Knowledge, Beliefs, and Practice: A Multidisciplinary Perspective on Applied Behavior Analysis and Naturalistic Teaching Approaches

If you have concerns about your child’s development and behavior, your child should be seen to tell if she needs therapy. You do not need a diagnosis of autism spectrum disorder (ASD) to begin many kinds of therapy. There can be a long wait for ASD diagnosis, so it is important to start therapy while your child is still waiting for a diagnosis. However, once your child is diagnosed with ASD, she may be able to get more interventions, such as applied behavioral analysis (ABA). It is important to have your child seen by an ASD specialist even if your child is already receiving intervention.The goals of any autism intervention are to help your child achieve his potential by learning key life skills in the areas that are hard for him. Most ASD therapy focuses on improving social communication and interaction skills and on reducing problem behaviors such as not being flexible or wanting to do the same thing over and over. Autism therapy can be provided at home, at school, or in a clinic setting. Most children with ASD need therapy in more than one setting. Most autism intervention is usually provided by speech pathologists, occupational therapists, psychologists, or behavioral analysts.When deciding what kinds of interventions to pick for your child, it is important to think about which of them are evidence based, or shown to work in scientific studies. No matter what approach is used it is very important that you and other caregivers get involved. Then you can use the approach at home and in the community with your child.You might want to start by finding out what intervention types are available in your area. Consider what kinds of intervention will be covered through your child’s school and/or health insurance programs. Talk with your child’s pediatrician, other parents, and community organizations to get a better idea about what will be the right fit for your family.For some families, there may not be many choices. For instance, there may be only one ABA provider in your area that is covered under your child’s insurance. Keep in mind that the individual provider is just as important as the type of intervention. You may need to try several types of intervention to find one that is the best match for your child. It is also important to think about how your child’s needs may change over time. Set aside time every year to look at the services your child is getting and to see if they are meeting your child’s needs.Autism therapy in school (including early intervention, early childhood special education, and public school) is your child’s legal right under the Individuals with Disabilities Education Act, and it is free to your family. To get autism therapy through your school system, you need to ask for an Individualized Family Service Plan (for children younger than 5) or an Individualized Education Program (for children older than 5). Ask your child’s pediatrician if you need help with this. Schools must provide autism-related therapy to children within a few months of a request.Intervention services can also be given through your child’s health insurance. How much and what kinds of services your child’s insurance will pay for depends on the type of insurance and where you live. Many states have laws that make health insurers cover autism therapy services, even up to 40 hours per week. You can look online to find out what the autism therapy coverage laws are in your state. Intervention services through your child’s health insurance may require a co-pay. You can call your insurance company to find out what is covered under your child’s health plan and how much you will have to pay. You can also ask them for a list of in-network autism intervention providers, to lower costs to your family.Getting autism intervention services is usually hard. You and your child’s pediatrician may need to fill out a lot of paperwork, and your child may be placed on a long waiting list. Sometimes you will be asked to have more tests done before therapy can be started. It will help to stay organized and get help from your child’s pediatrician, social worker, child psychiatrist, family counselor, or community organizations. It is normal to feel frustrated, confused, or “stuck.” Remember that your job as a parent is to advocate for what your child needs, so don’t feel bad about checking in with providers if you have been waiting for a long time.Early intervention and early childhood special education are programs given through the educational system for children aged 0 to 3 (early intervention) or 3 to 5 (early childhood special education). These services are offered either in your home or in a center. Early intervention and early childhood special education are available locally in all parts of the United States. These services can be just for autism or can be more general, such as speech therapy. You can refer your child for these services, and you do not need any paperwork from a doctor or school to do so. The best way to find out how to get these resources in your state is to ask your child’s pediatrician or look online. Once you have made a request, federal law requires that your child be seen in 45 days and that therapy be given to your child if she needs it. Early intervention and early childhood special education programs use many different kinds of autism intervention, some of which are described in this handout.Applied behavioral analysis is an intervention that teaches children developmental, social, and language skills. The therapy is intensive, which for most children means at least 15 hours per week. Therapy is usually covered through your child’s medical insurance. Applied behavioral analysis can be done at home or in the clinic or community. It also typically involves a lot of parent participation.In ABA therapy, goals are set by a therapy team, and the therapist works with the child and sometimes the parent, one goal at a time. A strong ABA program will consider your child’s favorite interests and activities, have a good learning environment, develop clear behavioral plans, measure your child’s progress, and work with your child at home and in other places your child often visits.Although ABA will not cure your child’s ASD, studies show ABA works in skill building and improvement in challenging behaviors. Some say that more hours per week of therapy works better than fewer hours.There are several different approaches to ABA therapy. Some common evidence-based approaches includeMany ABA providers use a combination of approaches.Developmental relationship interventions focus on teaching adults how to improve a child’s communication and social skills through play. By playing with others, children learn to communicate, control their emotions, and understand more about social relationships. These interventions have been shown to improve ASD symptoms like social attention in scientific studies. Some common evidence-based developmental interventions includeNaturalistic developmental behavioral interventions (NDBIs) use both ideas from ABA and ideas from developmental relationship interventions. They focus on child-led teaching, chances for natural learning, clear goals, and measuring progress. The most studied NDBI is the Early Start Denver Model, which has been shown in small studies to improve IQ and problem behaviors of children who have ASD.Recent evidence shows that parents can be good autism therapists for their child when given the right tools. Training sessions for parents and other caregivers can happen in the home, the school, or other community settings, or even through an electronic tablet. JASPER (Joint Attention, Symbolic Play, Engagement, & Regulation) is an example of an evidence-based parent training intervention for ASD. Other parent training programs may be available in your area.Many children with ASD have a hard time having conversations, understanding social cues (such as eye contact or facial expressions), or playing with others. Social skills instruction is used mainly for school-aged children with ASD, both at school and outside of school. Social skills instruction can happen one-on-one with an adult, or with a small group of other children. There have also been some studies showing that video and computer social skills training may also help children. An example of an evidence-based social skills intervention for teens is the Program for the Education and Enrichment of Relational Skills intervention. If you are interested in social skills instruction for your child with ASD, you can ask your child’s school, or contact your child’s pediatrician to find a program in the community.Other types of treatment that might help your child include speech therapy, alternative and augmentative communication therapy, occupational therapy, and physical therapy. These therapies are often not just for ASD but for more general problems that these children face. These types of therapies are often available both at school and through your child’s health insurance.The information contained in this resource should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances. Original resource included as part of Caring for Children With Autism Spectrum Disorder: A Practical Resource Toolkit for Clinicians, 3rd Edition.Inclusion in this resource does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of the resources mentioned in this resource. Website addresses are as current as possible but may change at any time.The American Academy of Pediatrics (AAP) does not review or endorse any modifications made to this resource and in no event shall the AAP be liable for any such changes.

