Can Autism be Treated?

Therapy

This is a common and very good question that we hear “new” families ask during intake or in the very early phases of services; however, before we proceed, something needs to be clarified: treatment is not cure.  Cure implies that we know a definitive cause and we have stopped the cause. Right now, we don’t know a definitive cause of autism. Although some, professionals will claim that autism can be cured based on their studies or personal experience, it is fairly safe to say that for now, there is no cure for autism.

That last statement can be something difficult for some families to take in. From our experience in the applied setting working with families over the years, we have heard that question a handful of times and as professionals, we do feel some responsibility to, in a way, inform new parents early on duirng services so they can focus on what is doable: autism can be treated.

You have probably heard the statement “no two individuals living with autism are the same.” This statement is fairly accurate as what differentiate one person from another are the “symptoms” or difficulties that each live with.

Symptoms. Difficulties. Focusing on these then make addressing the diagnosis of autism doable.  As behavior analysts, it is our responsibility to only administer ABA-based treatment programs that have been proven to be effective given a specific difficulty.  This is called evidence based practices. The specifics of a treatment program will vary of course from one person to another, but the foundations of treatment programs are the same. A foundation derived from sound, empirically proven methods repeatedly implemented in the applied setting over time.

As parents, we will do pretty much anything for our child; however, before doing so, it is highly advised that we inform ourselves about a specific treatment before committing to such treatment especially if it will require additional resources from you (for example, money, time, and effort).

With qualified ABA professionals, proper assessments in the beginning and throughout services, goal-setting, teaching supports to maintain and generalize learned behaviors or skills, and hard work over time, measurable and quality gains can be observed.

The topic of treatment is beyond the scope of this blog; therefore, we do encourage you to communicate with a qualified behavior analyst in your area or you can check out our website at www.leafwingcenter.org for more information on this and other related topics.

Does Research Show that ABA is Successful in Treating Children with Autism?

Yes—research does show that ABA is successful in treating children living with autism. As a matter of fact, since the early 1960s, the effectiveness of ABA based interventions has been very well documented particularly when helping children with developmental disabilities. Over 400 research articles were published between 1964 and 1970 alone and all have concluded that behavior analytic interventions demonstrated the most consistent results with individuals living with developmental disabilities. From the mid ‘80’s to 2010, there were over 500 peer-reviewed, published articles on autism and Applied Behavior Analysis.

Many families of children with autism are or are becoming familiar with the 1987 study published by Lovaas. That 1987 study was the first “group study” looking at children with autism receiving intensive ABA treatment (i.e., 40 hours per week) and children with autism that received 10 hours of ABA treatment or none at all.  In this famous study, Lovaas and his research team implemented many of the basic principles and techniques of behavior analysis into an early intensive intervention program for children with autism. After approximately two years of ABA based interventions, 47% of the children in his study made tremendous gains and were able to enter a typical first grade classroom without any additional assistance and scored in the average range in IQ tests when prior to the intervention these same children scored in the low range in IQ tests. Of the control groups, the children in the study that did not receive ABA interventions but only community supports, only one child was placed in a first-grade placement and scored average IQ.

While this study is over 30 years old, there are recent replications and research studies that indicate similar findings. While it’s beyond the scope of this post to go into all the research studies indicating the effectiveness of ABA programs for children with autism, ABA currently is widely recognized as a safe and effective treatment for autism.  It has been endorsed by a number of state and federal agencies, including the US Surgeon General and the New York State Department of Health. And for that reason, the use of ABA principles and techniques has rapidly expanded in recent years as more studies demonstrate that these principles help individuals with autism live more independent and more productive lives.

Some Current Dimensions of Applied Behavior Analysis…Explained for Parents

In the first Journal of Applied Behavior Analysis article in 1968, Baer and colleagues described six dimensions of behavior analysis. To facilitate your understanding of this seminal article, we suggest that you substitute the word “characteristic” for the word “dimension.” We will do so for you in the following description. The six characteristics are; 1) that it is Applied; 2) that it is Behavioral; 3) that it is Analytical; 4) that it is Technological; 5) that it is Conceptually Systematic and Effective; and 6) that it has Generality. The reason why these six dimensions identified almost 40 years ago still pertain to this day has to do with their importance in the effectiveness of an ABA program when it comes to the treatment of children with autism. We will discuss each dimension briefly; however, for more in-depth analysis of these dimensions, I recommend you reviewing the article mentioned previously. It is available online at the Journal of Applied Behavior Analysis (JABA) for free.

