Applied Behavior Analysis and its Effects on Autism

Abstract

During my research i have found several studies that have been done to support the fact that Applied Behavioral Analysis (ABA) does in fact make a positive impact on children with Autism through discrete trials. It is based on the thought that when a child is rewarded for a positive behavior or correct social interaction the process will want to be repeated. Eventually one would phase out the reward. Dr Lovaas, who invented this method, has spent his career devoted to making the lives of Autistic children better.

The one-on-one intensive behavioral treatment program is customized to meet the needs of each child and family served. The program is available nationwide at 12 Lovaas centers as well as through certified consultants across the country who are employed by the Lovaas Institute. (Lovaas) This method does not yield the same results for everyone but about half the kids that try this method see remarkable improvements.

The Lovaas Method of Applied Behavior Analysis (ABA) underwent research at UCLA under the direction of Dr Lovaas, proving its effectiveness in treating children with Autism. This treatment is very individualized by the individual and their needs and abilities. Instructors and parents begin this treatment by one on one activities to build positive relationships. Positive interactions are first developed through the use of favorite activities and responding to any attempts to communicate. Motivation is encouraged through the use of familiar materials and child-specific reinforcers. Success is promoted through positive reinforcement of successive approximations and prompting and fading procedures. Parental involvement is critical. Parents are empowered through training and collaboration to create an environment in which treatment is provided most of a child's waking hours, at home, at school, and in the neighborhood. Requesting is developed as early as possible. (Lovaas) Lovaas also states that learning to talk and understand language is considered a fundamental part of social development. Imitation is also crucial, allowing a child to learn by observing other children learn. Social interactions and cooperative play are integral to treatment. Facilitated play starts first with siblings and then with peers during play dates and at school. This method is generally used with children between the ages of two and eight. Treatment usually begins between ten to fifteen hours per week for kids under three but can increase slowly to thirty five to forty hours from three on up. Teaching in natural surroundings is best to start with tow year old’s, as well as following their lead. Once a positive learning environment is established then the more structured sessions can begin. Kids between three and eight usually have five to seven hours a day of instructions with play breaks built in.

In the article Effectiveness of ABA Therapy for Children with Social Needs of Autism we learn from a psychiatrist named Dr Suzy Yusna SpKJ. She stated that before the year of 1990 the number of patients diagnosed with an Autism Spectrum Disorder in a year was around five. Present times we see probably five per day. There were five children selected as participants for this study. The data comes from Rumah Autis Bogor, appears to be a school in Indonesia that is an institute for the development of children with special needs. The method they used to collect the data for this study was by using a pre-test and a post test. The pre-test is to find out the extent to which the subject matter to be taught, is known by the students. The post test is to find out if all the important subject matter has been mastered. It is stated that the researcher used mostly non verbal testing methods due to the difficulty of communicating with children with /autism. The method used in this study is ABA by Lovaas that focuses on the principals of how learning takes place. Positive reinforcements is when a behavior is followed by a reward. Most times when the behavior is followed by a reward the behavior will want to be repeated. After decades of research, ABA has developed many techniques for increasing useful behaviors and decreasing those that cause harm or interfere with learning. Most often as stated above the adults direct the instruction but some therapists allow the children to take the lead to build positive atmospheres. The main finding of this study is that the number of children with ASD that have difficulty communicating, learning language and labeling objects is that once the ABA method is applied, changes happen with only one action that the child can follow the request correctly. (Ithriyah S) The authors of this study conclude that ABA by Lovaas proves its effectiveness through the therapies and staged of the method.

In the article Parents experiences of ABA based Interventions for Children with ASD takes place with families from Northern Ireland (NI) and Italy. ABA is one of the standard treatments for North American, but this is not the case for Europe. In Europe they use a non-specified “eclectic” approach. This study looks into the validity of ABA with fifteen European families who had experience with home based, self-managed ABA for their children. The results of this study show the positive impacts that ABA had on the children in areas of social skills, challenging behaviors, communication, gross and fine motor skills, concentration, interaction, independence and the overall quality of life and hope for the future. (McPhilemy & Dillenburger). Research was conducted with in Queens University Belfast (QUB) and was approved by QUB school of Education Research Ethic Community. Fifteen families we re in the study, twelve lived in Northern Ireland and two in Italy. Northern Ireland used one of two agencies called A or B, Italy used agency B. There were seventeen children in the study ages twenty four months to twenty years old, fifteen boys and two girls. One family had twin boys and one family had boy/girl siblings. Ten families at the time of this study still were using ABA, five families had stopped because they felt that their child had progressed, and they didn’t need it anymore. The average age of these seventeen individuals when they started ABA therapy was 38 months.

