Review two articles
JASH 1999, Vol. 24, No. 3, 162-173
copyright 1999 by The Association for Persons with Severe Handicaps
Early Intervention for Young Children with Autism: Continuum-Based
Behavioral Models Stephen R. Anderson
Summit Educational Resources
Raymond G. Romanczyk State University of New York-Binghamton
Over the last three decades, instructional methods de rived from applied behavior analysis ( ABA) have shown considerable promise for many young children with au tism. The ABA approach establishes a priori that assess ment and intervention methods must be based on gener ally accepted rules of scientific evidence. On one hand, the approach has produced a rich resource of conceptu ally consistent and scientifically validated techniques that can be applied in various combinations across many dif ferent contexts. On the other hand, this diversity has re sulted in some confusion regarding the precise charac teristics of ABA. In this article, the authors first describe many of the common programmatic and methodologic elements that form the foundation of the approach. A summary of the scope of the behavioral research is pro vided including greater detail on six studies that demon strated large-scale interventions. Finally, the authors de scribe components of program models that share com mon elements of the ABA approach and use a broad continuum of traditional behavioral techniques. Some specific myths about the approach are simultaneously addressed.
DESCRIPTORS: applied behavior analysis, inter vention methods, program models, autism
Autism is a serious developmental disability that pro vides a complex challenge for parents, professionals, and all those who come in contact with the child. Au tism is a syndrome, as opposed to a disease entity, that is characterized by specific behavioral patterns and characteristics. A complex disorder (Berkell Zager, 1999; Cohen & Volkmar, 1997; Matson, 1994; Roman czyk, 1994; Schopler & Mesibov, 1988), autism spec trum disorder (ASD) has been studied for 50 years, yet
Address all correspondence and reprint requests for re prints to Stephen R. Anderson, Summit Educational Re sources, 300 Fries Road, Tonawanda, NY 14150-8897. E-mail: [email protected]
162
still results in controversy, misinformation, and is a source of great confusion for parents attempting to make treatment and education decisions for their chil dren. For the purposes of this article, we assume that the reader is familiar with the difficult and complex issues of obtaining an accurate differential diagnosis for young children, as well as with the critical process of obtaining an assessment of the child’s development (Harris & Handleman, 1994; New York State Depart ment of Health, 1999a; Powers & Handleman, 1984; Romanczyk, Lockshin, & Navalta, 1994; Schopler & Mesibov, 1988).
A general historical reading in the field of autism quickly results in the impression that autism is a severe disability for which little evidence is found for long term positive outcome, that it is difficult to diagnose, and that incidence and prevalence figures are contro versial (California Department of Developmental Ser vices, 1999). Autism is also strongly associated with a great number of “fads” and “movements” that over the last several decades have promised much, but consis tently have failed to deliver when the harsh light of objective evaluation is focused on supposed break through procedures (Delmolino & Romanczyk, 1995; Green, 1996a; Olley & Gutentag, 1999; Smith, 1996). Often “models” are promulgated with little empirical support, but with a wealth of sincerity and enthusiasm. By studying this history, an appreciation is formed for the complexities of generating a viable model that stands the test of time and objective evaluation.
It is in this context that we first describe an approach that establishes a priori that the selection of assessment and intervention approaches must be based on gener ally accepted rules of scientific evidence for efficacy. It is a “bottom up” approach, in that principles and pro cedures with demonstrated efficacy are assembled into a coherent model that is again subjected to empirical validation. This is quite different from the process of developing a conceptual model and then seeking to find confirmatory evidence.
Downloaded from rps.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 17, 2015
http://rps.sagepub.com/
Continuum-Based Behavioral Models 163
To date, only one nonmedical approach meets the boundary conditions of this model as applied to autism. This approach has consistently produced outcomes that are reproducible, describable in precise terms, are tied to a conceptualization that has strong and extensive experimental support, and uses, as a necessary compo nent, continuing objective evaluation. This approach, known as applied behavior analysis (ABA) in the con text of autism, but more generically as behavior therapy or the behavioral approach, was first applied in the treatment of autism more than three decades ago. Its roots are strongly within a research/academic frame work, and it has been applied with empirically evalu ated success to a wide array of human problems (Bar low, 1988; Barlow, Hayes, & Nelson, 1984; Spiegler & Guevremont, 1993). Interestingly, perhaps because of its focus on objective evaluation rather than on consen sus of opinion, it has not become popularized and has often been grossly misunderstood (cf. Maurice, 1993).