Few professionals working with children and families affected by autism spectrum disorders (ASD) would deny that behavioral intervention is the treatment of choice. Programs based in Applied Behavior Analysis (ABA) methodology such as discrete trial instruction (DTI) and applied verbal behavior (AVB) remain popular interventions for children diagnosed with ASD. They remain popular to the extent that special education litigation has increasingly involved requests that school districts provide or reimburse parents for a program characterized by ABA. Several distinctions, important for school personnel and educational consultants alike, can be made between a these programs. These distinctions are provided along the following dimensions: curriculum, reinforcement and motivation, delivery of instruction, prompting and error correction, language acquisition, augmentative communication, and data collection. Key Words: autism, behavioral intervention, Discrete Trial Instruction, Applied Verbal Behavior. ********** Schreibman (1997) indicates that few professionals working with children and families affected by autism spectrum disorders (ASD) would deny that behavioral intervention is the treatment of choice. Behavioral treatment has been defined as synonymous with applied behavior analysis (ABA), and as the application of the principles of learning to human behavior for the resultant effect of improved socially significant behaviors (Schreibman, 1997). Despite some methodological criticisms of the research (Connor, 2003, Eikeseth, 2001, Gresham, Beebe-Frankenberger, & MacMillan, 1999, Gresham & MacMillan, 1997, Gresham & MacMillan, 1998), ABA-based early intervention is empirically supported in helping children with ASD to achieve significant gains (Herbert & Brandsman, 2002). Programs based on ABA methodology remain popular interventions for children diagnosed with ASD (Herbert & Brandsma, 2002, Lovaas, 1987, McEachin, Smith, & Lovass, 1993, Schreibman, 1997). Special-education litigation has increasingly involved requests that school districts provide or reimburse parents for a program characterized by ABA (Yell & Drasgow, 2000). For example, the New York State Guideline Technical Report for clinical practice of the assessment and treatment of ASD for children ages 0-3 years recommends the principles of ABA be included as an important programmatic element (NYDH, 1999). Given the increased demand for ABA methodology for preschool and school-aged children with ASD in school settings, it is necessary that teachers of special education and other school personnel understand the distinction between different types of programs that fall under the umbrella of ABA and what is implied when parents request discrete trial or applied verbal behavior programs. In their selective review of treatments for children with autism, Gresham, Beebe-Frankenberger, and MacMillan (1999) evaluated several programs categorized as comprehensive behavioral and educational treatment programs. These include, among others, the UCLA Young Autism Project (YAP), based on the work by O. Ivar Lovaas (1987); Treatment and Education of Autistic and Related Communication Handicapped Children (Project TEACCH), based on the work of Schopler and Reichler (1971); and Learning Experiences Alternative Program (LEAP), based on the work of Strain and others (1977) (Gresham, Beebe-Frankenberger, & MacMillan, 1999). Since the publication of the Gresham, Beebe-Frankenberger, and MacMillan article in 1999, additional approaches considered behavior analytic in nature have come to the forefront. These include Pivotal Response Training (PRT) (Koegel, Koegel, & Carter, 1999) and Applied Verbal Behavior (AVB) (Sundberg & Michael, 2001). For some educators, the distinction among ABA programs remains nebulous. The purpose of this paper is to distinguish between two popular approaches currently provided for early intervention and school-aged children in home- and school-based settings: Lovaas' Young Autism Project (YAP), more commonly referred to as Discrete Trial Instruction (DTI) or Discrete Trial Teaching (DTT), and B. …

