The Promise of ABA: Creating Meaningful Lives Throughout Adolescence and Adulthood (page 5)
The past decade has seen dramatic reports citing the increase in the prevalence of autism and related disorders. From an earlier prevalence estimate of approximately 2-5 cases per 10,000 individuals (2.5 per 1,000), according to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), the figure most often cited today is approximately 4-7 cases per 1,000 individuals, with the higher estimate resulting in the 1 case per 150 individuals most recently identified by the Centers for Disease Control in 2007. While the reasons behind this increase remain unclear (e.g., Gernsbacher, Dawson & Goldsmith, 2005; Shattuck, 2006), and at times controversial (e.g., Kirby, 2005; Williams, Mellis, & Peat, 2005), what is generally accepted is that there are greater numbers of learners being diagnosed with autism spectrum disorder (ASD) in general and, subsequently, of adolescent and young adult learners in particular who are in need of appropriate, evidence-based interventions and services than ever before.
With this increase in prevalence has come an increased demand for appropriate and effective services for adolescents and young adults with ASD. Unfortunately, the need in both areas continues to far exceed the available resources, leaving a generation of learners with ASD and their families in programmatic, financial and personal limbo (e.g., Howlin, et al., 2004). The reasons behind this disparity between needs and services are myriad and include, but are not limited to:
- poorly implemented transition services required under IDEA;
- a continued misunderstanding as to the potential of individuals with ASD to be employed, contributing and active members of their community when the appropriate interventions and supports are provided;
- a lack of coordination among the educational, behavioral, mental health, vocational rehabilitation and MR/DD systems intended to support individuals into adult life and, most relevant to this discussion;
- a pervasive and inaccurate belief that interventions based upon principles of Applied Behavior Analysis (ABA) are no longer applicable to adolescent and adult learner.
Given this list of challenges, it seems reasonable to argue that the potential of adults with ASD to become employed and engaged is limited more by the inadequacies of the system charged with supporting them than by the challenges presented by their disability. And the economic cost of these systemic inadequacies is not inconsequential and, in fact, is rather far reaching. As Ganz (2007) notes, “Autism is a very expensive disorder, costing our society upwards of $35 billion in direct (both medical and nonmedical) and indirect costs to care for all individuals diagnosed each year over their lifetimes” (p. 343). Absent a concerted effort on behalf of all stakeholders (i.e., parents, professionals, employers, society at large) to correct these inadequacies, these costs can only be expected to grow in the coming years.
Research Supports ABA for Adult Learners
There are, however, things that can be done. Among the many interventions currently available to educate individuals with autism, those based upon the principles of ABA are the most well documented and empirically validated (Rosenwasser & Axelrod, 2001), with over 35 years of research support. Unfortunately, behavior analytic research specifically addressing the instructional needs of older learners is less available, which can present a major challenge to those interested in supporting adolescents and adults on the spectrum. And while much of the research targeting younger learners can be generalized, with some modification, for use with older individuals, this, in practice, would appear to be more the exception than the rule. For those who know how to look for it, there is a broader research base supporting the use of behavior analytic interventions with adults on the spectrum. Take, for example, a study by Hagner & Cooney (2005). In this study the authors interviewed the supervisors of 14 successfully employed individuals on the spectrum to determine effective supervisory practices. A qualitative analysis found that a specific set of supervisory strategies were associated with employment success. Their results, presented below, are not necessarily surprising. But what may be remarkable is that despite being discussed by the authors in less than behavior analytic terms, all of the identified strategies are well-documented behavior analytic interventions. For example:
Hagner & Cooney (2005) Findings
In Behavior Analytic Terms Activity
|Findings Maintaining a consistent schedule and set of job responsibilities||Activity schedule and task analysis|
|Using organizers to structure the job||Visual supports|
|Reducing idle or unstructured time||Environmental modifications and/or providing instruction in appropriate use of idle time|
|Being direct when communicating with the individual employee||Provide a clear and accurate discriminative stimulus (Sd)|
|Providing reminders and reassurances||Prompting, shaping and reinforcement|
Why ABA is not Frequently Used with Adults?
So if the research exists, why are such potentially effective behavior analytic interventions not used with adults as frequently as would seem to be appropriate? One reason may be the continued confusion regarding the relationship of discrete trial teaching (DTT) to ABA. In brief, ABA is a field of inquiry dedicated to investigating and modifying behavior in a systematic way. ABA is data-based, analytical, able to be replicated, contextual, accountable and results in socially valid behavior change (Sulzer-Azaroff & Mayer, 1991). DTT, on the other hand, is simply one instructional intervention that meets these criteria. The persistent idea that “because we don’t do DDT with adults, we can’t do ABA” is, quite simply, wrong. These same criteria are also associated with a broad range of behavior analytic interventions (e.g., modeling, prompting, reinforcement, pivotal response treatment, shaping, relaxation training, chaining, precision teaching, etc.) that can be used to the benefit of adults on the spectrum. The potential applications of behavior analytic interventions with adults are as diverse as the challenges they are intended to address once a broader, and more accurate, understanding of ABA is put into place.
