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The assertion that applied behavior analysis is the most powerful approach in the treatment of autistic behaviors warrants examination. Applied behavior analysis is characterized by discrete presentation of stimuli with responses followed by immediate feedback, an intense schedule of reinforcement, data collection, and systematic trials of instruction. This highly structured format seems to meet the needs of individuals with autism who typically respond to routine and directness. However, a critical analysis of the approach is necessary to determine the real potential of applied behavior analysis in the treatment of children and youth with autism.
Autism is a spectrum disorder that encompasses many labeled disorders such as autism, pervasive developmental disorders, and Asperger syndrome (Jacobson, 2000). Symptoms of this psychological disorder typically include varying levels of impairment in interpersonal skills, emotional or affective behavior, and intellectual functioning. One of the most pervasive characteristics of the disability, however, is a delay or impairment in the ability to produce and respond to language (Secan, Egel, & Tilley, 1989). Many children with autism do not develop speech and other children with the disorder often exhibit unusual speech patterns such as echolalia or the repetition of what has been heard. Frequently, the tone of their speech is flat and unexpressive. Language difficulties are compounded by social impairments. Children with autism frequently are unresponsive to others, fail to make eye contact, and miss social cues such as a person's facial, verbal, postural, and gestural responses (Gena, Krantz, McClannahan, Poulson, 1996). In addition to these areas of difficulty, other common disturbances involve stereotypic behaviors, self-stimulatory behaviors, self-injurious behaviors, repetitious actions, preoccupation with select objects or topics, aggression, inflexibility in routines, and over-sensitivity to sensory stimuli.
One treatment approach is behavioral in nature. It focuses upon increasing appropriate behaviors and decreasing inappropriate behaviors. In order for behavioral treatments to work, there needs to be an understanding of how children with autism use the stimulation around them to predict an appropriate response (Schreibman, 2000). This stimulus-response relationship attempts to build a connection for children with autism. Applied behavior analysis, which emphasizes this relationship, has been reported by the Surgeon General of the United States to be the most effective way to treat autism (Rosenwasser et al., 2002). A closer examination of this acclamation is warranted. The remainder of this paper will critically analyze the potential of applied behavior analysis in the treatment of children and youth with autism.
Applied behavior analysis had its beginnings with laboratory experiments on animals and trials with humans in the severely retarded range of functioning (Snell, 1978). After the technique was used successfully in clinical settings, it extended to additional exceptionalities of children in classroom settings. The process of applied behavior analysis is very systematic. Children are first individually analyzed to assess the behavior that needs to be altered. Once the behavior is identified, intervention strategies are determined to suit the situation and, then, used to modify the behavior. During this time, the instructor provides reinforcement to elicit and maintain the desired behavior. Evaluations are made throughout the modification process to assess the effectiveness of the intervention (Simpson, 1998). When an intervention is found to be ineffective, another strategy is substituted.
Each case of applied behavior analysis (ABA) must be conducted around the context of the environment and particular characteristics of the individual. The behavior that is targeted for change must also be observable and measurable. Five more specific steps are followed in the ABA process (Snell, 1978). First, the positive behavior is measured directly. Second, the behavior is measured daily based on the target responses. Then, systematic procedures are followed so that, if successful in modifying the behavior, those procedures can be replicated. Fourth, data is recorded on the individual level, usually by graphing progress. Finally, the interventionist demonstrates that the results were completed in a controlled manner in an attempt to prove that the intervention accounted for the change in behavior.
Applied behavior analysis has been implemented in various areas of learning, including language acquisition, self-help skills, vocational skills, and daily living skills (Grindle, & Remington, 2002; Snell, 1978). Although applied behavior analysis can take many, forms, the common core procedure described above links all the attempts taken to modify, behavior. For example, techniques such as discrete trial training, direct instruction, and response prompt systems (e.g., increasing assistance, decreasing assistance, time delay) provide repeated practice and rigid presentation. This format of presentation seems to fit the characteristics of the population of autistic individuals. The need for routine, structure, and concrete examples meshes with the applied behavior analysis approach.