Over the past three decades, systematic research in vestigations have demonstrated the utility of specific components of ABA. More recently, larger scale out come studies again have consistently demonstrated that significant impact can be made for children with autism (New York State Health Department, 1999a). For those who are influenced by research versus anecdotal reports, there exists a growing and diverse behavioral technology that can be applied. One unexpected out come of this extensiveness has been a clustering of be havior analysts into several schools with strongly held positions. In our opinion, these are divisions based largely on emphasis on one particular instructional technique or another, a grouping of techniques in a certain clustering, or differences in the strategy of ser vice delivery. However, all fall within the rubric of ABA. It is our opinion that no single technique nor collection of techniques can be correct ( or effective) for every person in every situation. Thus, the data based feedback loop in ABA is inherently a self-correcting mechanism if applied in the context of clinical decision making. It is our goal in this article to first outline the common programmatic and methodologic elements of the ABA approach. We discuss some of the features that seem to define typical behavioral models and within this context respond to the many myths that have arisen regarding ABA.
Programmatic Common Elements
It is probably accurate to state that many models, behavioral analytic and nonbehavioral analytic, share some common programmatic elements. Dawson and Osterling (1997) reviewed a number of programs for children with autism that met the boundary condition of having published detailed descriptions of the pro grams and provided intake and outcome data (many are reviewed in this special issue of JASH). They pre-
sent a series of common elements that were observed that are considered tried and true. More precisely, by examining common elements that exist across programs that differ significantly in approach, the authors state that these programmatic common elements are “un likely to reflect an idiosyncratic viewpoint or one inves tigator’s philosophical attitude” (p. 314 ). These pro grammatic common elements are specific curriculum content, highly supportive teaching environments and generalization strategies, predictable routine, func tional approach to problem behaviors, planned transi tion, and family involvement.
These programmatic common elements perhaps re flect the minimum starting point for program develop ment, along with appropriately trained and caring staff, adequate resources, and supervisory and review mecha nisms. Given these as “basics,” then the task is to utilize a methodology that allows each of these elements to be addressed in an individualized manner, for children, family, and staff. It is at the point of selecting specific methodology for instruction that behavioral and non behavioral models sometimes begin to diverge.
Methodologic Common Elements
There are methodologic common elements within the behavioral approach. First, the approach views be havior as functional and purposeful, even when func tion and purpose are not immediately discernible by an observer. Behavior is viewed as the result of a complex blend of variables that include the individual’s strengths and limitations, physical status, history, and the current social-environmental circumstances (Romanczyk & Matthews, 1998). As with many complex approaches, there are often subtle differences between specific methodologies and theories that are associated with the approach. With respect to autism, ABA is a specific form of the more general behavioral model.
Analysis and Measurement ABA places stress on understanding the behavior in
question, whether it is the acquisition of a skill that is currently absent in a person’s repertoire or the amelio ration of a problem behavior. If emphasis is placed on the analysis level, then it follows that there need to be certain prerequisite steps.
The first of these prerequisites is the objective mea surement of behavior. Most measurement systems have technical pros and cons, as well as practical cost effec tiveness parameters. There is a large body of literature within the field of science in general and psychology specifically that indicates human observers are prone to a number of very specific errors in conducting obser vations. We are all subject to influences and biases that limit our objectivity. One credible reason for this diffi-
Downloaded from rps.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 17, 2015
http://rps.sagepub.com/
164 Anderson and Romanczyk
culty in objective measurement is that one of our strengths with respect to information processing is the ability to detect patterns. However, as with all systems, our ability to detect patterns is not perfect. We are able to perceive specific patterns where, in fact, none exists. We can be differentially influenced by information, context, and experience that have emotional as well as informational content.
Often in clinical and educational service delivery, we violate this basic principle of objectivity so that the in dividuals performing assessment, delivering services, and evaluating outcome are one and the same. It is important to stress that the influences that limit our ability to make objective observations are not primarily based on such factors as sophistication, education, fal sification, intentional bias, and deception. Rather, they are based on an information processing limitation that all humans share. By understanding these processes, we can guard against potentially inaccurate observations and conclusions. Thus, the sine qua non of the applied behavior analytic approach is that objective measures are taken of the individual’s behavior and that these measures must meet the boundary conditions of being operationally defined, reliable, and valid.