A second reason may be that the response effort associated with the effective use of behavior analytic interventions with older learners may be significantly greater than that required by other, less well-documented (and less effective), instructional interventions. And absent that effort, previously effective interventions may no longer produce significant outcomes. In less technical terms, it is probably safe to assume that for a typical 5-year-old child with autism, DTT would be the method of choice to teach color discrimination. Let’s also assume that for this particular learner 1,000 such trials were required in order for him or her to master the expressive and receptive discrimination of all 64 colors in the big box of Crayola® crayons. This is not all that much, actually, and so the response effort on the part of the instructor is relatively low (i.e., sit at a desk; present Sd; prompt, reinforce and collect data) and the intervention (DTT) would be regarded as effective.
Applying ABA Effectively with Adults
Now assume this same learner is 16 years of age and instead of color discrimination the instructional goal is independent purchasing of lunch at McDonald’s. If the resources are only available to provide direct community instruction once every other week, it would take approximately 40 years for the same number of instructional opportunities to be presented as were necessary to master a simple discrimination task (color ID) much earlier in life. So the low response effort in this case (one instructional opportunity every other week) would be insufficient to produce significant results—independent responding—and the implication would be that behavior analytic interventions (i.e., task analysis, shaping, chaining, prompting and reinforcement) are ineffective with older learners. However, with a higher response effort (e.g., daily instructional opportunities), independent purchasing of lunch may be acquired (particularly given the reinforcing value of task), and the associated interventions regarded as effective.
As children with autism become adolescents with autism who become adults with autism, the instructional challenge becomes twofold. The first step is to use instructional interventions that have the greatest research base and are, therefore, most likely to be effective. In the vast majority of cases, these will be behavior analytic interventions. These interventions have been shown to be effective in teaching community living skills such as shopping, using public transportation and job training (Lattimore, Parsons, & Reid, 2002); leisure skills such as independent walking, playing soccer and interacting socially (Gaylord-Ross et al., 1984) ; as well as a wide array of daily living skills (Taylor et al., 2004). The second step, however, is to ensure the implementation of these interventions in a way that is congruent with the research and, just as importantly, includes sufficient response effort (i.e., instructional intensity) to result in significant and socially valid behavior change.
Improving Competence and Quality of Life
Implicit in the discussion thus far is the notion that ABA, when properly implemented, can contribute to the quality of life for adolescents and adults with autism. Quality of life is defined by an individual’s personal satisfaction with such core considerations as physical well-being, emotional well-being, interpersonal relations, social inclusion, personal growth, selfdetermination and individual rights. These considerations all reflect a degree of personal competence. In this sense, then, one of the most significant contributions of ABA is that it reliably defines, observes and increases the competence of individuals with autism.
As previously noted, through ABA, many adolescents and adults can achieve competence in job training, social integration and leisure skills that facilitate their participation in the community and, consequently, improve their quality of life. This fact justifies a belief in a hopeful future for children with autism as they grow up, but it is also clear from the present overview that much more remains to be done if the promise of ABA in creating meaningful lives throughout adolescence and adulthood is to be fully realized.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th Ed.). Washington D.C.: Author.
Ganz, M.L. (2007). The lifetime distribution of the incremental societal costs of autism. Archives of Pediatric and Adolescent Medicine, 161, 343-349.
Gaylord-Ross, R.J., Haring, T.G., Breen, C., & Pitts-Conway, V. (1984). The training and generalization of social interaction skills with autistic youth. Journal of Applied Behavior Analysis, 17, 229-247.
Gernsbacher, A.M., Dawson, M., & Goldsmith, H.H. (2005). Three reasons not to believe in an autism epidemic. Current Directions in Psychological Science, 14, 55-58.
Hagner, D., & Cooney, B.F. (2005). “I do that for everybody”: Supervising employees with autism. Focus on Autism and other Developmental Disabilities, 20, 91-97.
Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2004). Adult outcomes for children with autism. Journal of Child Psychology and Psychiatry, 45, 212-229.
Kirby, D. (2005). Evidence of Harm. New York: St. Martin’s Press.
Lattimore, L.P., Parsons, M.B., & Reid, D.H. (2002). A prework assessment of task preferences among adults with autism beginning a supported job. Journal of Applied Behavior Analysis, 35, 85-88.
Rosenwasser, B., & Axelrod, S. (2001). The contributions of Applied Behavior Analysis to the education of people with autism. Behavior Modification, 25, 671-677.
Shattuck, P.T. (2006). The contribution of diagnostic substitution to the growing administrative prevalence of autism in U.S. special education. Pediatrics, 117, 1028-1037.
Sulzer-Azaroff, B., & Mayer, R.G. (1991). Behavior Analysis for Lasting Change. Fort Worth, Texas: Holt, Rinehart and Winston, Inc.
Taylor, B., Hughes, C., Richard, E., Hoch, H., & Rodriquez Coello, A.(2004). Teaching teenagers with autism to seek assistance when lost. Journal of Applied Behavior Analysis, 37, 79-82.
Williams, K., Mellis, C., & Peat, J.K. (2005). Incidence and prevalence of autism. Advances in Speech and Language Pathology, 7, 31-40. About the Author Peter Gerhardt, E d.D., is the President of the Organization for Autism Research, whose mission is the promotion of applied research and the subsequent dissemination of evidence-based information. He is also a member of ASA’s Panel of Professional Advisors.
Reprinted with the permission of the Autism Society.
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