Recent mandates related to the implementation of evidence-based practices for individuals with autism spectrum disorder (ASD) require that autism professionals both understand and are able to implement practices based on the science of applied behavior analysis (ABA). The use of the term “applied behavior analysis” and its related concepts continues to generate debate and confusion for practitioners and family members in the autism field. A general lack of understanding, or misunderstanding, of the science and practice of ABA is pervasive in the field and has contributed to an often contentious dialogue among stakeholders, as well as limited implementation in many public school settings. A review of the history of ABA and its application to individuals with ASD is provided, in addition to a discussion about practices that are/are not based on the science of ABA. Common myths related to ABA and ASD, as well as challenges practitioners face when implementing practices based on the science of ABA in public school settings are also described. The use of applied behavior analysis (ABA) with students with autism spectrum disorders (ASD) is not a new concept, as many professionals working in the autism field state that they “do” ABA with their students/clients. Though the science of ABA has been in use for decades questions remain about what constitutes ABA, its efficacy, and its use with individuals on the autism spectrum. Critics of ABA have historically disputed the evidence of efficacy of ABA for reasons ranging from criticisms that it is too punishment-based, lacks generalizability across settings and contexts, and issues with study methods and design. Such criticisms are not without merit, as will be discussed in this paper. However, much criticism is based on broad misconceptions about what it means to “do” ABA today in public school settings. ABA is much more than “Table Time” or discrete trial training, and “time out” or punishment. Today’s ABA is based on a well-founded and researched science, uses positive reinforcement over punishment, seeks to establish a clear connection between treatment and outcome (e.g., functional relationship, discussed later in this paper), and is focused on generalization of socially important skills to the natural environment. This paper provides an overview of ABA. This overview lays the foundation of the science and provides a historical context. Next, strategies and interventions based on the science of ABA will be discussed, as well as some of the myths and misconceptions of ABA as it pertains to individuals with ASD. Finally, challenges in the implementation of ABA (e.g. personnel preparation, litigation, blended methodology) are presented. The purpose of this paper is to provide readers, both new and seasoned professionals in the field of ASD and ABA, a reference for the use of ABA techniques with students with ASD, and to provide clarity about what today’s ABA is, and is not, for individuals with ASD. Overview of Applied Behavior Analysis Applied behavior analysis was first defined by Baer, Wolf, and Risley in 1968 as “the process of applying sometimes tentative principles of behavior to the improvement of specific behaviors, and simultaneously evaluating whether or not any changes noted are indeed Correspondence concerning this article should be addressed to Kara Hume, University of North Carolina at Chapel Hill, FPG Child Development Institute, 517 South Greensboro Street, Carrboro, NC 27510. Email: kara.hume@unc.edu Education and Training in Autism and Developmental Disabilities, 2012, 47(1), 23–38 © Division on Autism and Developmental Disabilities Today’s Applied Behavior Analysis / 23 attributed to the process of application” (p. 91). Using principles of behavior to shape, modify, or change behavior has a lengthy history in the field of special education, yet behavior modification alone does not qualify as ABA. Applied behavior analysis specifically includes the analysis of whether or not changes in behavior are caused by the behavioral modification techniques used, or whether there were other variables, or pure coincidence that leads to behavior change (Alberto & Troutman, 2009). In this way, the field has gone beyond training and moved to evaluation and prediction as well. In order to say with confidence that a particular intervention has led to a change in behavior, one must evaluate it according to specific criteria (e.g., against baseline) and determine whether or not it is likely that this behavior change would be seen again if the same intervention were to be used. This is known in the literature as establishing a functional relation between the behavior and the intervention, and is key to the analysis of behavior change (Kennedy, 2005).

Various practices are applied to make the education of children with autism spectrum disorder (ASD) qualified. These practices should be evidence based to be effective for the children with ASD and their families. In this study, evidence based practices applied in the education of the children with ASD and their families are explained within the frame of the literature. The most effective practices are applied in terms of the applied practices and practitioners’ competence in the evidence based practices, and the laws and policies lay emphasis for utilizing these practices. When examining the practices evidence based applied for the children with ASD, most of them are seen to be based on Applied Behavior Analysis (ABA) approach. ABA approach focuses on the skills needed by the children with ASD, when they are compared to their normally growing peers, and lays emphasis on the structured and individualized teaching. The most important behavior principles of the approach are negative reinforcement, punishment, result and formalizing. ABA methods decrease the negative methods; increases the communication, learning level and positive behavior. However, ABA also has some limitations, as every practice does. Mostly emphasized among these is that ABA based practices are applied mostly in clinical environments or classrooms. The existing interventions regarding ASD vary the practices and bring the discrete trial teaching approach, the relational approach, the unified approach and the developmental responsive approach into light. In the discrete trial teaching approach, new communication styles are taught effectively. This approach is based on that the behavior is learned by the individual, if the adult responds to the target behavior appropriately and consistently. In the relational approach, the skill wanted to be acquired in the interaction environment created within game context that develops social interaction is taught by disintegrating into steps. This approach is based on the assumption that the child should be directed to utilize an advanced and a higher level communicative behaviors. In the unified approach, the components of the discrete trial teaching approach and the relational approach have been combined. It utilizes the components of these approaches all together. In the developmental responsive approach, there is an intervention group named interaction based education and developmental, individual differences relationship based model. The most important priority of the approaches including these models is the positive emotional relations arising between the specialist and the child. It is based on the assumption that the positive emotional relation between the specialist and the child increases the child’s motivation for social communication and eases following the clues regarding social interaction. In the interventions executed with the children with ASD, families are seen as partners and it is seen that the relation based approaches are utilized in supporting child’s development and family-child interaction. The relation based approach depends on the parental modelling and asserts that families and other caretakers have a fundamental psycho-social effect in the development of all children. Article visualizations:

