In the decades since it was developed, Applied Behavior Analysis (ABA) has become the evidence-based treatment of choice to help autistic children acquire skills and diminish behaviors that are harmful to them, such as self-injury.
As the treatment has become widespread it has become confusing because there are a number of different approaches to ABA, from very structured to more play-based. It has also become controversial, in part because the training of the practitioners who implement it varies widely, as does the actual therapy they deliver.
How can the parent of a toddler getting ABA treatment at home, or of a child receiving it at a clinic or in school, know whether the child is getting effective treatment?
Tameika Meadows, an Atlanta-based board certified behavior analyst (BCBA) — the highest certification given by the field’s professional organization — has been providing direct therapy and consulting with families to help them hire qualified staff for 13 years.
She offers some of the red flags that could indicate that ABA practices are not being properly implemented:
- It’s not a program that has been proven in studies to be effective.
- There is no collection of data to track the child’s behaviors and skill levels to determine the course of treatment.
- There is no supervision of young or inexperienced practitioners.
- There is a lack of individualized curriculum. Some agencies providing the ABA practitioner have a cookie-cutter approach to all 2-year-olds or all 6-year-olds, regardless of what the child’s individual needs are.
- There is a lack of positive reinforcement techniques.
- Punishment is used.
- There’s a lot of focus on getting rid of behaviors considered problematic, and little on development of new skills and behaviors.
One important hallmark of ABA, explains Meadows, is that true ABA “is always going to look at what skill deficits does this individual have that are leading to problem behavior. Because problem behavior doesn’t happen in a vacuum.” There’s a reason that the child is doing what he’s doing. For instance, a child who isn’t able to verbalize his wants may become frustrated and self-injure or melt down. “So if I just take that away I really haven’t solved anything,” she says.
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What to look for in an ABA therapist
If you’ve chosen Applied Behavior Analysis for a child on the autism spectrum, how do you go about finding an ABA practitioner you can trust?
The most highly credentialed practitioners of ABA are called board certified behavior analysts, or BCBAs. The training for this credential involves starting with a master’s degree in a related field such as speech therapy, special education or psychology. Then several ABA courses are required, after which the candidate has to pass an exam. After that, he or she has to complete 1,500 hours of fieldwork while reporting to a supervisor.
A new certification
The demand for BCBAs is so high, many of them do not offer direct therapy and instead consult, helping families hire qualified practitioners who may not have the BCBA certification but are supervised closely by someone who does.
Meadows is one such consultant. She works with families to identify the child’s needs and find a therapist who would be a good fit. “For example, if I’m working with a client and the child has a lot of self-injurious behavior, that tells me right off the bat what expertise I need in my staff.”
She often runs into situations in which families hire college students who don’t have a lot of applied behavior analysis training. The first thing she does is to make sure the student has a supervisor with a BCBA certification and a background in a related field.
One route she recommends families pursue is hiring someone with the newer registered behavior technician (RBT) credential. The Behavior Analysis Certification Board (BACB) — the same organization responsible for the BCBA credential — created the RBT certificate program in response to the shortage of BCBAs.
An RBT is a paraprofessional who works directly with the child to implement ABA under the supervision of a BCBA. The supervisor does the child’s assessment and designs the treatment plan. Requirements for the RBT involve only a high school diploma, a background check and 40 hours of training, which can be done online.The RBT must also pass an exam and an evaluation of her mastery of the relevant skills, based on observation of her working with a child.
Other types of applied behavior analysis training
But many other professionals who practice ABA aren’t credentialed by the BACB. They may be occupational therapists or speech/language pathologists or clinical psychologists. Some may take courses in ABA designed by the BACB without getting a credential. And some get their ABA training from courses offered by specific ABA programs such as the Pivotal Response Training (PRT) and the Early Start Denver Model (ESDM), which offer their own credentials.
Dr. Catherine Lord, director of the Center for Autism and the Developing Brain at Weill Cornell Medical College & New York Presbyterian Hospital, notes that the variation in training can make things confusing to parents. “It’s frightening that the standards are so vague and variable.”
She added that while there is evidence that more education and training in ABA practitioners improves the response rate of the children, there is no evidence that one particular form of training produces better treatment results than another.
States and insurance companies
Complicating things for parents is the fact that different states and insurance companies have different requirements. To be licensed, a given state might merely require training in a behavioral approach to learning, while an insurance company might narrow reimbursement only to a BCBA or PhD provider.
Ari Ne’eman, who is president and co-founder of the Autistic Self Advocacy Network, argues that a lot of what gets reimbursed as ABA may actually be some other therapy — which he notes may not be a bad thing.
“Because ABA has been mandated for coverage by many state insurance laws, a lot of practitioners will call what they’re doing ABA even when it’s not ABA,” Ne’eman says. “So you’ve got a lot of folks who may actually be practicing totally different methodologies, may be practicing Floortime, may be doing stuff with speech/language pathology or occupational therapy, which is very good, and for insurance purposes they’ll call it ABA.”
Clinic or home?
One issue parents must consider is whether to have ABA treatment at home or in a clinical setting. While home-based treatment may be more convenient, Dr. Lord notes, in a clinic a child will be on the radar screen of more practitioners with various kinds of expertise. “There are more people to see how things are going, detect problems, discuss problems with. At home, there are fewer minds working on things.”
Dr. Lord adds that the concern isn’t that kids getting ABA at home are being mistreated, but that the different therapists a child might be seeing for various issues may not be working together well. “Each individually says, ‘It’s going great,’ but they’re not getting together to say, ‘What’s going on here?’ We get very focused on seeing whether what we’re doing is effective, not whether we’re doing the most effective thing.”
Whether you opt for home treatment or clinical treatment, it’s important for families to learn the techniques to extend learning beyond hours of therapy.
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A good ABA experience
Stephanie Kenniburg has been extremely happy with the treatment her son Holden, now 6, has received. The Kenniburgs live in the Detroit area and waited a year for Holden to get off of a wait list so he could start ABA. But in that year since he started, she’s seen a huge difference in him.
“He will focus more on tasks, particularly with the type of behavior plan that we have with him where he knows that first he has to do his task and then he gets to do his fun thing or get his reward,” she says. “I think he really enjoys the structure. He does best in that type of situation.”
And she says Holden has come out of his shell socially. He’s more engaged with the world around him and with other people. “He’s starting to ask people questions that are not just pertaining to him,” she says. “He’s asking ‘What are you doing?’ He’s really interested in what others around him are doing where he wasn’t before. Before he just did his own thing.”
His teachers and classroom aide have noticed the shift as well. And the ABA worked quickly for Holden. “We started noticing changes probably within the first couple of months,” Kenniburg says. “He was doing things better in school. His vocabulary was getting better; he was starting to talk with us and socialize with us more. He’s a completely different kid than he was a year ago.”