I heard behavior modification [now called applied behavior analysis or ABA] might be helpful to autistic children, and I subsequently visited UCLA, where psychologist Ivar Lovaas was pioneering this method. "It's amazing," Lovaas tells me. "All these years we've known how well it worked for Helen Keller, but no one thought to try it on autistic children."
— Afterword by Dr. Bernie Rimland in "Let Me Hear Your Voice" (1993) by Catherine Maurice
Early intensive behavioral intervention (EIBI) is a treatment approach that is based upon the principles of applied behavior analysis (ABA) and the research of Ivar Lovaas and colleagues at the UCLA Young Autism Project... Influenced by theories of learning and motivation, practitioners of EIBI refer to it as "the science of teaching."
— Susan Hepburn, 2013, Springer Link
Behavior analysis is the scientific study of behavior. Applied behavior analysis (ABA) is the application of the principles of learning and motivation from behavior analysis, and the procedures and technology derived from those principles, to the solution of problems of social significance.... Specifically, ABA refers to a systematic approach to the assessment and evaluation of behavior and the application of interventions that alter behavior.
— Center for Autism and Related Disorders (CARD), Inc.
The late Drs. Ivar Lovaas and Bernie Rimland transformed the way we view and treat autism today.
The late Drs. Ivar Lovaas and Bernie Rimland transformed the way we view and treat autism today, passing away in 2010 and 2006, respectively.
Lovaas proved Behavior Modification, now called Applied Behavior Analysis (ABA), to be an effective teaching tool for children with autism at the University of California, Los Angeles (UCLA) in 1987, where he utilized the technique for a number of years.
His early work with this population of children and their parents led to the formation of the Autism Society of America—which, at the time, was called the National Society for Autistic Children—that he co-founded with Bernie Rimland, whose book Infantile Autism: The Syndrome and Its Implications for a Neural Theory of Behavior first published in 1964 changed the mental health community's perspective on autism by doing rid with the "Refrigerator Mother" theory that the condition was somehow triggered from poor parenting styles.
Not only did Dr. Rimland happen to detect autism in his own son, Mark—who was a client of Lovaas' at the UCLA Young Autism Project, but his son also partially served as the basis for Dustin Hoffman's lead role in the film Rain Main (1988), considered one of the very first—and among the most memorable—to shed light on the condition.
Lovaas earned his Ph.D. in clinical psychology at the University of Washington, where he studied under Don Baer, Todd Risley, Mont Wolf, Sidney Bijou, Jim Sherman, and Jay Birnbrauer, all of whom moved to the University of Kansas to establish the Journal of Applied Behavior Analysis (JABA) in 1968.
That's not to imply that ABA started with JABA, or the researchers from the University of Kansas. While Systematic Desensitization—officially replacing "Flooding" Desensitization as a first-line approach—was initially applied to the clinical treatment of phobias in 1958, other faculty from the psychology department at the University of Washington, including Bill Hopkins practiced ABA in the form of Organizational Behavior Management (OBM). Lindsley (1956) and Ayllon & Michael (1959) even used it for adults with the psychotic features of schizophrenia, and Goldiamond (1965) implemented ABA for children who stuttered.
By the 1980s, ABA also expanded to classroom behavior management with the use of Positive Behavior Support (PBS) systems in schools nationwide, as well as interventions geared toward counseling, such as Acceptance and Commitment Therapy (ACT) and Functional Analytic Psychotherapy (FAP).
Over the years, the term "Applied Animal Behavior" was coined to refer to the science being used for the training of animals, and recent research in JABA had amounted so substantially to include other evidence-based clinical procedures, particularly Pediatric Feeding Therapy and Voucher-Based Contingency Management (CM) for substance abuse.
But, it was at the Indiana University School of Medicine where Charles Ferster (1961), who co-founded the Journal of the Experimental Analysis of Behavior with B.F. Skinner at Harvard University, was the first to use ABA—or more specifically, Errorless Learning*—to teach children who had infantile autism, serving as the basis for Lovaas' groundbreaking—but sometimes initially harsh—work.
