Autistic experiences of applied behavior analysis.

Social-communicative abilities and theory of mind (ToM) are crucial for successful social interactions. The developmental trajectories of social and communicative skills characterizing individuals with Autism Spectrum Disorder (ASD) are rather complex and multidimensional, including components related to theory of mind. Due to its mentalistic nature, theory of mind has been rarely addressed as an outcome for Applied Behavior Analysis (ABA) intervention in children and adolescents with ASD. However, there is evidence that ABA intervention might be effective in promoting social abilities in individuals with ASD. Thus, this topic is worth investigating. We present a systematic review to explore the Ins and Outs of an ABA approach to promote social and communicative abilities and ToM in children and adolescents with ASD. We applied a PRISMA checklist to consider studies published up to December 2024. The keywords that we used were ToM, perspective-taking, false belief, social cognition, and mental states, in combination with ABA intervention and ASD (up to age 18). We searched for studies using Scopus, Google Scholar, and Medline. We included twenty studies on perspective-taking, identifying emotions, helping, detecting eye gazing, and social engagement, reviewing fifteen dedicated to teaching the interpretation of mental states (involving 49 children and 10 adolescents). The ToM was addressed with a multiple baseline design on target behaviors associated with ToM components such as identifying emotion, helping behaviors, and mental states. The intervention included a behavioral package consisting of Behavioral Skill Training, Derived Relations, video modeling, and role playing. The results indicated a significant number of participants who followed ABA intervention to promote social abilities and mastered the target behavior in ToM tasks; however, they showed maintenance and generalization issues across trials and settings. The role of predictors was highlighted. However, the studies are still rare and exhibit specific methodological limitations, as well as some clinical and ethical considerations. More research is needed to define best practices in ABA intervention to promote social abilities in individuals with ASD.

Intervention programs based on applied behavior analysis (ABA) are currently viewed as the first line treatment for autism spectrum disorder (ASD) in early childhood (Vismara and Rogers 2010). Apart from beneficial effects on a group level, studies have consistently shown large variation in individual gains. Several factors have been suggested to explain this differential response, including child characteristics, intensity of training and level of trainer fidelity to the protocol. Despite scientific evidence, ABA treatment methods as well as goals remain controversial. The structured nature of the intervention program and use of reinforcers can be uncomfortable for parents and trainers in pre-schools. Previous psychotherapy research in adults has shown that therapist allegiance to treatment techniques is linked to the gains achieved (McLeod 2009). It is not unlikely that trainer allegiance to ABA treatment, and thus fidelity to the treatment protocol, is a crucial mediator of ABA efficacy and treatment outcome variation, respectively. To examine the hypothesis that the level of allegiance of trainers is important for ABA treatment gains in preschoolers, a pilot study of 24 children with ASD was conducted. Children were consecutively recruited from a larger ongoing ABA intervention follow-up study in Stockholm county (for details see Fernell et al. 2010) covering all children diagnosed with ASD by psychiatric outpatient departments before the of age 5 years and treated with ABA. Children included in the present pilot-study had received intensive ABA (30 h/week) for 2 years. Two children had been a priori excluded from the sample: the parents of one child declined participation; another child was not included due to a new diagnosis of Rett’s syndrome. Of remaining 24 children (20 boys and 4 girls, age range 2.5–5 years at intake), 19 had autistic disorder, 4 had PDDNOS and one had Asperger’s syndrome. One child had fragile X and one tuberous sclerosis with epilepsy. According to an evaluation of existing test results in records, nine had mental retardation, 12 had uncertain or borderline intellectual functioning, and 3 had normal IQ. Children scored at a mean of 69.9 on the composite score from Vineland Adaptive Behavior Scales (VABS, Sparrow et al. 2005; which includes norm data used) and 49.0 on the Autism Behavior Checklist, above the recommended cutoff of 45 points (Nordin and Gillberg 1996). Thus, this sample may have been representative of the larger group from the follow-up study, who, in turn, can be considered representative of all children receiving an ASD diagnosis in Stockholm (for discussion, see Fernell et al. 2010). For the assessment of treatment outcome, the children’s parents completed the VABS pre and post 2 years of intensive ABA treatment. The 24 children all had one preschool trainer each. These trainers were all employed at the kindergartens and worked exclusively with the child in the study. They were L. Klintwall (&) Akershus University College, P.O.Box 423, 2001 Lillestrom, Norway e-mail: lars.klintwall@hiak.no