Operational definitions simply translate the normal colloquial reference that we give to certain behaviors into more objectively defined observational terms. A good example would be attempting to assess a child who is “anxious.” This is a term that most individuals would recognize and believe that they have an under standing of what it means. Difficulty arises with respect to precision and the application of such terms to spe cific individuals. For example, with anxiety, one could view it as a construct, the summation of a number of different factors that are assumed to be coherent. We can divide the imprecise construct of anxiety into a number of components: cognition, self-report, overt be havior, performance, and physiologic.
Although anxiety is a useful term for the purpose of communication concerning a problem the individual is experiencing, from a behavioral perspective it would be further defined within the above categories. This allows highly individualized assessment for a given person as to how specifically anxiety is manifested for the indi vidual. ABA emphasizes addressing the specific, unique expression of behavior by the individual.
Reliable observations refer to the degree to which the various specific behavioral observations conducted by different observers are in agreement. This is typi cally done by having two independent observers per form observations and then compare very precisely the degree to which they agree and disagree on the specific temporal pattern of the behaviors observed. To be in dependent, individuals should not be given specific ex pectations such as “medication is being considered,” or “we are seeing problems with rising anxiety,” or “it’s clear he’s anxious and we need to document that.” Op-
erationalized, unbiased, and reliable observation serves as the basis for hypothesis testing as to factors that may be of importance and influence the individual, and thus leads to the process of conducting a functional analysis (a point to be discussed next).
Assessing the Child Assessment is a crucial component of any clinical/
educational model. Because there are as many differ ences between young children with autism as similari ties among them, assessment must be a constant focus point when developing and implementing a compre hensive intervention program. Traditional assessment methods such as the administration of standardized psychological, speech, and achievement tests, “survey” assessments such as rating scales, and behavioral assess ment all have relative strengths and weaknesses.
Within the practice of ABA, there are various sub components of assessment. First, assessment of an in dividual with autism, particularly a young child, can be a very difficult task. While assessment is often some what arbitrarily divided into standardized psychometric evaluation, social history/family status assessment, in formal observation, and much more rarely, functional assessment, ABA focuses strongly on functional assess ment (functional analysis). It is not and should not be seen as incompatible with the assessment methods mentioned above. For example, standardized assess ment, if feasible and properly conducted, provides im portant information. Such assessment allows the estab lishment of a “marker” as to the current repertoire of the child with respect to various developmental do mains and allows a comparison to other individuals, as well as relative strengths and weaknesses within the individual. It also serves as a standardized format to assess the ability to interact in a social manner with respect to the various directions and demands and in terchanges that occur during standardized assessment. Standardized assessment, however, is not necessarily directly useful in the selection of specific, immediate, short-term goals. Nor is it typically useful in determin ing the specific intervention methodology that will be utilized. It is beyond the scope of this article to examine in detail the various aspects of the assessment process. We focus on that aspect most specific to the behavioral model, that of functional analysis.
Functional analysis is an often misunderstood term, partly because different disciplines have varying defini tions. Within ABA, functional analysis is the process of ascertaining empirically the controlling variables that enhance or inhibit the expression of a behavior. It is not done by observation, filling out a behavior checklist or scale, nor by consensus among involved parties. Rather, these sources of information are used to form hypoth eses as to what factors may be involved, and then to test these hypotheses (Iwata, Vollmer, Zarcone, & Rod gers, 1993; Miltenberger, 1998). It is a process of ob-
Downloaded from rps.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 17, 2015
http://rps.sagepub.com/
Continuum-Based Behavioral Models 165
serving, hypothesizing, testing, evaluating, refining hy potheses, and repeating.
The essential aspect of functional analysis is the ex plicit testing of factors presumed to be important, and to conduct the testing in a manner that has the potential to clearly disprove the hypothesis. There are many uses for this very powerful methodology beyond under standing problem behaviors, and it is particularly useful for assessment of children without verbal language. While it is often technically difficult and time consum ing to perform, the accuracy of the information ob tained through functional analysis and its direct appli cability to intervention make it a most important com ponent of ABA.
Developing an Individualized Curriculum The word curriculum has various connotations and
meanings for various professionals. In the context of this article, curriculum means a sequence of goals: (1) organized from both the long-term and short-term per spective, (2) resulting from focused assessment, (3) re flecting the collective priorities of involved adults, and ( 4) tempered by the current developmental level of child.