Some of the implications of the article were to distinguish ABA from laboratory research and also from other fields that worked with behavior (e.g., psychology). There is nothing wrong with laboratory research. In fact, it has supplied us with a lot of the principles, laws, and techniques we use in ABA today. However, ABA was a relatively new applied science and setting the foundations was very important.

Let’s take a look at each of the dimensions in greater detail. The first dimension mentioned by the authors was that of behavior analysis being Applied. Everything that is typically studied in the research and/or addressed by change procedures in applied behavior analysis is studied because of its potential social significance in society rather than for the means of theory alone. If what’s being studied doesn’t have any social importance (i.e., it is not important to the majority of people), behavior analysts typically do not see it as important. This has direct implications on the implementation of the research being conducted in ABA as the research findings can be used in everyday settings to help people in socially significant and important ways. This also has relevance to individuals with autism. It is apparent that society values the use of applied behavior analysis to teach individuals with autism to communicate or to reduce self-injurious behavior for example. Without social significance, or intent to actually apply to the every-day world what’s being researched, everything a person could find out in a research study would contribute to theory, but would not immediately impact society. Research conducted in this manner would add to our scientific knowledge but not improve our everyday lives. The same applies to intervention. So, application in socially significant ways is the first dimension of ABA.

Second, the authors described one of the dimensions as being Behavioral. Unlike some forms of psychology and education which might rely on people’s personal accounts and other indirect representations of behavior, ABA is concerned with direct measures of actual behavior. Behavior, of course, is composed of physical, observable events. In other words, ABA is concerned with facts and actual occurrences of behavior, things that can be observed and measured. It’s pragmatic in that it is guided by practical experience and observation rather than theory. With intervention programs for individuals with autism, teams are focused on observing behavior—teaching behavior and not so much with that individuals inferred thoughts are.

Next is the suggestion that ABA is Analytical. What does this mean? Well according to the authors of the article, in order for results of any experiment to be credible, a researcher or the person actually conducting the experiment has to show that somehow the variables used or manipulated in the study actually controlled the behavior that they were looking at to the greatest extent possible (e.g., antecedent and consequence stimuli). In other words, the experimenters must show that by changing one or more aspects in a person’s environment a change in behavior occurred, and by returning those variables back to what they were before the experiment, you can stop the behavior from happening (this is sometimes referred to as experimental control or is referred to as the process of establishing a functional relationship). In an intervention program for children with autism, Analytical would refer to the fact that the individual performs behaviors when asked to do so (e.g., “touch the blue card” and the individual touches the blue card) and that the function of behaviors is analyzed (Baer does not explicitly state this in the article and this article pre-dates the concept of the behavioral function, but he is describing the foundations of the concept of behavioral function intentionally or not when he says ….”a believable demonstration of the events that can be responsible for the occurrence or non-occurrence of that behavior (p 94)”). So applied behavior analysis is Analytical.

The fourth dimension described by Baer and his colleagues pertains to the dimension of ABA being Technological. This simply means that the procedures used in ABA have to be thoroughly identified and described so that someone who has no familiarity with the procedures can read the description and know exactly what behavior to look for and how to implement the techniques needed. This is an important concept in ABA programs for individuals with autism. Operational definitions are used. The information is written clearly, objectively, and in a way in which it’s easily understandable for people involved. This concept is consistent with good practices in science and scientific practice in other fields.

Next, we have the dimension referred to as Conceptual. In the field of behavior analysis, it is important that any analysis conducted on changing behavior in socially significant ways can be related back to the basic principles of behavior.  When describing any teaching procedure with an individual with autism, it is important to describe the procedure in enough detail for others to follow (Technological), but to also tie that procedure back to the underlying concept or principle (e.g., forward chaining procedure). This provides others with two bits of information to assist them to recreate what you have done (i.e., the technical and the conceptual). Results of any analysis or any experiment can be and should be applicable to the basic principles of behavior analysis.