Background/Objective: Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by lifelong impacts on functional social and daily living skills, and restricted, repetitive behaviors (RRBs). Applied behavior analysis (ABA), the gold-standard treatment for ASD, has been extensively validated. ABA access is hindered by limited availability of qualified professionals and logistical and financial barriers. Scientifically validated, parent-led ABA can fill the accessibility gap by overcoming treatment barriers. This retrospective cohort study examines how our ABA treatment model, utilizing parent behavior technicians (pBTs) to deliver ABA, impacts adaptive behaviors and interfering behaviors (IBs) in a cohort of children on the autism spectrum with varying ASD severity levels, and with or without clinically significant IBs. Methods: Clinical outcomes of 36 patients ages 3-15 years were assessed using longitudinal changes in Vineland-3 after 3+ months of pBT-delivered ABA treatment. Results: Within the pBT model, our patients demonstrated clinically significant improvements in Vineland-3 Composite, domain, and subdomain scores, and utilization was higher in severe ASD. pBTs utilized more prescribed ABA when children initiated treatment with clinically significant IBs, and these children also showed greater gains in their Composite scores. Study limitations include sample size, inter-rater reliability, potential assessment metric bias and schedule variability, and confounding intrinsic or extrinsic factors. Conclusion: Overall, our pBT model facilitated high treatment utilization and showed robust effectiveness, achieving improved adaptive behaviors and reduced IBs when compared to conventional ABA delivery. The pBT model is a strong contender to fill the widening treatment accessibility gap and represents a powerful tool for addressing systemic problems in ABA treatment delivery.

Autism, kinematics and social cognition

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by social communication difficulties and restricted repetitive behaviors or interests. Applied behavior analysis (ABA) has been shown to significantly improve outcomes for individuals on the autism spectrum. However, challenges regarding access, cost, and provider shortages remain obstacles to treatment delivery. To this end, parents were trained as parent behavior technicians (pBTs), improving access to ABA, and empowering parents to provide ABA treatment in their own homes. We hypothesized that patients diagnosed with severe ASD would achieve the largest gains in overall success rates toward skill acquisition in comparison to patients diagnosed with mild or moderate ASD. Our secondary hypothesis was that patients with comprehensive treatment plans (>25-40 hours/week) would show greater gains in skill acquisition than those with focused treatment plans (less than or equal to 25 hours/week). Methods: This longitudinal, retrospective chart review evaluated data from 243 patients aged two to 18 years who received at least three months of ABA within our pBT treatment delivery model. Patients were stratified by utilization of prescribed ABA treatment, age, ASD severity (per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), and treatment plan type (comprehensive vs. focused). Patient outcomes were assessed by examining success rates in acquiring skills, both overall and in specific focus areas (communication, emotional regulation, executive functioning, and social skills). Patients receiving treatment within the pBT model demonstrated significant progress in skill acquisition both overall and within specific focus areas, regardless of cohort stratification. Patients with severe ASD showed greater overall skill acquisition gains than those with mild or moderate ASD. In addition, patients with comprehensive treatment plans showed significantly greater gains than those with focused treatment plans. The pBT model achieved both sustained levels of high treatment utilization and progress toward patient goals. Patients showed significant gains in success rates of skill acquisition both overall and in specific focus areas, regardless of their level of treatment utilization. This study reveals that our pBT model of ABA treatment delivery leads to consistent improvements in communication, emotional regulation, executive functioning, and social skills across patients on the autism spectrum, particularly for those with more severe symptoms and those following comprehensive treatment plans.