Because this should be an interactive process, and typically involves individuals at various levels of exper tise, it is useful to have an outline or document that serves as a map (Romanczyk, 1996). However, caution must be expressed in that a curriculum should not be seen as a specific sequence of learning and skill activi ties that all children will progress through in a sequen tial manner.
One of the important characteristics of children with autism is uneven learning ability and skill levels. Thus, individualization of intervention cannot be overstated. While generally an excellent starting point, it is not necessarily most effective to teach all skills in a “typi cally developing” sequence. Use of a curriculum must occur within a very tight feedback loop that assesses not only the logic and priority of a goal and its subcompo nents, but also its interaction with assessment informa tion which includes a child’s current repertoire, moti vation, and preferences. A good curriculum should have a conceptual structure (we suggest a developmen tal sequence), offer great detail ( operalization), and be used in a child specific manner (nonlinear branching).
Selecting and Systematically Using Reinforcers It is a truism concerning human behavior that moti
vation is an important component of learning and main taining skills. Motivation can come from a number of sources. For most individuals, this diversity provides a rich context for acquiring and maintaining skills. It is also the case that some individuals, such as children with autism, have impairment in motivation. At times, motivation may be quite idiosyncratic and limited in its extensiveness. An example would be children who are
not motivated by social attention and praise, physical contact, and the sense of accomplishment for complet ing a task or solving a problem. Rather, these individu als might find their own repetitive and stereotyped be havior more interesting and enjoyable, and thus engage in it disproportionately compared to prosocial behav ior. The term reinforcer describes a functional relation ship that is empirical in nature, not speculative. This is a critical aspect of the behavioral model: procedural or technique components are not to be used in isolation, detached from the critical process of ongoing assess ment. The stereotyped and incorrect reinforcement procedure “for children with autism who fail to make eye contact, each time they look at you, reinforce them with a fruit loop,” is completely erroneous and misses the point entirely. Also erroneous would be the con clusion that “eye contact is not getting better even though we keep reinforcing them with fruit loops.” Even at its most basic level, ABA is intimately tied to continuous assessment of the individual and not simply the application of misperceived standard techniques.
Promoting Generalization Generalization is a key concept. It is often viewed as
the degree to which a behavior or skill learned under particular conditions and settings will be expressed in other conditions and settings. An example might be taking piano lessons and being able to perform a par ticular musical piece quite adequately at home with the piano teacher, and then being asked to present that same piece during a recital where performance may be observed to be significantly impaired.
From the inception of ABA, generalization has been a focal concept that is bound directly to goal selection, teaching, and evaluation of behavior. In their classic article that appeared in the first issue of the Journal of Applied Behavior Analysis, Baer, Wolf, & Risley (1968) stated that generalization is a central component of ABA and that ” … generalization should be pro grammed, rather than expected or lamented” (p. 97). That is, an important characteristic of ABA is that the intervention process must explicitly address strategies and procedures to teach and promote generalization across time, setting, people, and tasks.
There is an extensive generalization methodology to be found in the published literature. It involves knowl edge of stimulus control, stimulus generalization, rein forcement schedules, prompt hierarchies and fading, setting events, antecedent conditions, response variabil ity, contingency criteria, use of multiple exemplars, set tings, people, and contexts, as well as task analysis and response repertoire assembly. Because generalization can be problematic for certain individuals, and given the complex factors that influence generalization, a spe cific and detailed plan for generalization should be a part of all intervention programs.
Downloaded from rps.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 17, 2015
http://rps.sagepub.com/
166 Anderson and Romanczyk
Selecting Intervention Techniques With Documented Effectiveness
From a clinical perspective, selection of intervention techniques has two components. The first is to ascertain controlled research evidence concerning specific skills, behaviors, or conditions for individuals with a similar diagnosis/characteristics that appear in peer reviewed journals and that meet generally accepted criteria for well controlled clinical studies. Anecdotes, case studies, “expert opinions,” theoretical arguments, and appeals to “clinical experience” are not acceptable substitutes. Such sources can provide potentially useful information in order to test hypotheses about effectiveness compari son of different approaches and procedures in a re search context, but should not be used as a substitute for controlled research evidence for clinical practice.