Applied behavioral analysis has the best documented outcome data supporting this approach as compared with other methods (Rosenwasser et al., 2002; Jacobson, 2000). The first: positive results of ABA with the autistic population were demonstrated in the 1960s, when programs were established in classroom sites (Schreibman, 2000). The strategy helped to increase desired behavior and diminish undesirable behavior.
Many studies have revealed the successful application of ABA, and many advocacy groups support its use. According to Jacobson (2000), the only data that shows consistent improvements with autistic children is applied behavior analysis. In a nation study called Project Follow-Through, the findings supported the idea that direct instruction, behavior analysis methods, and additional behavioral approaches were the strongest ways of instruction for these children. There are also various associations, such as Families for Early Autism Treatment (FEAT), Parents for the Early Intervention of Autism in Children (PEACH), and New Jersey Center for Outreach and Services for the Autism Community (COSAC), which support behavior-analytic treatments for autistic populations.
In another study at Princeton Child Development Institute, children between the ages of 11 and 18 were included in an experiment to modify stereotypic and disruptive behaviors (Gena et al., 1996). The children and therapist sat face to lace during the sessions. They were confronted with scenarios, given 5 seconds for a response, and then presented with a consequence. Each session was videotaped and, during the session, twenty-four scenarios were presented. At specific points, training trials were used to model appropriate responses. The individuals were then verbally prompted to match the model. The therapist distributed tokens based on the responses given to the scenarios. If twenty-three tokens were attained, they could be exchanged for desirable objects. The results were that an error-correction procedure and token economy produced effective results in all participants. The Princeton Child Development Institute researchers concluded that gains in their system's effectiveness were directly tied to the use of applied behavior analysis (McClannahan & Krantz, 1993).
In an additional study, four students with delayed social interactions, play skills, and behavior issues were taught responses to what, why, and how questions (Secan et al., 1989). The study focused on four types of probes - storybook questions, natural-context questions, spontaneous questions, and maintenance probes. The students were instructed each day for ten to fifteen minute sessions. The children were shown pictures and asked questions corresponding with each picture. When a correct response was given, praise was used as a reward. When incorrect responses were given, the teacher would model the correct response and question the student again. The study found that all students reached or exceeded the desired criteria. There were increases in responses, but students failed by 35% on meeting generalization criteria for storybook and natural-context techniques, when the visible cue was not present. The taught material was also maintained over time.
Further, Lovaas (1987) argues that empirical results from behavioral intervention with autistic children have been both positive and negative. He accepts that the treatment is often primarily effective in the original learning environment, although he cautions that the reports of recovery from autism are false. Lovaas' (1987) own research study targeted declining aggressive behaviors, increasing correct verbal responses, teaching imitation, teaching appropriate play at different at levels, functioning with peers, teaching appropriate expressions and emotions, and learning pre-academic skills. The results showed that only nine out of the nineteen autistic children succeeded in a regular first grade classroom, after treatment had been delivered. Also reported was increased intellectual functioning, with a gain of 30 IQ points (Lovass, 1987). Rimland's (1999) review of this study questions the empirical support; however, the use of ABA must have had have some bearing upon the outcome.
There are many limitations to the use of applied behavior analysis treatments with individuals with autism. First, applied behavior analysis is very intense and intrusive in its format and delivery. Stressful reactions by the recipient of the procedure should be carefully monitored. Sensitive and knowledgeable interventionists are essential in observing adverse treatment outcomes. Second, setting results may occur, with individuals with autism responding to stimuli in one environment, but unable to generalize the learning to other contexts (Schriebman, 2000). Care needs to be taken in selecting natural environments for instruction in order to promote skills in real world situations. Third, the spectrum of difficulties, range of abilities, age of the child, culture of the family, and characteristics of the individual combine to suggest that the use of a single treatment would be poor advise. The many particular variables complicate the treatment selection process. Obviously, treatments must be tailored to meet specific considerations.
Reflection Exercise #10