that all persons with special needs have the following rights:

• The right to a therapeutic environment.
• The right to services whose overriding goal is personal welfare
• The right to treatment by a competent behavior analyst
• The right to programs that teach functional skills
• The right to behavioral assessment and ongoing evaluation
• The right to the most effective treatment procedures available.

The right to treatment by a competent behavior analyst is elaborated as follows:

“In cases where a problem or treatment is complex or may pose risk, individuals have a right to direct involvement by a doctoral-level behavior analyst who has the expertise to detect, analyze and manage subtle aspects of the assessment and treatment process that often determine the success or failure of intervention. A doctoral-level behavior analyst also has the ability, as well as the responsibility, to insure that all individuals who participate in the delivery of treatment or who provide support services are trained in the methods of intervention, to assess the competence of individuals who assume subsequent responsibility for treatment, and to provide consultation and follow-up services as needed.”