The fifth characteristic of ABA is Effectiveness. This notion of effectiveness means that the changes that were brought about by the ABA techniques must be significant enough to be of practical value and seen as helpful or significant to the people being helped (a conceptual precursor to social validity and the introduction of the concept of effect size in ABA). In addition, the change in behavior must be large enough to make a difference in an individual’s life (e.g., increasing attending to the classroom teacher during instruction time from 1-2 seconds to 3-5 minutes rather than increasing attending to the classroom teacher from 1-2 seconds to 4-5 seconds). The qualification of social importance can be determined by the child, the parents, the student, the teacher, and so on (and all should have a say in determining this). If the changing behavior isn’t seen as significant (i.e., meaningful) to the people you are trying to help, then all your efforts are wasted.

Lastly, Baer and colleagues looked at the dimension of Generality. Simply put, generality refers to changes that have been produced by behavioral techniques and the necessity that these changes should be durable over time, observable in a wide variety of environments, or spread to a wide variety of related behaviors.  All of us that work with individuals with autism know very well the importance of generalization of skills.

In 1987 Baer, Wolf, and Risley revisited the dimensions of ABA and found them still very relevant. Some of the dimensions were refined in terms of tactics, but still represent ABA. Now while all these dimensions were highlighted back in 1968 and 1987, all of these dimensions are still directly related with what experts believe as being effective characteristics of treatment programs for children with autism today.

How Does Senate Bill 946 Affect Individuals with Autism in California?

Senate Bill 946, passed by the State Assembly and the State Senate on September 9th, 2011 and signed by then Governor Brown and filed with the Secretary of State on October 9th, 2011 is a monumental step for individuals with Autism and Pervasive Developmental Disorder (PDD) in California. The new law took effect on July 1st, 2012.

Previous to this bill signing, individuals with autism could get necessary services in one of three ways. First, families or caregivers could pay out-of-pocket. Only a small segment of the population could afford this as estimated costs for monthly services ranged from $3,000 to $12,000. The second way to get services was to request them from your local school district. This has proven to be very challenging as the school districts have been unfamiliar with the unique service type and more recently are financially challenged. Last was the option of regional centers. There are 21 in the state of California at present and each one has taken a slightly different approach to providing services for Individuals with Autism and Pervasive Developmental Disorder. In addition, the budget crisis in California in the early 2010’s has greatly affected most regional center’s abilities to provide services. Thus, using a regional center then for services for an individual with Autism or PDD depending on where one lived and the policies of that regional center, could also prove challenging.

As a result of SB 946 over the last few years, individuals with Pervasive Developmental Disorders or Autism are entitled to use their medical insurance to obtain services. Specifically, as of July 1, 2012 individuals in the state of California can now use their medical insurance to obtain services Pervasive Developmental Disorders or Autism. This applies to the following medical service providers: Every health care service plan contract that provides hospital, medical, or surgical coverage. It appears that SB 946 does not apply to a medical insurance plan that does not provide behavioral health or mental health services, a health care service plan in the Medi-Cal program, a health care service plan in the Healthy Families Program, or health care benefit plan or contract entered into with the Board of Administration of the Public Employees’ Retirement System.

It is important to note that SB 946 specifically states that there is no intention of the bill to alter the responsibilities that have typically fallen under an Individual Educational Plan (IEP) under the Individuals with Disabilities Education Act (IDEA and its amendments and reauthorizations) or in and Individual Program Plan (IPP) under Title 17. We interpret this to mean that SB 946 does not mean that school systems will no longer have to provide services or will have to alter the services they provide to individuals with Pervasive Developmental Disorders or Autism because the bill now requires that medical insurance will now also cover services. In addition, we feel that the same conclusion can be reached that SB 946 will not eliminate, reduce, or alter regional center’s responsibilities to provide services to Pervasive Developmental Disorders or Autism under Title 17.

What treatments are covered? The following is what SB 946 is referring to when it is talking about services. Specifically, “Behavioral Health Treatment” means professional services and treatment programs, including Applied Behavior Analysis and evidence-based behavior intervention programs. Other than Applied Behavior Analysis, no specific mention of another treatment approach is made.