Brian is a 6-year-old boy who was diagnosed with autism spectrum disorder (ASD) and global developmental delay at age 2. He has no other health conditions of note. Brian lives with his parents and an older brother, who also has ASD, in a rural area 2 hours from the center where he was diagnosed. Brian has a history of intermittent self-injurious behaviors (head-banging, throwing himself onto the floor, etc.) that regularly result in bruising, intense and lengthy tantrums, and aggression toward family and teachers. Brian will occasionally indicate items that he wants, but otherwise has no functional communication skills. Over the past 18 months, Brian's challenging behaviors have waxed and waned. The regional special education program is not equipped to safely manage his behaviors, and there are no in-home or center-based agencies that provide applied behavior analysis (ABA) available. Brian's developmental pediatrician initiated guanfacine (eventually adding a small dose of aripiprazole) and referred the family to psychology for weekly telehealth behavioral parent training to address behavioral concerns using the Research Units in Behavioral Intervention curriculum.1Brian's behavioral problems decreased during the initial weeks of the COVID-19 crisis, when he no longer had to leave home or attend special education. However, as summer continued, his behaviors worsened substantially (regular bruising and tissue damage, numerous after-hours consultations with his psychologist and developmental pediatrician, and one trip to the emergency department). The intensity of Brian's behaviors (maintained primarily by access to tangible items and escape from demands) made progress with behavioral supports slow and discouraging for his parents. Other psychosocial stressors coalesced for the family as well, including employment loss, limited social support because of social distancing requirements, and illness of one of his parents. The developmental pediatrician continued to modify the medication regimen over the summer, transitioning Brian from guanfacine to clonidine and increasing his aripiprazole incrementally (with clear increased benefit); hydroxyzine was also used as needed during the episodes of highest intensity.Despite the availability of best-practice guidelines for children with Brian's presenting concerns,2 a confluence of barriers (geographic, economic, ABA work force, global pandemic, etc.) present serious questions for his family and care team related to the next steps in Brian's care. Should he attend in-person school in the fall, knowing that the available program may have limited educational benefit and increase his risk of COVID-19 exposure (not to mention self-injury)? Would the potential benefits of cross-country travel to an intensive behavioral treatment program outweigh the associated psychosocial and economic stressors? How else can the virtual care team support this family? 1. Bearss K, Johnson C, Smith T, et al. Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: a randomized clinical trial. JAMA. 2015;313: 1524-1533.2. Hyman SL, Levy SE, Myers SM, et al. Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics. 2020;145:e20193447.

Effectively serving students with autism spectrum disorders (ASDs) requires professionals to possess specialized knowledge, skills, and understanding. When students with ASDs are from culturally or linguistically diverse (CLD) families, the professionals assessing and providing services to the students need the additional dimension of how cultural and linguistic differences may affect identification, assessment, and treatment strategies.

The purpose of this study was to examine patterns of service receipt and patient outcomes for children receiving applied behavior analysis (ABA) for autism spectrum disorder (ASD) in an integrated health care system in which commercially insured children were covered by a state autism mandate. This retrospective, observational study used a random sample of children with ASD (3-17 yrs) who were members of a large integrated health care system in Southern California and referred for ABA between January 2016 and November 2018. From the 4145 children referred, a random stratified sample of 334 was selected to extract data from clinical reports over 24 months of services. The primary outcome measures were time in ABA and child adaptive behavior. Thirteen percent of the sample never received ABA after referral. Of those who were referred for ABA, 66% initiated ABA and remained in services for 12 months, whereas less than half (46%) remained in services for 24 months. Having a history of special education was associated with longer time spent in ABA, whereas having a single parent was associated with discontinuation of ABA. A minority of children received a full ABA dose (28%), but the lowest functioning children still experienced clinically significant adaptive behavior gains after 24 months of ABA (p = 0.02). In a health system implementation of ABA for children with ASD, there were high rates of ABA discontinuation and low ABA dosing. These challenges may diminish the potential benefits of ABA, even in a context in which there is mandated commercial insurance coverage.

