The Future of Applied Behavior Analysis in Autism Spectrum Disorder: New Opportunities for Improving Lives

The articles in this special issue make clear that Applied Behavior Analysis (ABA) is arguably the most powerful tool that exists for improving the lives of people with ASD and their families, helping them to reach meaningful goals and a better future. As ABA practitioners and researchers have extended their efforts into a host of real-life settings, barriers to further success have become increasingly apparent. However, these same barriers suggest many new opportunities to collaborate across disciplines, to change systems, and to rethink our goals and priorities (Carr, 2007). In doing so, we are likely to enhance the impact of ABA even further and the wellbeing of people with ASD and their families even more. In this concluding article, we discuss six emerging themes that will shape future efforts in ABA and help define how we think about and address ASD. As co-editors, we have chosen to emphasize the big-picture accomplishments of ABA and how they relate to the ultimate goals most cherished by those with ASD and their families.

Not All People with ASD are the Same

Some people with autism become professors of computer science. Others remain nonverbal, nonsocial and totally dependent on others for their survival. These differences are the reason why autism is referred to as a spectrum disorder. Increasingly, researchers have been suggesting that the idea that there is a best treatment for autism is counterproductive and misleading. The reality is that there are many different subgroups, each of whom may respond optimally to a particular form of treatment (Rogers & Vismara, 2008). To illustrate, some data show that young children who initially display more toy play and less social avoidance have far better outcomes following ABA than those who have problems in these areas (Sherer & Schreibman, 2005).

The remarkable heterogeneity displayed by people with autism calls into question the idea that randomized clinical trials (RCTs) should, at this time in the development of the field, be considered the gold standard for evaluating whether a specific treatment has merit. In an RCT, children are randomly assigned to either an experimental group that receives treatment or a control group that does not receive the treatment in question. Should the experimental group outperform the control group, one concludes that the treatment has merit and can be used successfully with children who have autism. However, given the heterogeneity just noted, this conclusion begs the question, “Which children?” In fact, RCTs simply show that the average or mean score for the entire experimental group is better than that for the entire control group. We learn nothing about how any given child has performed. Yet, in clinical practice what we most want to know is how best to help a specific child. Indeed, when data from the experimental group are examined on a case-by-case basis, one commonly finds that the treatment had little effect or even a negative effect on some children, while improving many others. This type of finding highlights the urgency of identifying exactly how different child characteristics might call for different treatment approaches. ABA research methodology is uniquely positioned to help distinguish among different subgroups of children because of its focus on evaluating treatment effects at the level of the individual rather than the group (Horner, Carr, Halle, McGee, Odom, & Wolery, 2005). As such, for any given treatment, one can readily detect responders and nonresponders, and this information, in turn, can be used to build profiles of important child characteristics related to outcome. Thus, ABA methodology could prove invaluable in facilitating the process of subgroup identification so that parents and practitioners are able to choose treatment options in a more rational and systematic manner than is currently the case.

The heterogeneity seen in people with autism also raises the question of whether everyone so labeled needs treatment. Many advocates feel that the focus on treatment, cause and cure is insulting. They see themselves as a “neurological minority” and note that other minorities who are defined, for example, on the basis of race do not provoke discussions of treatment and cure. To return to our initial example, does a successful professor of computer science really need to be treated and cured? More likely, for the professor and many others with success stories, the issue is one of acceptance and support. Here, the goal of ABA, should such intervention be requested, must be to help create effective support systems that ensure continued success—a topic that is addressed later in this article. Of course, many people with autism are not as fortunate as the computer science professor and can benefit from respectful and well-thought-out treatment that promotes a good quality of life, an issue that we take up next.

A Lifespan Approach is Essential

Following ABA intervention, some children with autism recover (Granpeesheh, 2008; Granpeesheh, Tarbox, Dixon, & Herbert, 2008). Many, however, do not. For them and their families, autism will be a lifelong disability. In this respect, autism is no different than chronic medical problems such as diabetes and asthma. These conditions may not be “curable,” but with appropriate management and support, people who suffer from them can have a good quality of life. This thinking has begun to permeate the field of autism as well. Specifically, systematic and carefully constructed support can create meaningful life options for people with ASD (Carr & Pratt, 2007).

In the absence of recovery, the focus shifts to the issue of quality of life (QOL). What is QOL? It is a multidimensional construct that includes issues related to material well-being, health and safety, social well-being, emotional well-being, leisure and recreation, and autonomy. Individuals who experience a poor QOL make a poor adjustment to society and frequently display problem behavior. Therefore, QOL represents a challenge and an opportunity for ABA to make a contribution over the entire lifespan of people with ASD. In fact, each dimension of QOL suggests meaningful goals that can be pursued and achieved via ABA, as individuals move from one stage of life to the next.

Consider material well-being. By teaching meaningful job skills, we can help adults with autism to earn money to pay for basic necessities, creature comforts and transportation to enjoyable community settings. By teaching personal safety skills, we can minimize the risk of injury. Health and wellness training in hygienic practices reduces the risk of illness. Social well-being can be promoted by addressing skill deficits so that individuals gain acceptance into community, ethnic and religious groups, thereby replacing isolation with friendships. Emotional well-being can be enhanced by focusing on building close relationships within the family and, when appropriate, dating and romantic relationships. Leisure and recreation can be addressed by encouraging interests in hobbies, sports, entertainment and vacations. Autonomy is enhanced by building self-sufficiency in daily routines and supporting significant choice-making with respect to living arrangements, vocation, social relationships and religious preference. These goals, though complex in nature and logistically challenging, provide multiple opportunities for ABA to expand its reach across the lifespan in ways that are universally recognized as constituting the core of what it means to have a good life.