Introduction Applied behavior analysis (ABA) is a fundamental practice-based intervention for treating autism spectrum disorder (ASD). Few studies have directly measured and evaluated the effects of ABA on verbal behaviors, mainly using the Verbal Behavior Milestones Assessment and Placement Program (VBMAPP) and the Assessment of Basic Language and Learning Skills (ABLLS) as outcome measures. This study aims to fill this gap by examining the relationship between ABA interventions and the enhancement of verbal skills, as measured by the VBMAPP and the ABLLS, in a convenience sample of individuals with ASD. Materials and methods At The Oxford Centers (TOCs) in Brighton and Troy, Michigan, USA, 33 individuals with autism received treatment from January 2018 to July 2021, spanning 43 months. A pretest-posttest design was employed to retrospectively examine any impacts between ABA interventions and alterations in verbal scores among individuals with ASD. Depending on developmental age, all subjects underwent two verbal assessments with a six-month interval in-between. Twelve children were administered the VBMAPP, while 21 were given the ABLLS. Results Paired t-tests for pretest and posttest VBMAPP subscales resulted in statistically significant effects (p<0.05) for (VBMAPP - Mand), (VBMAPP - Tact), (VBMAPP - Listener Responding), (VBMAPP - Visual Perceptual Skills and Matching-to-Sample), (VBMAPP -Independent Play), (VBMAPP - Social Play), (VBMAPP - Motor Imitation), (VBMAPP - Spontaneous Vocalization), (VBMAPP - Intraverbal), (VBMAPP - Group Behavior), and (VBMAPP - Linguistic Structure). As measured by Cohen's d, effect sizes were moderate to mostly high (-0.623to -1.688). There were non-significant results (p>0.05) for (VBMAPP - Listener Responding by Feature, Function, and Class) and (VBMAPP - Echoic). Paired t-tests for pretest and posttest ABLLS subscales resulted in statistically significant effects (p<.05) for all ABLLS scales: (ABLLS - Receptive Language), (ABLLS - Requests), (ABLLS - Labeling), (ABLLS - Intraverbals), (ABLLS - Spontaneous Vocalizations), (ABLLS - Syntax Grammar), (ABLLS - Social Interactions), and (ABLLS - Generalized Responding).As measured by Cohen's d, effect sizes were moderate to mostly high (-0.656 to -1.372). Conclusions The administration of ABA treatments had a noteworthy influence, with statistically significant impacts on improving verbal behaviors on 11 of the 13 VBMAPP scales and all of the ABLLS scales. As measured by Cohen's d, effect sizes were moderate to high for both scales. These findings underscore the importance and effectiveness of ABA interventions in enhancing verbal skills in children with ASD. However, it's crucial to note that further confirmatory studies are required to verify the reliability of these original findings, emphasizing the ongoing need for research in this field.

Shifting Paradigms

Background: Children with Autism Spectrum Disorders (ASD) are at particular risk of impairment in social interaction, repetitive and stereotyped behaviors, and a poor quality of life. We tested whether applied behavior analysis intervention could, compared to a control condition, reduce repetitive and stereotyped behaviors, and increase social skills and thus enhance the quality of life among children with ASD. Methods: Thirty children with ASD (mean age: 6.5 years) were randomly assigned either to applied behavior analysis intervention or to a control condition. All participants completed Gareth test on stereotypical behaviors, social communication, and interaction skills at the following time points: baseline, and six months later at completion of the intervention. Findings: Stereotypical behaviors, social communication, and interaction skills improved over time from baseline to intervention completion, but more so in the applied behavior analysis intervention than in the control group. Compared to the control group, the applied behavior analysis intervention group reported had more positive scores. Conclusion: The findings suggest that among children with ASD and compared to a control condition, applied behavior analysis intervention has the potential to improve symptoms of autism, thus contributing to their quality of life.