Autism spectrum disorder is a developmental disability affecting individuals across their entire lifespan. Autistic individuals have differences from nonautistic people (sometimes called allistic or neurotypical people) in social skills, communication, and atypical interests and/or repetitive behaviors. Applied behavior analysis is one of the first and most common interventions recommended for autistic children. However, autistic individuals argue that applied behavior analysis damages their mental health and treats them as though they are a problem to be fixed. This study examined the experiences of seven autistic individuals who received applied behavior analysis interventions as children to understand what autistic adults think about their applied behavior analysis interventions, how they feel about the applied behavior analysis interventions they received, and what recommendations autistic adults have for the future of applied behavior analysis. The findings include: Autistic adults remember traumatic events from applied behavior analysis, do not believe that they should be made to behave like their peers, gained some benefits but suffered significant negative long-term consequences, believe that applied behavior analysis is an unethical intervention, and recommend that applied behavior analysis practitioners listen to autistic people and consider using interventions in place of applied behavior analysis.

technologies, emergence of, 43 Assistive listening devices (ALDs), 77 Assistive technology (AT), 2-3, 16, 52, 63, 72, 77, 145 barriers to, 19-20 categorization with examples, 54 as compensatory strategies, 145-146 independence and transition, 58-63 instructional aids/academics, 53-58 for learning disabilities, 16-17 for students with visual impairments, 91-92 support communication, 111-114 Assistive Technology Act, 216 Association for Education and Rehabilitation of the Blind and Visually Impaired website (AER website), 96-97 Association of Assistive Technology Act Programs, 19 Attention, strategies to accommodate, 149-150 Attention deficit hyperactivity disorder (ADHD), 19 Audio SOPS, 60 Audiobooks, 56-57 Augmentative and alternative communication (AAC), 111 Augmented feedback, 223 Augmented reality (AR), 4, 62 Aural rehabilitation, 74-75 Autism, 118-119 Autism spectrum disorder (ASD), 35, 105-106 communicative and social challenges, 106-107 Bone-anchored hearing aids, 73-74 Brain trauma, 146 Bug-in-ear technology, 41 Built-in accessibility features for students with visual impairments, 88-91 Calculators, 53 Center for Inclusive Technology and Educational Systems (CITES), 18 Centers for Disease Control and Prevention (CDC), 143-144 Certified Assistive Technology Instructional Specialists for People with Visual Impairments (CATIS), 96 Certified Orientation and Mobility Specialists (COMS), 96 Chrome extensions, 23 Chromebooks, 23, 224-225 Classroom learning, 148 Classroom noise, 78 Classroom practices, 2 Classroom teachers, 9-10 Classroom technology specific to DHH, 78-82 Closed captioning (CC), 194-195 Cloud computing, 208-209 Cochlear implants (CI), 73-75 Cognitive rehabilitation, 145 Collaboration, 98-102 Comics and text complexity, 165-166 Common Core State Standards (CCSS), 162-163, 166 Communication, 2, 43-44 using TAII to enhance, 110-114 Communication access real-time translation (CART), 77 Communicative supports, 111 Compensatory interventions, 145 Compensatory strategies to enhance learning for students with TBI, 148-150 strategies to accommodate attention, 149-150 strategies to accommodate for working memory, 148-149 strategies to accommodate language, 150 Complex communication needs (CCN), 130 Computer modeling, 44-45 Computer-aided note-taking (CAN), 77 Computer-assisted instruction (CAI), 1-2 Computer-based instruction (CBI), 205-206 Computer-based technology, 205-210 Concrete, representational, and abstract learning (CRA), 25-26 Concrete manipulatives, 55-56 Concussions, 144 Constant time delay (CTD), 129 Content areas, 129-130 Cooperative learning, 206-210 Council for Exceptional Children (CEC), 96-97 Covert audio coaching (CAC), 136

This extensive global study examines the effectiveness of Applied Behavior Analysis (ABA) therapy in improving social and communicative skills in children diagnosed with autism spectrum disorder (ASD). This research aims to investigate the impact of treatment duration and individualized approaches on treatment outcomes. It provides insights into the potential use of ABA treatment for children with ASD in various social contexts. A research design that used both quantitative and qualitative methodologies was utilized. This research encompassed a diverse sample of around 500 children affected by autism spectrum disorder (ASD) from multiple countries. Data was collected during ABA therapy sessions over the span of a year using systematic observations, standardized exams, and parent surveys. Statistical analysis, such as ANOVA and regression, was performed using Microsoft Excel. According to the study, children with autism spectrum disorder (ASD) who received Applied Behavior Analysis (ABA) treatment showed significant improvements in their social and communicative abilities. Members in both zones achieved significant progress over the course of a year. Importantly, the duration of therapy and the level of customization were identified as crucial factors influencing the extent of change, emphasizing the preference for personalized and postponed intervention. The results emphasize the effectiveness of ABA therapy as a scientifically supported intervention for children with ASD, facilitating their social and communicative development. In order to optimize the effectiveness of therapy, it is recommended to have longer therapy sessions and personalized treatment regimens. This research emphasizes the importance of early intervention and the effectiveness of ABA therapy in addressing cultural disparities in autism treatment. In order to ensure that children with autism spectrum disorder (ASD) receive the necessary support to flourish, it is strongly recommended that policymakers and clinicians prioritize the availability and accessibility of Applied Behavior Analysis (ABA) therapy. Keywords: Autism Spectrum Disorder (ASD), Applied Behavior Analysis (ABA) therapy, social skills, communication skills, therapy duration, individualization, international study, early intervention. DOI : 10.7176/JEP/15-10-06 Publication date : September 30th 2024