What is required of the treatment programs? The treatment programs must include all of the following criteria to be eligible for coverage. First, the treatment has to be prescribed by a physician or licensed psychologist. Second, the treatment follows a treatment plan prescribed (developed by) a qualified Autism service provider and administered by a qualified Autism service provider, a qualified autism service professional supervised and employed by the qualified autism service provider, or a qualified autism service paraprofessional supervised and employed by a qualified autism service provider. Third, the plan developed by a qualified Autism service provider has measurable goals that are specified to a timeline and that are unique to the individual being treated. The treatment plan has to be reviewed no less that once every six months, modified when appropriate, and describes the individual with Autism’s impairments that will be treated; develops an intervention plan that specifies the service type (i.e., techniques and methodology), the number of hours required, the level of parent participation to achieve those goals, and the frequency of progress evaluation and progress reporting. Fourth, discontinues intensive intervention services when goals have been achieved or are no longer appropriate. Last, the treatment is not used as a means of or a reimbursement for a respite program, day care, or educational services and cannot be used as a means to reimburse a parent for participating in the program.

What is a qualified Autism service professional? SB 946 specifies the following criteria must be met to be considered a qualified Autism service professional. First, this person provides behavioral health treatment (e.g., treatment for individuals with Autism). Second, if they do not meet the criteria to be a qualified Autism provider, that the person is employed and supervised by a qualified autism service provider (e.g., an agency or clinic). Third, that individual provides treatment that follows a treatment plan developed and approved by the qualified autism service provider. Third, is a behavioral service provider approved as a vendor by a California regional center to provide services as BCBA-D, BCBA, BCaBA, a Behavior Management Assistant, a Behavior Management Consultant, or a Behavior Management Program as defined in Section 54342 of Title 17 of the California Code of Regulations. We interpret this to mean that one of the criteria to be considered a qualified Autism professional is to have met the vendor requirements of a California regional center. Fourth, that the individual has training and experience in providing services for pervasive developmental disorder or autism.

SB 946 also provided for an Autism Advisory Task Force. The purpose of the task force was to submit a report to the Governor and specified members of the Legislature by December 31, 2012. The report developed recommendations regarding behavioral health treatment that is medically necessary for the treatment of individuals with autism or pervasive developmental disorder.

Using Mini Schedules and Task Organizers to Help Students with ASD In Classroom Settings

There are many types of visual schedules that can complement children’s daily tasks and activities by providing more specific cues about those tasks and activities. Mini schedules are used to provide specific information about the task at hand. These mini schedules can be highly individualized based on the individual’s skill level to meet the requirements of a given task. For example, if a student needs support on steps necessary to complete a math task, a mini schedule would be used to help identify step-by-step instructions of the task.

A mini schedule can also be designed to provide opportunities for choice making. For example, a mini schedule for an art lesson would direct a student to the stages required for drawing and coloring an object. At specific points along the mini schedule, the student would be required to make a choice between two or more items to create the art project. In this application, the mini schedule provides both the structure and the opportunity for decision-making.

Another visual schedule – the task organizer, can be used to add more structure to a lesson or activity depicted on the mini schedule. Task organizers provide a task analysis, or breakdown, of the steps required to complete activities. In the case of a math lesson, a task organizer could be used to further describe the steps within a specific activity, such as writing odd or even numbers.

Mini schedules and task organizers should only be used when a student needs extra structure for understanding activities, or to provide opportunities for decision-making to help a student perform at the most appropriate, independent level. For example, some students require minimal external structure and would need only a daily schedule to keep on task. However, those students who need more assistance to complete a task on their daily schedule would benefit from a series of mini schedules for each major activity.

Remember that a mini schedule or task organizer is usually not enough to help the student be successful. Most often, each of the steps in the mini schedule would need to be taught by repeatedly prompting and correcting attempts by the student. Last, remember that you will need to reinforce (reward) the student’s correct performance of the steps in the mini schedule or task organizer.

How Do Attention and Learning Rates Play a Role in a Child’s ABA Program

Children with autism can be easily distracted and may require a high level of assistance in order to attend to tasks and activities. Their attention span is typically shorter than that of their typically developing peers. When this is the case, an ABA program will begin teaching concepts by breaking them down into simple teachable steps in a distraction free environment, such as in their bedroom or in a quiet room in the house. For example, it may be too difficult for a child with autism to learn to count from 1-10 all at one time. Therefore, each number in the sequence will be taught one by one, at the pace of your child’s learning (chaining). On Monday, they may learn the number ‘one,’ on Tuesday, if they still maintain the memory of the number “one,’ they will be taught the number ‘two,’ on Wednesday, if they still maintain the memory of numbers ‘one’ and ‘two,’ they will be taught ‘three,’ and so on. While this may seem like a very slow learning rate, a child will be taught at the rate they are capable of learning.