Applied Behavior Analysis (ABA) is a widely recommended intervention for autistic children, but it has recently been criticized because of its potential negative effects on mental health. This study aims to map experiences with ABA and related techniques in the Netherlands by investigating different types of ABA interventions, experiences and satisfaction levels, and explores variations across techniques and stakeholders. An exploratory sequential mixed methods design was employed, beginning with qualitative focus groups (n = 22) followed by a quantitative online survey (n = 219). Participants included autistic adults, parents/legal representatives, and healthcare professionals. Focus groups revealed six main themes: diverse interpretations of ABA, variations in its application, positive experiences, concerns about overburdening and psychological impacts, criticisms of the healthcare system, and quality control issues. Survey results indicated that satisfaction with ABA interventions varied, with autistic adults being less satisfied than parents and healthcare professionals. Positive outcomes included improved communication and independence, while negative experiences involved trauma and concerns about ethical application. Better quality interventions were associated with higher satisfaction levels. The study reveals diverse experiences and interpretations of ABA. Participants raised significant concerns that merit attention alongside the noted benefits of ABA. Improving training and ensuring ethical practices are crucial to maximize ABA's potential to positively impact the lives of autistic individuals. Future efforts should focus on enhancing regulation, standardization, and incorporating autistic perspectives to optimize outcomes.

Intervention Approaches Used for Children With Autism Spectrum Disorder—Autism Toolkit

What is self-compassion?: Self-compassion is when we: are friendly toward ourselves (kindness)are aware of our feelings and thoughts (mindful awareness)realize that everyone feels pain and makes mistakes (common humanity)What is the purpose of this article?: We think that practicing self-compassion is important for autistic adults. No research has studied self-compassion in autistic individuals. We provide examples of how to improve self-compassion. We make recommendations for future research on self-compassion for autistic adults.What perspectives do the authors bring to this subject?: We bring together different and unique perspectives in this article. One author is a researcher whose research has focused on emotion regulation and mental health in autistic youth and adults. The other author is a self-compassion researcher who is also a private practice clinical psychologist. We have practiced self-compassion and personally experienced the benefits of developing our self-compassion skills. We think that cultivating self-compassion has helped to improve our mental health and enriched our lives.Why is self-compassion important?: Self-compassion is associated with a lot of positive aspects of life in nonautistic individuals. These positive aspects include greater happiness and well-being, and lower levels of depression and anxiety symptoms.How is self-compassion relevant to autistic adults?: We know that as a group, autistic adults have poorer mental health when compared with nonautistic adults. That is, autistic adults experience higher rates of anxiety and depression. Research shows that practicing self-compassion in nonautistic people can improve their mental health. We think that cultivating self-compassion can also be helpful to autistic adults.What do the authors recommend?: We suggest that cultivating self-compassion may improve the mental health of autistic adults. There are several ways to improve self-compassion. Self-compassion can be improved by identifying and practicing self-compassionate behaviors. For example, we can take a walk outside. Another way to improve self-compassion is to record our thoughts. This can be performed by keeping a log of self-critical thoughts. We can also practice self-compassion by meditating. It is too early to tell how self-compassion should be practiced by autistic adults. Research is needed to observe if self-compassion is helpful to autistic adults. We made a series of recommendations for researchers and clinicians. Researchers should first check if there is a relationship between self-compassion and mental health in autistic adults. If more self-compassion is associated with better mental health, then researchers and clinicians can try and find out how we can improve autistic people's self-compassion.How will these recommendations help autistic adults now or in the future?: We hope that our recommendations will start a conversation on the relevance of self-compassion for autistic adults and lead to the development of self-compassion-related research programs that involve autistic adults. The ultimate goal is to improve the mental health and psychological well-being of autistic adults in the future.

To study the effect of probiotics combined with applied behavior analysis (ABA) in the treatment of children with autism spectrum disorder (ASD). A total of 41 children with ASD who attended the Affiliated Hospital of Jiangsu University from May 2019 to December 2020 were enrolled and randomly divided into an observation group with 21 children and a control group with 20 children. The children in the observation group were given oral probiotics combined with ABA intervention, while those in the control group were given ABA intervention alone. The treatment outcomes were compared between the two groups. Autism Treatment Evaluation Checklist (ATEC) was used to evaluate the severity of behavioral symptoms in both groups before intervention and at 3 months after intervention. The fecal samples were collected to analyze the difference in intestinal flora between the two groups based on 16s rRNA high-throughput sequencing. Before intervention, there was no significant difference in the ATEC score between the observation and control groups (P>0.05). At 3 months after intervention, both groups had a significant reduction in the ATEC score, and the observation group had a significantly lower ATEC score than the control group (P<0.05). Before intervention, there was no significant difference in the composition of intestinal flora between the observation and control groups. At 3 months after intervention, there was a significant difference in the composition of intestinal flora between the observation and control groups. Compared with the control group, the observation group had significantly higher relative abundances of Bifidobacterium, Lactobacillus, Coprobacillus, Ruminococcus, Prevotella, and Blautia (P<0.05) and significantly lower relative abundances of Shigella and Clostridium (P<0.05). Probiotics may improve the effect of conventional ABA intervention in children with ASD by regulating intestinal flora.

