Wednesday, January 08, 2014
Dear Ms. Lambert:
Thank you for highlighting the struggle families face in finding educational settings that incorporate individualized, effective treatment for their children with autism. However, some facets of your story are inaccurate and could lead parents to draw erroneous conclusions about – or even reject– what is considered to be the "gold standard" of treatment for autism: applied behavior analysis (ABA).
In your article, applied behavior analysis is portrayed as a special therapy for children on the autism spectrum. While it is true that ABA is an effective approach for this population, it is actually the science of human behavior, which can be applied in any setting to develop skills and decrease anti-social, problematic behavior in a variety of populations. Intervention based on ABA provides children with autism the opportunity to live richer, more dignified lives within society, and leads to more freedom and independence for adults with autism rather than the alternative, which is often lifelong institutionalization.
Unfortunately, many people remember the questionable use of aversive consequences in Lovaas’ early behavioral research, rather than the significant progress made by children in his study. In those days (the late 1960s /early 1970s), there lacked an enforceable set of ethical standards guiding treatment. Today, over twenty-five years since the original study was published in 1987, we now have ethical guidelines for treatment established and enforced by a number of governing bodies and institutions, including the Behavior Analyst Certification Board.
One may wonder why it matters which approach is used, and why it is so different for children with autism. You included a statement from Luke Beardon, EdD, who argued that “ABA's focus on behaviour and rewards means that children may not learn how to make decisions for themselves.” This is a gross misrepresentation of behavioral treatment for autism, based on the fundamental principles of ABA. If a student does not learn from natural contingencies in the environment, and verbal praise is not enough, external rewards are initially used to increase the child’s motivation to learn. Competently designed ABA programs teach self-management skills to learners who demonstrate readiness, and slowly and systematically fade back the use of external rewards.
Children with autism often progress and learn in the same developmental order as do typical children. To illustrate, a typically-developing four year-old child is not always expected to truly understand “why” she should not follow a stranger, but is taught what to do in the situation. Understanding the reasoning behind a behavior is certainly an important aspect of problem-solving, and becomes the focus at the appropriate developmental level of that person with autism.
You state that, “but critics still warn the method is overly demanding – some programmes involve 40 hours a week of contact time – and have likened the approach to ‘dog training.’ ” Autism is a condition that exists twenty-four hours per day, seven days a week. It does not take evenings or weekends off. Although early intensive behavior treatment (EIBT) may seem onerous, the alternative is a life of dependency and misery as a ward of the state – an outcome in which no dignity lies. The research is clear: intensity is a prerequisite to significant improvement in the condition of autism. For information on EIBT, we suggest that you visit the Association for Science in Autism Treatment website at: http://www.asatonline.org/treatment/procedures/early.htm.
You again quote Beardon, who states: “For a certain percentage of children, ABA is helpful…But it's best if other approaches are bolted on. There's no one-size-fits-all because every child is different.” Unfortunately, this statement has no empirical support. These other approaches are filled with detailed theories, but no peer-reviewed research to back up their assertions. In terms of the “no one-size-fits-all” argument, the ABA program set up for every child is, by definition, customized. An ABA-based intervention begins with a comprehensive assessment of each learner’s abilities and needs, upon which an individualized treatment plan is developed. Studies that have specifically compared ABA to eclectic (a combination of) methods have not found identical outcomes for both groups. Below are but a few of the many studies in which children who received eclectic treatments did not achieve the clinically significant progress equal to those in the ABA group (Zachor et al., 2007; Howard et al., 2005; Eikeseth et al., 2002; Eldevik et al., 2006). There are no well-designed studies demonstrating the benefit of using “other approaches” to supplement progress made with ABA-based interventions.
In posing the question as to why ABA has not been adopted by more state schools, you add that “much of the evidence suggests that autistic children do best with a combination of approaches.” Again, the research suggests otherwise. It is without debate – based on published scientific studies comparing autism treatments – that behavioral approaches reap the most benefit for children with autism, particularly when started at an early age and at a high intensity, with skill acquisition continuing as the child ages (Harris & Handleman, 2000; Virués-Ortega, J., 2010). The reason ABA is not adopted by more public schools is that a data-based, empirical system with accountability requires financial resources and a paradigm shift by special educators, who will need additional training and ongoing supervision in order to objectively measure and assess the progress of children with special needs, and specifically, children with autism.
Paul Smith of Treetops rightly emphasizes realistic expectations for parents, “There's no doubt that all the children improve – and some are transformed – but, of course, some don't improve as much." The research in ABA does not make a curative claim; however, some children do progress to the point where the untrained eye would not identify them as having autism. Countless studies have shown ABA to be effective in helping individuals develop a variety of social, communication, daily living and work-related skills, thus allowing them to lead more productive lives – regardless of whether they may remediate to the point of “indistinguishability.” A fulfilled, productive life is certainly something that we should all want for any child.
Alice Walkup, MS, BCBA and Sabrina Freeman, PhD
Association for Science in Autism Treatment
Eikeseth, S., Smith, T., Jahr, E. & Eldevik, S. (2002). Intensive behavioral treatment at school for 4- to 7-year-old children with autism: A 1-year comparison controlled study. Behavior Modification, 26, 49-68.
Eldevik, S., Eikeseth, S., Jahr, E., & Smith, T. (2006). Effects of low-intensity behavioral treatment for children with autism and mental retardation. Journal of Autism and Developmental Disorders, 36, 211-224.
Harris, S. & Handleman, J. (2000). Age and IQ at intake as predictors of placement for young children with autism: a four- to six-year follow-up. Journal of Autism and Developmental Disorders, 30(2), 137-142.
Howard, J.S., Sparkman, C.R., Cohen, H.G., Green, G., & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic treatments for young children with autism. Research in Developmental Disabilities, 26, 359-383.
Virués-Ortega, J. (2010). Applied behavior analytic intervention for autism in early childhood: Meta-analysis, meta-regression and dose–response meta-analysis of multiple outcomes. Clinical Psychology Review, 30, 387-399.Zachor, D.A., Ben-Itzchak, E., Rabinovich, A., Lahat, E. (2007). Research in Autism Spectrum Disorders, 304–317.