With shorter attention spans, it is also important to note that clear, concise, and simple instructions are typically more effective in producing effective learning opportunities. This is why simple and clear language is often used in ABA programs. For example, the instruction, “point to number 1” is a much clearer instruction than “can you please point to the piece of paper that has the number 1 written on it?” and therefore, more likely to produce the desired response. However, it is also important to note that with continued success, and as attention and learning rates increase, language and instructions should be modified to include more complexity. This will help to promote generalization.

Children with autism typically need to not only learn in small steps, but require much repetition until the skill comes easily to them. Therefore, in an ABA program, the learning environment is structured so that it will allow as much repetition as a child needs while maintaining their motivation  and interest in learning. When children begin ABA programs, they may need many repetitions on the concept before learning or mastering the concept. However, it is common to find that over time as a child learns “how to learn,” that these repetitions become fewer and fewer and learning rates increase. Some describe this phenomena as “learning to learn”.

Why Does ABA Help Children With Autism?

Why is Applied Behavior Analysis treatment helpful when teaching children with autism?  What is it about these principles and techniques that seem to be a good fit in helping improve the lives of those affected with autism? These are very important questions to ask and their answers are imperative to understanding why individuals with autism often need specialized teaching environments to learn.

We all know that typically developing children learn throughout all waking hours, even when they are not being formally taught. Typically developing children watch other children, watch adults, watch TV, learn from school, and incorporate what they have learned into their repertoire.  Often times they only need to see something once or twice before it comes easily to them. Parents are often amazed at what their children are learning and frequently ask, “where did you learn to do that?” Furthermore, when children acquire language, they often begin to ask questions of others in their environment. From the basic “why” question that parents so often get asked to more elaborate questions about “How this thing works, or how that thing works”. They become their own information seeking beings.

Unfortunately, this is not the case for the majority of children with autism. Children with autism learn much less from their environment. They have a weakness in what’s called observational learning or learning via imitation, that is, watching someone else do something, and learning to do it themselves without any specific teaching.  Children with Autism typically have decreased language skills and thus attend less to others, or they understand less of what is said to them, or they ask fewer questions of others. For most children with autism, you cannot expect to put them in a classroom setting and have them learn and absorb what the teacher is saying, mainly as a direct result of the characteristics of autism.

However, ABA programs create a very structured environment where conditions are optimized for learning, and over time, this very structured environment is systematically changed so that it mimics what a child could expect if and when they are placed in the classroom. In other words, initially, an ABA program will create a somewhat unnatural or atypical learning environment for a child, such as teaching them in a distraction free, one-to-one environment in their home, but over time, this environment will slowly change so that it looks like every other classroom that a child may encounter in their school years.  It is important to note that the main premise of an ABA program is teaching a child, “how to learn,” so that they will no longer need such structured and specialized services.

Also, ABA programs take into consideration generalization and maintenance and plan accordingly for these issues. That is, another common challenge with children with autism is that they don’t easily apply something that was learned in one environment into another environment (e.g., if something was taught at home, the child may not do it at school). Last, it is sometime difficult for children with autism to remember something that was taught at some time in the future. That is tough for all of us sometimes. However, it is essential for children with autism as their programs often are composed of skills that build on one another.

Individualization in the Treatment of Children with Autism

In ABA programs, the individual’s behavior is the primary focus when it comes to intervention development, execution, and monitoring. As such, the design and implementation of all ABA programs must be individualized. This is not only an ethical requirement, but also clinically relevant because each child has their own strengths, skill deficits, environments they spend time in, learning histories, and a unique biology. These factors must be considered during the design of an ABA program. Autism is a spectrum disorder and that means there are a lot of differences in the characteristics that each individual may have.

