One of the most difficult aspects of navigating autism treatment decisions for families is making sense of the vast array of claims of effectiveness. Many treatments claim to be effective, though few have data to support those claims. Parents are confronted with such claims and with the complexity of the disorder. Many are confused about which interventions might have relevance for their child. It can be difficult for parents to choose a treatment path, and many worry that they may later regret not trying a particular treatment.
Most of the treatments that claim to be relevant or effective have little scientific evidence to support those claims. An exception to this is Applied Behavior Analysis (ABA). ABA intervention has been widely documented as highly effective for individuals with autism (e.g., Fenske, Krantz, & McClannahan, 2001; Lovaas, 1987; MacDuff, Krantz, MacDuff, & McClannahan, 1988; McEachin, Smith, & Lovaas, 1993; Sallows & Graupner, 2005). The data base supporting the effectiveness of ABA interventions distinguishes it from other approaches. The success of ABA intervention is likely the result of several core characteristics of ABA, including: the provision of intensive intervention, clear and specific targets of intervention, precise techniques of instruction, the collection of objective data to evaluate learner progress, data-based decision making, and dynamic alterations in programming in response to the learner’s needs.
Behavior analysis has been described as having seven dimensions that define it (Baer, Wolf, & Risley, 1968). A description of each of these characteristics appears below:
Applied – Behaviors targeted must be socially significant. An intervention must address a behavior that has immediate importance to the individual.
Behavioral – The behavior studied must be one in need of improvement (social significance.) Additionally, it must be possible to measure the behavior in need of improvement. This is why behavior analysts put so much emphasis on the observability of behavior.
Analytical – There must be an attempt to identify a functional relation between the manipulated events and the behavior.
Technological – All of the procedures used must be completely identified and precisely described. We must have operational definitions of our behavioral targets and/or goals, and all of our procedures must be clearly defined.
Conceptually Systematic – Procedures for behavior change are described in terms of the relevant (basic, behavioral) principles from which they were derived
Effective – Applied behavior analysis must produce clinically or socially significant results to be judged effective.
Generality – Behavior change lasts over time, appears in environments other than the one in which the behavioral techniques were applied, or spreads to other behaviors not directly treated by the behavior change techniques. In other words, treatment extends into untrained environments and to untrained behaviors.
All of these characteristics are essential to behavior analytic treatment. They are especially relevant to the problems faced by individuals with autism, whose needs are so profound and pervasive. It is imperative that changes are socially significant and extend to the natural environment. Increasingly, behavior analysts have attended to issues of social significance in selecting and defining targets for behavior change. Evaluation of impact is determined not just by skill acquisition, but by maintenance over time and generalization to other behaviors, settings, and contexts.
Perhaps most importantly in this list of characteristics, behavior analysts value effectiveness as a primary characteristic of intervention. In fact, the ethical code of behavior analysts mandates this. Section 2.09 (Treatment Efficacy) of the Behavior Analyst Certification Board’s Guidelines for Responsible Conduct (bacb.com) states that:
(a) The behavior analyst always has the responsibility to recommend scientifically supported most effective treatment procedures. Effective treatment procedures have been validated as having both long-term and short-term benefits to clients and society.
(b) Clients have a right to effective treatment (i.e., based on the research literature and adapted to the individual client).
(c) Behavior analysts are responsible for review and appraisal of likely effects of all alternative treatments, including those provided by other disciplines and no intervention.
These guidelines are pivotal in defining how behavior analysts treat individuals with autism. Behavior analysts recommend interventions that have demonstrated effectiveness. Behavior analysts are familiar with levels of evidence, and recommend evidence-based interventions. They remain familiar with the research literature and with the evolution of clinical practices in the field, so that they continually alter their recommendations in response to the evolution of scientific knowledge.
In addition to recommending interventions that are evidence-based, behavior analysts may assist parents and teachers in evaluating the impact of alternative or ancillary interventions. They use their knowledge of the science of behavior and of research design to help determine functional relationships for individual clients. There is a value on understanding functional relations across all interventions used for individuals. (In other words, behavior analysts want to determine cause and effect relationships. They want to be able to identify the specific variables responsible for behavior change. They seek to show relationships between variables – social greetings increased when reinforcement was used, stereotypy decreased in the presence of preferred music, aggression decreased when tasks were modified or choices were provided, etc.)
Behavior analysts want to help parents and educators make treatment decisions that are data-based and that are based on a demonstrable level of effectiveness. Behavior analysts possess the skills to design methods to study an intervention on an individual level. This approach helps to objectify the question of whether a particular intervention should be tried with a particular learner. There are some interventions that are clearly harmful or ineffective for individuals with autism, and these would not be recommended by behavior analysts (e.g., facilitated communication). However, many interventions have yet to be shown to be effective or ineffective. They may lack data regarding their effectiveness, data may be mixed, available studies may be weak or flawed, or there may be a paucity of data that are meaningful or objective.
These are the interventions that a behavior analyst might design a strategy to evaluate on an individual basis. It is not likely that a behavior analyst would recommend such interventions, but it may be the case that they could assist the family or members of the educational team to assess the impact systematically and rigorously.
However, the value on effectiveness overrides a desire to explore ancillary interventions that are not likely to be effective or that have not shown promise with the learner. Most importantly, a behavior analytic view requires that the data determine the treatment. If interventions do not show merit, they should be discontinued.
Summary
To understand ABA intervention, one must understand the dimensions of behavior that are so highly valued by practitioners. It is essential that we target behaviors that are important, that we evaluate our success by transfer of skills to real-world contexts, that we assess for generalization, and that we identify controlling variables. Our recommendations for treatment come from the research literature. We can use our science to investigate the impact of experimental interventions, as long as they do not diminish access to effective intervention. In behavior analytic intervention, data guide decisions about treatments to recommend and to continue. Practice evolves based on the objective verification of success.
Mary Jane Weiss, PhD, BCBA is the Director of Research and Training at the Douglass Developmental Disabilities Center and a Research Associate Professor at Rutgers University. She consults to The McCarton School. Cecelia M. McCarton, MD is the founder and CEO of The McCarton Foundation. Ivy Feldman, PhD is Educational Director at the McCarton Foundation.
References
Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1, 91-97.
Fenske, E. C., Krantz, P. J., & McClannahan, L. E. (2001). Incidental teaching: A not-so-discrete-trial teaching procedure. In C. Maurice, G. Green, & R. M. Foxx (Eds.), Making a difference: Behavioral intervention for autism. Austin, Texas: Pro-Ed.
Lovaas, O. I. (1987). Behavioral treatment and normal intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.
MacDuff, G. S., Krantz, P. J., MacDuff, M. A., & McClannahan, L. E. (1988). Providing incidental teaching for autistic children: A rapid training procedure for therapists. Education and Treatment of Children, 11, 207-211.
McEachin, J., Smith, T., & Lovaas, I. (1993). Long-term outcome for children with autism who received early intensive behavioral treatment. American Journal of Mental Retardation, 97, 359-372.
Sallows, G. O. & Graupner, T. D. (2005). Intensive behavioral treatment for children with autism: Four-year outcome and predictors. American Journal on Mental Retardation, 100, 417-438.
