What potential does the applied behavior analysis approach have for the treatment of children and youth with autism?

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.

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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.

Autism is a developmental disorder that is usually identified before 3 years of age. Strange behaviors appear early in the child' s life and diagnosis has been expedited by more public awareness of the disability (e.g., popular cinema such as Rain Man). This is certainly a positive outcome of such attention, but inaccurate portrayal of the disability can lead to public misunderstanding. For example, only a small percent of individuals with autism possess the splinter skills of "Raymond" in Rain Man (i.e., card counting ability).

Research has not been able to pinpoint any single causation of autism; consequently, interventions for the disability have varied greatly. Heflin and Simpson (1998) provide a very thorough overview of interventions for children and youth with autism that incorporate strategies from psychoanalytic, medical, educational, and behavioral perspectives. The sheer number of possible interventions for parents and/or guardians to consider is overwhelming and confusing. Researchers, themselves, debate about the potential of various treatment options (Lovaas, 1987). Some experts make optimistic claims to cure the disability (Lovaas, 1993), while other professionals focus on remediating a specific behavior or building a particular skill (Stromer, Mackay, & Remington, 1996). Caregivers and educators are faced with the problem of choosing the most promising treatments.

Treatments that concentrate on emotional disturbances related to autism stem from the psychoanalytic approach. Holding Therapy, for example, attempts to build a bond between the child with autism and the parent/guardian. The caregiver is advised to hold the infant very closely and tightly as s/ he speaks in a comforting tone, even when the child tries to escape the embrace. Another approach that emphasizes relationship building is the Son-Rise program (Kaufman & Kaufman, 1998). Parents are to repeat the actions of the child in an environment that is not distracting or stimulating. The majority of the caregiver/child time must be spent in trying to enter the child's world and provide unconditional love and acceptance. The difficulty of these treatments and others like them are significant. First, there is a guilt-based underlying assumption that the family relationship is problematic. Second, the intensity of the treatment may not be feasible for many families with other work and parenting demands. Third, the treatments are highly invasive with close and on-going proximity to the child.

Other treatments emphasize a physiological basis for the disability and rely upon medical interventions. Medications for individuals with autism range from tranquilizers, anti-depressants, anti-anxiety drugs, and stimulants to anti-convulsants (Heflin & Simpson, 1998). More natural, dietary treatments are also suggested. Rimland (1999) strongly advocates the use of high dosage vitamin B6, magnesium, and dimethlglycine. Concerns regarding natural and prescribed remedies are numerous. What are the side effects of these treatments? New drug therapies for this population lack supportive research and study. What are the proper dosages for young children? What adverse effects can result from the combination of biological treatments? Clearly, careful physician monitoring of such interventions is essential to the health and welfare of the child.

Another approach centers on educational options and is broader in scope. Alternatives for consideration in this category of interventions focus on the placement of the child. A continuum of educational services is available from a segregated special education program to a fully inclusive placement in general education classes with support services. A highly individualized program is required to meet the specific needs of the child. Of particular concern is the issue of the onset of treatment. Repeatedly, early intervention programs initiated before the age of 5 years have been strongly related to progress (Fenske, Zalenski, Krantz, & Mc Clannahan, 1985; Rosenwasser, & Axelrod, 2002).

A final 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 face 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.

Through the increased request for ABA strategies, the public has shown that recognition for the technique has become widespread. For instance, in a web listing of schools that claim to use ABA as a primary intervention, 59 sites were identified (http:/ /members.tripod.con/~Rsaffran/ schools.htm). Findings have reported that ABA even produces improved results on standardized tests for this population of students (Rosenwasser et al., 2002). Many researchers agree that the most effective strategy for autistic children is the use of an intensive intervention that is applied in high dosages (Schreibman, 2000). Using the predictable and planned out organization of applied behavior analysis benefits autistic children's learning style. Although ABA is very effective with this population overall, different forms of the technique may be more beneficial than others, and finding those variables that influence effectiveness will be an on-going process.

Applied behavior analysis has not been without controversy over the years. Although there are some advocates who state that ABA is the only way to successfully teach autistic children, others will defend different treatments. Rimland (1999), for instance, debates that there are numerous other methods to the treatment of autism that include documented evidence that the treatment works. Vitamin therapy, casein-free diets, sensory integration, and auditory integration are some of the other techniques that have been tested with autistic populations. Studies with vitamin therapy have followed scientific procedures that include double-blindness as well as factual evidence of normalization in the brain waves (Rimland, 1999). With regard to the various dietary studies, improvements in behavior resulted in many individuals (Rimland, 1999). These additional findings show that ABA is still a very powerful treatment, but it may not be the only means of obtaining desired results.

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.

Finally, new treatments require closer examination of current and future empirical studies. Rimland (1999) pointed out that there are 18 studies related to the vitamin B and magnesium treatment alone. The viability of other options that better suit the individual and family cannot be overlooked.

Substantial contributions have been made in using applied behavior analysis as the basis for designing treatments that are useful in coping with a wide variety of behaviors related to autism (Laties, & Mace, 1993). The most scientifically effective treatment seems to be based upon a behavioral model, which is done intensively and early in the child's life (Schreibman, 2000). Besides these overall findings, treatment for autism depends upon the individual as well as family variables. Autism is such a fascinating disability and many questions about the condition are still unanswered. Therefore, there is no current treatment that completely addresses the needs of the disability. Perhaps a complement of eclectic strategies is necessary to meet the complex challenges and spectrum of characteristics associated with autism. As Lovaas (1987) indicates, one may have to intervene on all behaviors, in all environments, and with the help of all significant persons. Realistically, a plethora of individualized treatments may have to start early in life and continue intensively for a long period of time.

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Alexis Ann Schoen, Graduate Student, Counseling Psychology, La Salle University.

Correspondence concerning this article should be addressed to: Alexis Ann Schoen, Graduate Student, LaSalle University, Olney Hall, Room 354, Philadelphia, PA 19141; Email: [e-mail].