Research was gathered using questionnaires that had twenty open needed questions. The first part of the questionnaire focuses collecting info about demographics, reasons parents decided to use ABA therapy and how they found out about it. The next section focused on the expectation’s parents had prior to the start of therapy and then the impact the therapy had on the family as a whole. The third section focused on procedures that were used in the home based programs and they type of support parents received prior to and through out the duration of the program. The last part of the questionnaire focused on the implementation of ABA as finding a locally trained therapist, time constraints it put on the family and behavioral targets. (McPhilemy & Dillenburger). Agencies A and B offer services to families in just Northern Ireland while agency B offers services to families in other European countries such as Italy. The results of this study found that most parents had learned about ABA through their own research and most parents stated their reason for seeking an alternate treatment was they felt desperate for some kind of help due to their child’s challenging behaviors and having little support from professionals, lack of services and supports and four families needed help getting a diagnosis. Families found out about ABA by doing their own research, talking to other parents who had ASD kids and were using it, and one family stated they learned by hearing about a celebrity that was using it for their child and looked into it.

Initial expectations of the majority of parents was having hope that ABA based therapy would help with social behaviors and bring back some level of normalcy to their lives. Others listed were a better life for the child and the family as a whole, some hoped for their kids to catch up in all areas to kids their age. Some parents stated that initially they didn’t have any expectations that they would be happy with even small improvements like eye contact, toileting, better speech and/or ways to communicate. Findings on the impact therapy had on family’s state that all families noted positive impacts with emphasis on reduced frustration and problem behaviors due to increased communication. ABA impacted the children most in the areas of communication by improving eye contact by using a picture care exchange system for wants and needs, behavior and independence. The impact on families noted were most parents said that ABA involved a lot of time and commitment by attending workshops, conferences and networking with other parents. Many parents formed a close relationship with their therapists. For the Italian family they needed a language translator, so the relationships were a little bit different. For some families the Autism diagnosis was devastating, and they felt a grieving period. Two of the families stated that the diagnosis contributed to the downward spiral of their marriage. Three parents stated they felt depressed and stressed. One parent joined a charity and helped four other families maneuver their way through the educational processes well as got involved in fund raising and eventually went on to get a counseling degree and now helps parents deal with the Autism diagnosis.

The attitude of professionals was noted, and some parents described the schools as positive. The teachers and aides received trainings and speakers were invited into the schools. While the majority of parents had problems with the education system. They were not open to implementing this type of therapy in the classroom. Other interventions in addition to ABA that were noted are six parents used a gluten and casein free diets for their child. The majority of children also had speech and occupational therapies. One family also used sensory and cranial sacral therapy. One Italian family had already implemented the TEACCH method due to lack of knowledge about ABA. Thw majority of families involves considered ABA as a very effective form of intervention for ASD. Most families stated that they did not receive and financial assistance to offset the very expensive cost of this therapy. One family received a disability allowance which helped cover some of the cost. Two families received help from the education board. Four families fund raised, one family sold their home while another family refinanced their mortgage. One Italian family was granted 15 hours a week government funding after a long fight to get that. Many family’s expectations changed. They no longer believed that Autism could be cured, instead they turn to the ABA approach to change the challenging behaviors of the children. The results of this study show that ABA had significant positive impacts on the child as well as the family as a whole and their overall quality of life. The study along with showing a high level of parent approval also showed that parents support the need for a wider use and more support of ABA is needed. Parents feel the services they are offered are severely lacking and professionals are unwilling to endorse it. Six years after this study was published of ABA therapy and its effective science based treatments, it is still basically the responsibility of the parents .

Another form of measuring the effectiveness of ABA therapy interventions is with a Longitudinal Growth Curve, although not many studies use this multi-level longitudinal analysis to examine which variables affect the rate of improvement through the course of therapy. It is studied in the article Predictors of Longitudinal ABA treatment outcomes for children with autism: A growth curve analysis. This type of growth curve is a technique that measures change over time. This is a useful technique that uses a slope and intercept method for tracking progress for ABA therapy. (Kim & Baldi) This study stated that many variables such as the child’s pre-treatment level of cognitive and social functioning, age they enter therapy, gender, diagnosis severity and socio-economic status can affect treatment. Studies show that higher cognitive functioning and starting therapy at a young age lead to better outcomes. Some studies also show that the number of hours in treatment and the level of language skills can also project the outcome of treatment. One study on the predictions of pretreatment cognitive functioning with the outcomes 4-6 years later showed that having a higher IQ at start of therapy did coincide with being in a regular mainstream classroom while lower IQ coincided with special education classes. The same hold true in studies on the earlier children start ABA therapy 4-6 years later were more apt to be in a regular education setting.