The diagnosis and management of autism spectrum disorder (ASD) and co-occurring medical and behavioral health conditions strain both health and educational resources in the United States. State mandates for insurance coverage for ASD-related health care were intended to improve access to indicated services, with inclusion of board-certified behavior analysts (BCBAs) as a newly licensed group of professionals to provide one approach to evidence-based intervention. McBain et al1 examined the association of the state by state passage of legislation on one indicator of access to services: number of providers who serve this population. Mandated insurance coverage, especially more-generous coverage, was associated with a greater growth in the workforce of BCBAs, a small increase in the number of child psychiatrists, and no change in the number of pediatricians.The authors acknowledged the associational nature of their study and their inability to explore use or distribution of services. However, when interpreting the impact of insurance mandates that focus primarily on reimbursement for applied behavioral analysis (ABA) as an intervention, there are additional implications that must be considered when examining actual health care provided for individuals with ASD. The insurance mandate did little to improve serious deficits in access to diagnostic services or to address the training needs of existing and available pediatric care providers.2 Augmenting workforce capacity includes current efforts to enhance pediatricians’ ability to contribute to timely ASD diagnosis, thereby promoting earlier entrance to intervention.3,4 Most interventions provided for children and youth with ASD have not been impacted by the wave of insurance legislation over the past decade but are provided through the legal mandate of the Individuals with Disabilities Education Act through the educational system. Consistent with patterns in specialty behavioral health care, special education and community services are not equitably distributed across a representative population (eg, based on race, ethnicity, age, income, language, and geographic region).5Increases in provider numbers resultant from insurance mandate legislation may imply false equivalence with evidence-based practice. Although behavior analytic services are efficacious for some,6 there is an increasing evidence base for interventions (eg, naturalistic developmental behavioral interventions7) that are not covered by insurance mandates. There is insufficient evidence to assume a single approach is effective for all individuals with ASD. Factors such as child characteristics and family choice become increasingly important drivers of treatment selection as predictors of success and outcome measurement are studied in greater depth. However, insurance legislation that is directly tied to funding ABA and advocated in parallel to licensure for BCBAs8 sends a message that ABA is the only effective intervention. This may come at the cost of awareness of and reimbursement for other possibly efficacious interventions, as well as development of comprehensive care plans including both the educational and medical systems.An additional erroneous assumption is that an increase in number of BCBAs and child psychiatrists leads to increased access to care. Indeed, families who are generally under-represented in service systems on the basis of race, ethnicity, and income level are especially likely to report unmet service needs.5 Such disparities are exacerbated by Medicaid restrictions for insurance mandates, which may disproportionately affect populations that are already underserved. Second, service quality remains independent from access. Community-based early intervention services, for instance, are delivered with highly variable fidelity, which may affect child outcomes. In addition, despite the general conviction in the field that more intensive intervention yields more positive results, conventions around the minimum recommended number of hours of ABA are not rooted in evidence.9 Recommendations to steer families toward readily available services should not supplant individualized, evidence-based determinations for intervention selection based on child and family variables and preferences.McBain et al1 add support to the evidence that the overall supply of child behavioral health services in the United States is inadequate to address the existing needs of not only children but people with ASD across the life span. We echo the recommendation that policies do need to address the existing behavioral and medical health needs but also suggest the following: (1) in addition to increasing the numbers of psychiatrists and BCBAs, the existing interprofessional workforce needs education and supports to improve quality of care; (2) care coordination must be recognized and funded as a method to improve efficiencies and access across health and educational systems; (3) providers and service systems must prioritize equitable access to services for all families; and (4) innovative research in this area will include the development and evaluation of cost-efficient and effective interventions for all people with ASD. Per Albert Einstein, “Everything should be made as simple as possible, but not simpler.” Full consideration of these numerous system complexities is necessary to adequately address the needs of individuals with ASD and their families.