Difficulties in making and maintaining social relationships is common among autistic people. These difficulties are thought to be due to differences in autistic social interaction and social communication that have been theorized to be the result of reduced social motivation. We argue that this theory does not account for camouflaging, a combination of strategies that are employed frequently by many autistic individuals in pursuit of obtaining social relationships; however, its utility in achieving satisfactory friendship and intimate relationships for the individual is not clear. This review synthesizes empirical evidence of camouflaging as a strategy for achieving friendships and/or intimate relationships among autistic adolescents and adults. A systematic search yielded 1421 records. Forty-nine full texts were screened, and eight qualitative studies were retained. Results reveal that camouflaging was a main strategy in pursuit of friendship, with little evidence for intimate relationships, in this sample of autistic adolescents and adults. For most, camouflaging is exhausting, often ineffective and inefficient, and ultimately a challenge to one's social authenticity. Research suggests that many autistic individuals rely on camouflaging in pursuit of friendship and intimate relationships, although this is often a nonpreferred strategy. Some autistic individuals seek to replace camouflage with alternative strategies to obtain social relationships, yet outcomes typically remain dissatisfying. This demonstrates that we need to reconsider the social motivation theory, and to better understand alternative strategies that can help autistic individuals to obtain authentic, satisfactory social relationships, and to support opportunities to achieve these desired outcomes. Why is this topic important?: Many autistic individuals feel dissatisfied with the quality and quantity of their social relationships and are, therefore, more vulnerable to loneliness and reduced well-being. This may be because autistic people communicate and interact differently to non-autistic individuals. These differences can, at times, be misinterpreted as a lack of motivation to socialize and connect with other people. But many autistic individuals are motivated to build meaningful friendships and intimate relationships and often rely on camouflaging to achieve these outcomes. Regardless of their efforts, many autistic people continue to struggle to make the social connections they desire. Therefore, the effectiveness of camouflaging on building friendships and intimate relationships needs to be better understood.What was the purpose of this review?: We set out to understand the impact that camouflaging has the friendships and intimate relationships of autistic individuals by examining the existing research.What are the results of this review?: We found that camouflaging is a common strategy used by many autistic individuals to connect with others in aim to build and maintain friendships, especially with non-autistic people. Pressure to camouflage began early in life, for many autistic participants, and continued to increase in both complexity and use across the lifespan. However, many autistic individuals remained dissatisfied with the friendships and intimate relationships gained through its use. For many, camouflaging prevented genuine social interactions, and the friendships that resulted from its use were often lacking in closeness and authenticity for the autistic individual. To reduce the reliance on camouflaging, some autistic individuals socially withdrew, or attempted to find friendship within the autistic community or in social contexts where camouflaging felt less necessary. Yet, many autistic participants remained feeling lonely, frustrated, and dissatisfied with their social relationships.What were the weaknesses of this review?: Only half of the eight studies involved an autistic researcher and author, while most studies incorporated community participation in the design of the study. We found that participants were mostly female, from countries such as the United Kingdom and United States of America, and most participants were above18 years of age. Results may be impacted by a lack of researcher and sample diversity, and minimal autistic input in study design and interpretation; thus, generalization of these findings may be limited. Camouflaging is an evolving area of research, and we recognize that there may be terminology or perspectives that were not captured by our review.What do the authors recommend and how will this help autistic adults in the future?: More research is needed to better understand autistic social interactions and to support alternative strategies to camouflaging, including environmental modifications and changes in the way non-autistic people understand and interact with autistic people. We recommend that autistic individuals' strengths and needs drive this area of research, and that supports address ways that all people can help to enhance autistic social outcomes. We anticipate that these strategies will promote more authentic social relationships, reduce reliance on camouflage, help to decrease loneliness, and improve well-being among autistic individuals.