A similar study found that in 245 children starting therapy at a younger age was indeed a predictor of increased skill gain over the course of therapy. Virues-Ortega and Rodrigues (2013) demonstrated that a multi longitudinal analysis using a multi-level modeling also known as a growth curve analysis, could improve the ability to predict the child’s growth trajectories and help guide clinicians in prognosis and long term treatment planning. (187) Patients in this study were past clients of an ASD treatment clinic in California between 2010 and 2015 that had a verified ASD diagnosis according to the DSM 5. Participants had to have complete records of their treatment course and parental consent to be included in the research anonymously. Thirty-five participants were chosen to examine a longitudinal growth curve. The data collected was not equal for all because length and number of sessions varied for everyone, but everyone had to have had at least two observations per person. With one hundred thirty-seven observations total. Even though the data collected was unbalanced it was enough to do the study. This study also used the Lovaas method of ABA and participants received early intervention using this method.

Therapy was done in the home with parent care giver present and trained staff were supervised weekly by a licensed clinician. Therapy focused on all areas of development: speech, language, communication, play skills, gross and fine motor, adaptive and social skills. Play dates with neuro typical kids were also included in the data. Parents were trained to do these behavioral methods during non-therapy times as well. Treatment hours for this study depended upon age, responsiveness to therapy and family availability, and funding. Therapy was individualized according to the child’s strengths and goals, with a lot focused around talking, self-care and motor skills. This study uses errorless learning, which is when the clinician helps the child complete increasingly complex tasks with their support, so they always succeed. The support is faded away gradually until the child can complete the task on their own. At the start of therapy, a Developmental Profile (DP) 3 was completed to make sure developmentally goals were appropriate as well as number of hours per week. The DP3 was re-administered every six months and was completed with parent and clinicians. The DP 3 measures developmental functioning in 5 developmental areas for children birth through twelve years old. They are cognitive functioning, communication, social emotional development, adaptive behavior and physical development. These are assessed using a 180-item checklist completed by parents and clinicians together. This study showed the following results in the following areas: Cognitive Functioning- the predictive growth rates were more predictive of this than any other areas variables, Children with higher cognitive functioning had a more rapid growth rate across all domains then lower cognitive functioning did.

Age at Entry: This predicted the initial status at the start of therapy but did not predict growth rates. It is stated that this does make sense in the fact that older children generally would start with more skills then younger kids due to the natural maturation process. ( Kim, Detmers & Baldi). Diagnosis Severity: In the physical aspect diagnosis is as expected, Higher functioning children tend to improve at faster rates then lower functioning children. Language: Those who spoke English as a primary language had faster growth rates then those that did not. This is to be expected since the test is given in English. Gender differences: Boys tended to improve quicker then girls in adaptive behavior and physical development. But this study had a huge difference in boys and girls with 27 boys to 8 girls. Treatment hours and parent education: This study finds that treatment hours and parent education did not have any significant impact. This researchers in this study do conclude that this study confirms that clients with higher cognitive functioning improve more rapidly during ABA Therapy and goals will need to be adjusted often.

While the above studies have showed the good and positive that ABA offers there are still some controversies around this therapy. One critics says that Lovaas form of ABA was not only discrete trials but punishment as well for individuals in a residential setting that had self-injurious behaviors. While aversive reinforcement and its use is generally gone, there is still a complaint that ABA therapy, which can involve a lot of repetition, is tough on the children, and the skills they learn don’t necessarily generalize to other situations. ABA therapists have this stigma that they are hard but Catherine Lord, director of the Center for Autism and the Developing Brain at Weill Cornell Medical College & New York Presbyterian Hospital, says that in current times the therapists are taught to be over the top fun. And most ABA therapists and programs now don’t use the DTT format, where the child sits at the table, but are play-based. Sara Germansky, a board certified behavior analyst or BCBA — the highest certification given to those who are trained by the ABA professional organization — gives this example: “I might set up something where we’re playing with cars, and if I’m working on colors with a kid I might have two cars in front of me — one that’s red and one that’s yellow. And he’ll say, ‘Can I have a car?’ And I’ll say ‘Oh, do you want the red car or the yellow car?’ And then he’ll have to expand his language by saying ‘I want the red car.’ And then I’ll say, ‘Which one’s red?’ And he’ll have to identify the color. So there are ways of manipulating the environment so that kids are more naturalistically learning these skills.” And, she adds, kids are more able to generalize skills learned in a naturalistic situation beyond the therapy sessions and take them out into the world with them. (Child Mind Institute) ABA is almost never done 40 hours a week anymore. It is usually 10-20 hours at the most. Children might be seen by the therapist for 2 hours a day 5 days a week depending on severity level. The higher the severity they may have closer to 20 hours per week. The focus is also not on eliminating behaviors per say, its teaching other behaviors to replace the negative or unacceptable ones.

While from all that I have read and having had my own child receive ABA in his preschool years I think that it is a positive therapy for kids with Autism. I have never witnessed any adverse treatment when I have watched this form of therapy.

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