Journal of Child and Adolescent PsychopharmacologyVol. 30, No. 5 EditorialsChallenges for Child and Adolescent Psychiatric Research in the Era of COVID-19Michael G. Aman and Deborah A. PearsonMichael G. AmanAddress correspondence to: Michael G. Aman, PhD, The Nisonger Center UCEDD, Ohio State University, 1581 Dodd Drive, Columbus, OH 43210, USA E-mail Address: [email protected]The Nisonger Center UCEDD, Ohio State University, Columbus, Ohio, USA.Search for more papers by this author and Deborah A. PearsonMcGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA.Search for more papers by this authorPublished Online:17 Jun 2020https://doi.org/10.1089/cap.2020.0081AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail View articleFiguresReferencesRelatedDetailsCited byRemote assessment of ADHD in children and adolescents: recommendations from the European ADHD Guidelines Group following the clinical experience during the COVID-19 pandemic11 February 2023 | European Child & Adolescent Psychiatry, Vol. 32, No. 6Serving Individuals With Autism Spectrum Disorder in the Age of COVID-19: Special Considerations for Rural Families2 May 2023 | Rural Special Education Quarterly, Vol. 3Perceived household financial decline and physical/mental health among adolescents during the COVID-19 crisis: Focusing on gender differencesPreventive Medicine Reports, Vol. 32Autism spectrum disorder, parent coping, and parent concerns during the COVID-19 pandemicChildren and Youth Services Review, Vol. 73Dietary supplements for aggressive behaviour in people with intellectual disabilities: A randomised controlled crossover trial12 October 2022 | Journal of Applied Research in Intellectual Disabilities, Vol. 36, No. 1The Law of Large Numbers in Children’s Education15 July 2022 | Applied Mathematics and Nonlinear Sciences, Vol. 8, No. 1Psychotropic Prescriptions During the COVID-19 Pandemic Among U.S. Children and Adolescents Receiving Mental Health Services Alejandro Amill-Rosario, Haeyoung Lee, Chengchen Zhang, and Susan dosReis15 September 2022 | Journal of Child and Adolescent Psychopharmacology, Vol. 32, No. 7Letter to the Editor: The Impact of the COVID-19 Pandemic on the Mental Health of Youth with Developmental Disabilities Maria Valicenti-McDermott, Erin Rivelis, Carla Bernstein, and Marie Joane Cardin16 December 2021 | Journal of Child and Adolescent Psychopharmacology, Vol. 31, No. 10Conducting CBT for Anxiety in Children with Autism Spectrum Disorder During COVID-19 Pandemic1 January 2021 | Journal of Autism and Developmental Disorders, Vol. 51, No. 11A Hybrid Clinical Trial Delivery Model in the COVID-19 Era28 April 2021 | Physical Therapy, Vol. 101, No. 8It took a pandemic: Perspectives on impact, stress, and telehealth from caregivers of people with autismResearch in Developmental Disabilities, Vol. 113Impacts on Children and Adolescents’ Lifestyle, Social Support and Their Association with Negative Impacts of the COVID-19 Pandemic29 April 2021 | International Journal of Environmental Research and Public Health, Vol. 18, No. 9Conséquences psychiatriques de la pandémie de la Covid 19 chez l’enfant et l’adolescentNeuropsychiatrie de l'Enfance et de l'Adolescence, Vol. 69, No. 3Relations between Child and Parent Fears and Changes in Family Functioning Related to COVID-1912 February 2021 | International Journal of Environmental Research and Public Health, Vol. 18, No. 4Changes in access to educational and healthcare services for individuals with intellectual and developmental disabilities during COVID‐19 restrictions17 September 2020 | Journal of Intellectual Disability Research, Vol. 64, No. 11Cross-Sectional Study of Self-Concept and Gender in Relation to Physical Activity and Martial Arts in Spanish Adolescents during the COVID-19 Lockdown13 August 2020 | Education Sciences, Vol. 10, No. 8 Volume 30Issue 5Jun 2020 InformationCopyright 2020, Mary Ann Liebert, Inc., publishersTo cite this article:Michael G. Aman and Deborah A. Pearson.Challenges for Child and Adolescent Psychiatric Research in the Era of COVID-19.Journal of Child and Adolescent Psychopharmacology.Jun 2020.280-284.http://doi.org/10.1089/cap.2020.0081Published in Volume: 30 Issue 5: June 17, 2020Online Ahead of Print:June 9, 2020PDF download

There have been many diverse and complex treatments (Napolitano et al. 2010; Sancho et al. 2010) developed in order to target improving the quality of lives of individuals with autism spectrum disorders (ASD). By implementing efficient interventions across a variety of environments and people with whom the individual comes into contact with on a consistent basis, the symptoms to this neurological disorder may be minimized (Meyers and Johnson 2007). Therefore, identifying, developing, and applying such treatments would be an essential process for a teacher to conduct when instructing children diagnosed with a form of autism since a considerable amount of a child’s time is spent within a school setting. However, since there is wide range of conflicting research available regarding what methods should be used and what factors should be taken into consideration (Rogers and Vismara 2008) when teaching students with autism, educators may require input regarding what particular scientific and evidence based practices should be utilized based on their reported history of effectiveness. (Ascroft et al. 2010) attempt to provide one such solution to this issue for teachers when they discuss academic, social, and behavioral interventions using practices of applied behavior analysis (ABA) in Success Strategies for Teaching Kids with Autism. The content presented throughout the book first serves to advocate practices of ABA when working with children with an ASD in a classroom. Ashcroft et al. (2010) start building their defense as to why integrating ABA in educational programing should be a necessary component for teachers working with children diagnosed with an ASD. While chapter 1 provides an overview of the characteristics, symptoms, and possible causes associated with the various forms of autism spectrum disorders, chapter 2 establishes a basic foundation for the inclusion of ABA in classroom settings as the authors cite federal laws and a variety of other sources (New York State Department of Health, Early Intervention Program 1999) to support their claims. Chapter 3 is dedicated to describing the science of applied behavior analysis and to provide common terminology and examples to behavioral principles that could increase or decrease specific behavior. The terms explained by the authors are basic components that anyone implementing ABA interventions should be fluent with. However, caution should be noted as the wording may not have been handled accurately in a several instances when the authors try to describe a few of the terms when offering readers with examples and ‘tips.’ After several of the principles of ABA are outlined, the authors offer an array of approaches to implementing behavioral procedures within a classroom environment in chapter 4. Here, the authors put forth the necessary effort at indicating the broad range of means in which ABA may be employed across the many methods in which a child may learn. The authors make respectable attempts at describing these somewhat complicated procedures using practices of ABA for the layperson. However, if an educator were eager to implement these strategies within their own classroom, they would be recommended to seek out further literature in order to gain more knowledge regarding the development of these interventions than what was presented throughout this chapter to better ensure the strategies success when implemented. As it relates to chapter 5, Ascroft et al. (2010) noted the importance of conducting comprehensive ABA based J. B. Smith (&) Leadership Department, University of Memphis, 1437 Dexter Lake Drive, Apt. 301, Cordova, Memphis, TN 38016, USA e-mail: BrianSmithBCBA@gmail.com