BackgroundAutism spectrum disorder (ASD) can have traits that impact multiple domains of functioning and quality of life, which can persevere throughout life. To mitigate the impact of ASD on the long-term trajectory of an individual’s life, it is imperative to seek early and adequate treatment via scientifically validated approaches, of which applied behavior analysis (ABA) is the gold standard. ABA treatment must be delivered via a behavior technician with oversight from a board-certified behavior analyst. However, shortages in certified ABA therapists create treatment access barriers for individuals on the autism spectrum. Increased ASD prevalence demands innovations for treatment delivery. Parent-led treatment models for neurodevelopmental conditions are effective yet underutilized and may be used to fill this care gap.ObjectiveThis study reports findings from a retrospective chart review of clinical outcomes for children that received parent-led ABA treatment and intends to examine the sustained impact that modifications to ABA delivery have had on a subset of patients of Montera, Inc. dba Forta (“Forta”), as measured by progress toward skill acquisition within multiple focus areas (FAs).MethodsParents received ≥40 hours of training in ABA prior to initiating treatment, and patients were prescribed focused (≤25 hours/week) or comprehensive (>25‐40 hours/week) treatment plans. Retrospective data were evaluated over ≥90 days for 30 patients. The clinical outcomes of patients were additionally assessed by age (2-5 years, 6-12 years, 13‐22 years) and utilization of prescribed treatment. Treatment encompassed skill acquisition goals; to facilitate data collection consistency, successful attempts were logged within a software application built in-house.ResultsImproved goal achievement success between weeks 1‐20 was observed for older age, all utilization, and both treatment plan type cohorts. Success rates increased over time for most FAs, with the exception of executive functioning in the youngest cohort and comprehensive plan cohort. Goal achievement experienced peaks and declines from week to week, as expected for ABA treatment; however, overall trends indicated increased skill acquisition success rates. Of 40 unique combinations of analysis cohorts and FAs, 20 showed statistically significant positive linear relationships (P<.05). Statistically significant positive linear relationships were observed in the high utilization cohort (communication with P=.04, social skills with P=.02); in the fair and full utilization cohorts (overall success with P=.03 for the fair utilization cohort and P=.001 for the full utilization cohort, and success in emotional regulation with P<.001 for the fair utilization cohort and P<.001 for the full utilization cohort); and in the comprehensive treatment cohort (communication with P=.001, emotional regulation with P=.045).ConclusionsParent-led ABA can lead to goal achievement and improved clinical outcomes and may be a viable solution to overcome treatment access barriers that delay initiation or continuation of care.

The Federal government mandates the use of evidence-based practice for interventions with students. Applied Behavior Analysis (ABA) is one of these evidence-based practices, but despite this, many school systems do not implement ABA as described in the literature, which leads to loss of fidelity and integrity with implementation, and often results in ineffective interventions in the classroom. The research question “What are the experiences of Board Certified Behavior Analysis (BCBAs) who use evidence-based practices in conjunction with staff in schools for interventions with American K-12 students using ABA?” was developed to ascertain, from a BCBA’s perspective, why ABA interventions are not implemented with fidelity in classroom settings. Participants were BCBAs in the United States who consult and collaborate with school staff to implement ABA services for children with autism spectrum disorders (ASD). Findings indicate that BCBAs are not given adequate time or resources to provide sufficient training in ABA, that principles of ABA are sometimes misused in training in such a manner that exacerbates myths of ABA, and that a general lack of support from school administrators exists, all of which lead to a loss of implementation fidelity. This lack of implementation fidelity in turn leads to decreased outcomes for students with ASD in schools when ABA is not implemented with fidelity.