To illustrate, the goal of teaching pretend play skills to a child who has limited pretend play skills might be a high priority goal. However, the same goal might not be a high priority goal for a different child who already demonstrates age level pretend play skills since he or she already has this skill in their repertoire. In the case of the latter scenario, it may be more clinically appropriate to teach ways in which the pretend play skills can be expanded upon, generalized, or to target different curricular areas in which there are deficits. This is an example of how one particular goal may not be clinically appropriate for two different children.

As mentioned earlier, individualization should take a learner’s strengths and skill deficits into consideration. With this, a learner’s strengths can be built upon while the areas of deficit are strengthened. Remember, ABA is never ‘one size fits all’ and a good program should rely on assessment tools such as observations, interviews, clinical assessments, and collaboration with the learner’s family to establish individualized goals that are in the best interest of the client.

Below are a few ways in which individualization can be achieved in an ABA program:

  • Consider the interests and preferences of the child. Create ways to incorporate these in to the ABA program.
  • Consider the sociocultural values of a child’s family, along with their top concerns as they relate to behavior challenges and skill deficits.
  • Through use of validated clinical methods, explore the child’s strengths and deficits as they relate to major domains – socialization, communication, self-care, motor skills, etc.
  • Promote collaboration between a child’s family members, other professionals (teachers, speech therapists, occupational therapists) in the child’s life, and the ABA provider.

Though the list above is not exhaustive, we hope this post has provided you with some information about individualization in ABA programs!

Observational Learning and Children with Autism

One of the main obstacles to learning that many children with autism face is a lack of observational learning skills. What is observational learning? It is learning that occurs without explicit teaching and by observing another person do something and simply doing what they do. Children with autism have difficulty learning by watching someone else and absorbing that information incidentally. For example, a typically developing child may look across the classroom and watch another child building a house using blocks. The next day at school this child may then build his or her own house using blocks without specifically being taught this task. This child simply watched another child, observed what the child was doing, was able to retain this information in his or her memory, and then accessed this information the next day in order to build a house. On the other hand, parents of typically developing children sometimes complain that their children are learning bad habits at school. This can also be observational learning at work. A child with autism may lack these imitation skills and so when they are in an environment filled with peers from which to learn, often times very little learning takes place. Opportunities for observational learning occur throughout the day and may contribute to a considerable amount of what we learn. Just think, was everything that you know explicitly taught to you? Chances are you answered “no”.

In an ABA program, one of the first skills taught to a child with autism is the skill of attending and imitating. Initially, this imitation might be as simple as imitating a handclap, or a wave. Over time, these imitation skills will expand so that the child can imitate complex behaviors such as how to watch a child from afar and build what they are building, how to play T-ball, how to draw pictures, or how to engage in self-care tasks such as brushing their teeth simply by watching, absorbing, and imitating. Imitation is one of the basic foundational skills needed for any child to be a successful learner. Therefore, there is much emphasis placed on imitation in ABA programs, particularly in the beginning stages of programs.

Why Do Some ABA programs Use Basic Language When Working with Children with Autism?

We know many children with autism typically have difficulty understanding language. These difficulties can be subtle. For example, a child may have difficulty understanding humor. In other cases, they may be more pronounced. That is, a child may respond to little or no language that is spoken to him or her. Taking this fact into account, most ABA programs will teach a child using simple and concise language at the beginning stages of the program. For example, if the goal is to teach a child to imitate a ‘clap’ the teacher would simply say, “Do this” or “Copy me” while demonstrating the action. The instruction would be limited to as few words as possible (in this example, two words and then a demonstration of the action). The teacher would refrain from using a longer instruction that contains more words such as, “okay, now I’m going to do something and I want you to watch me and then copy me after I’m done. Are you ready?” For a child who has difficulty understanding language, this instruction is laden with words that are unnecessary to complete the instruction and probably will include many words that the child does not presently know. Another example of this can be seen with one-word instructions given to children when attempting to teach them to perform actions. With this type of program, an instruction to the child may include something like “clap” or “stand up” and the child would perform the action. The general idea is here is to use fewer, and simpler words to evoke the desired response from the child.

Therefore, in the initial stages of an ABA program, the more concise and simpler the instruction, the more successful the child will be. It is important to note that the simplicity or complexity of language used should be based on the child’s language repertoire at the time of assessment. Over time, and with success, simple and concise instructions will be elaborated and more language will be incorporated into the instruction.