Second, the selected intervention must meet the boundary conditions of the original research param eters. Sadly, interventions are often implemented in name only, that is, terms are used to label what is being offered, but the specifics of the intervention as actually applied are not consistent with the specifics of the origi nal intervention research. Procedural integrity is mea sured and evaluated as is the objective evaluation of the child’s progress. Specifically, an evaluative process known as single subject methodology is employed (Bar low et al., 1984; Hersen & Barlow 1981; Sidman, 1988).
There are many very powerful tools currently avail able to parents, educators, and clinicians who wish to avail themselves of the empirical literature. One cau tion that should be raised is that it is essential in this process to read and review research reports in their original form, rather than as summaries. In particular, the explosion of information on the internet has suf fered greatly by misrepresentation and inaccuracy. In formation is often “packaged” to provide noncritical support for a particular point of view. In reading the original research report, one is able to ascertain the specific characteristics of the children who participated, the specifics of the procedures utilized, the adequacy of the research design, and the degree and magnitude of the outcomes. Certainly, it is possible to have a research study that demonstrates a significant statistical differ ence between intervention procedures, but that does not necessarily mean that this significant difference rises to the level of clinical significance. We require both statistical significance and substantial change in the child’s cognitive, social, and family and community life.
The task of reviewing such research can seem daunt ing. Because ABA is based on basic principles of hu man behavior, there is a wealth of research available. The published literature of professional journals was searched for research studies concerning applied be havior analysis and autism (Palmieri, Valluripalli, Arn stein, & Romanczyk, 1998). Given the varying termi nology, there are about 19,000 published articles if one
uses applied behavior analysis and its synonyms. While not all this literature is directly relevant to ABA as an intervention for autism, it underscores the vast base of research that serves as the foundation for the ABA approach and its broad applicability to a wide range of populations, skills, and behaviors.
Five hundred articles specific to both ABA and au tism were found. If we narrow the focus to research with young children with autism, conducted after 1980, and employ a single subject research methodology, ap proximately 90 published research studies were identi fied. These provide support for a broad continuum of behavioral techniques that focus on the development of skills in social, cognitive, self-help, independence, emo tion, language, self-control, attachment, recreation, and academic areas.
In short, there is a large base of research literature that addresses specific populations, ages, characteris tics, and specific educational, clinical, social, and physi cal emphases, as well as a substantial base of research specific to ABA and young children with autism. A full review of these articles is not possible here (for exten sive reviews, see Matson, Benavidez, Compton, Paclaw skyj, & Baglio, 1996; New York State Department of Health, 1999b ). However, there are several large-scale studies that base their conceptualization and proce dures on the large research base, which we will briefly review. They represent the important endeavor of con ducting controlled clinical trials.
Six studies have been published that evaluated the benefits of intensive home based intervention for chil dren with autism. Each of these studies involved at least 1 year of intervention, included a broad range of be havioral techniques, and evaluated its effects of a vari ety of developmental outcomes (intellectual function ing, language, social interactions, adaptive functioning). The most comprehensive study of home based inter vention for children with autism was published by Lovaas (1987). Lovaas assigned preschool aged chil dren to one of two groups: an intensive treatment group that received an average of 40 hours of one-on-one treatment per week or a minimal treatment control group that received 10 hours or less per week. Each child in the experimental group was assigned several well trained therapists who worked with the child and the parents in the home for 2 or more years. Pretreat ment measures revealed no significant differences be tween the treatment and control groups. However, posttreatment data indicated that 9 of 19 ( 47%) chil dren in the experimental group recovered. These chil dren were reported to have achieved normal intellec tual and educational functioning in the first grade. In contrast, only 2 % of the children in the control group met this criterion. A follow-up study was conducted when these children reached a mean of age 13 years (McEachin, Smith, & Lovaas, 1993). Evaluation was done by clinicians blind to the children’s prior history
Downloaded from rps.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 17, 2015
Read more
Applied Sciences
Architecture and Design
Biology
Business & Finance
Chemistry
Computer Science
Geography
Geology
Education
Engineering
English
Environmental science
Spanish
Government
History
Human Resource Management
Information Systems
Law
Literature
Mathematics
Nursing
Physics
Political Science
Psychology
Reading
Science
Social Science
Home
Homework Answers
Blog
Archive
Tags
Reviews
Contact
google+twitterfacebook
Copyright © 2021 HomeworkMarket.com