Autism spectrum disorder (ASD) is a complex neurodevelopmental condition characterized by deficits in social interaction, communication difficulties, and repetitive behaviors that profoundly impact the lives of affected individuals and their families. This article provides a comprehensive overview of ASD, focusing on screening, diagnosis, and intervention strategies. Early signs of ASD can manifest in infancy, but parents may not recognize them until their child falls behind in meeting social milestones. This delay in recognition is often due to a lack of awareness, societal stigma, and limited knowledge about developmental and behavioral disorders. Globally, ASD prevalence is increasingpotentially due to broader diagnostic criteria, increased awareness, and improved screening practices. Screening for ASD is crucial for early identification and intervention. Various tools are available such as the Modified Checklist for Autism in Toddlers (M-CHATs), Trivandrum Autism Behavioral Checklist (TABC), and the Social Communication Questionnaire (SCQ). Diagnosing ASD involves using established criteria such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and specific diagnostic tools like the Autism Diagnostic Observation Schedule (ADOS) and the Indian Scale for the Assessment of Autism (ISAA). Interventions for ASD should be multidisciplinary, involving professionals such as developmental pediatricians, psychologists, psychiatrists, special educators, occupational therapists, physiotherapists, speech therapists, and social workers. Applied behavior analysis (ABA), naturalistic developmental behavioral interventions (NDBIs), and parent-mediated treatment are among the evidence-based approaches. Additionally, speech-language therapy, motor therapy, and sensory integration therapy play vital roles in addressing the diverse needs of individuals with ASD. Medical interventions should be used alongside behavioral and environmental strategies. Early screening, accurate diagnosis, and tailored interventions are essential for improving the lives of individuals with ASD. A multidisciplinary approach and increased awareness are crucial in addressing the growing prevalence of ASD worldwide.

Objective To compare and analyze the short-term effect of play-based communication and behavior intervention (PCBI) and applied behavioral analysis (ABA) on the treatment of toddlers with autism spectrum disorder (ASD). Methods Seventy-four ASD toddlers aged from 19 to 30 months were recruited in Nanjing Brain Hospital Affiliated to Nanjing Medical University from November 2017 to May 2018.The toddlers who participated in this study were randomly assigned into PCBI group and ABA group, then they were intervened weekly by PCBI or ABA for a total of 12 weeks.Portage Early Development Checklist and autism treatment evaluation checklist (ATEC) were used to estimate the toddlers′ developmental level and the treatment efficacy respectively.The t-test was used to reveal whether there was significant difference between the 2 groups before and after intervention. Results (1)Compared with the ABA group, there was a significant increase in cognitive scores (ΔPCBI=9.03 scores, ΔABA=4.27 scores, t=3.997) and a significant decrease in social behavior scores (ΔPCBI=8.87 scores, ΔABA=16.91 scores, t=-4.022) of the Portage Early Development Checklist after 12 weeks of intervention in the PCBI group, and there were statistically significant differences(all P 0.05). (2)Compared with the ABA group, after 12 weeks of PCBI intervention, the scores of social contact, perception, behavior of ATEC were decreased, but the difference was not significant (P>0.05); the total score of ATEC scale(ΔPCBI total=14.89 scores, ΔABA total=22.22 scores, t=2.209)and the scores of language subscale(ΔPCBI language=2.89 scores, ΔABA language=6.43 scores, t=2.515)were decreased significantly, and there were statistically significant differences (all P<0.05). Conclusions After 12 weeks of the very early intervention of PCBI, the ASD toddlers all improved in clinical symptoms and developmental level.Compared with ABA intervention, PCBI very early intervention with parental guidance was comparable in short term efficacy, and PCBI was not taking up as much medical rehabilitation resources as ABA. Key words: Autism spectrum disorder; Toddler; Very early intervention; Play-based communication behavior intervention; Efficacy evaluation