Throughout the late 1960s and '70s, Lovaas and colleagues implemented aversive consequences, such as electric shocks and spanking, to stop a child's aggressive and self-injurious behaviors. They even yelled "no!" if answering inaccurately and also rewarded—or reinforced—correct responses and when otherwise behaving properly. Further, the antecedents and consequences were presumed to change behavior. But, as time passed, such linear approach to behavior management was discontinued.
According to Mace (1994) in the Journal of Applied Behavior Analysis, we were beginning to move "beyond behavior modification" with "a return to behavior analysis" in the mid-1980s (also see, i.e., Walsh, 1997; Pelios, Morren, Tesch, & Axelrod, 1999; Mace & Critchfield, 2010).
Applied Behavior Analysis (ABA) is an evidence-based approach to learning that initially relies on a functional analysis of behavior by analyzing historical consequences and previous behavioral responses to antecedent stimuli before attempting to change the contingencies in the current environment. That way, the practitioner can accurately determine the causes and function of the behavior (including attention-seeking, escape/avoidance, sensory stimulation, or tangible access to an item or activity), as well as anticipate the procedures that will work most efficiently (this is often accomplished through data collection, functional behavior assessments, and behavior intervention plans).
While ABA is broadly studied for a variety of diagnoses in a number of other situations, board certified behavior analysts (BCBAs) tend to work exclusively with children on the autism spectrum.
Early Behavioral Intervention (EBI) is a sub-discipline of ABA that encompasses several proven teaching strategies (both structured and play-based) for children with autism and other developmental disabilities under the age of 5 and implemented at an intensity of 25-40 hours per week. EBI is typically practiced within the family's homes, as well as in agencies, such as schools and clinics.
Lovaas' intensive therapy, known as Early Intensive Behavioral Intervention (EIBI, or 40 hours per week of what he called, "Discrete Trial Training" (DTT)), involves highly-trained behavior analysts instructing repeated and structured techniques of teaching by visually cueing eye contact, modeling and manually prompting a wide array of fine and gross motor exercises, vocally or orally prompting speech, and rewarding correct responses with praise and child-preferred reinforcers. Once the child has acquired stimulus control, such prompts are faded out, and tact (expressive label) training, as well as Incidental Teaching (also called Natural Environment Training or NET)—which relies on mand ("request") training—are employed so that generalization will take place.
As opposed to the old days, we now know from cutting-edge research that if the child has higher receptive language skills—also called listener behavior—and do not get distracted from their natural environment, the child will learn more rapidly from Pivotal Response Treatment (PRT), which differs from NET in that PRT exclusively uses mand training to elicit vocalizations.
PRT also encompasses Social Responsivity (sometimes called Reciprocal Imitation Training) that consists of using the child's interests and lead into play (i.e., singing a song, playing with a toy train or car, etc.) as natural reinforcers before expanding their play repertoire to engage them, and so the child forms a meaningful relationship with their caregivers and therapists.
Drawing back to 1987, Lovaas and colleagues at UCLA proved in a study that after 40 youngsters with autism obtained structured EIBI for three years, 47%—9 out of 19 children in the experimental group—obtained "normal educational and intellectual functioning" (Lovaas, 1987) and were independently mainstreamed in regular classrooms. 89% also progressed in their IQ, spoken language, and daily living skills. Further, by the time the 'best outcome' children reached early adolescence, a follow-up study in 1993 indicated that 8 of them (or 42%) fully recovered to the point where they no longer "showed signs of emotional disturbance and demonstrated adequate development [in] adaptive and social skills within the normal range" (McEachin, Smith, & Lovaas, 1993, p. 368).
Several federal organizations within the United States, including the American Academy of Pediatrics, National Research Council, New York State Department of Health, and Surgeon General, all acknowledge the validity of early ABA-based therapies for teaching children with an autism spectrum disorder (ASD). In addition to being the only approach "well-established" in the research literature (Rogers & Vismara, 2008; Smith & Iadarola, 2015), structured EIBI has proved to be highly effective throughout countless single-subject design studies for over 50 years.
According to a report on mental health made by the Surgeon General in 1999, "Thirty years of research have demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior." He also acknowledged that Lovaas' 1987 study was "well-designed."
By 2007, Pediatrics—the official journal for the American Academy of Pediatrics—even stated that "The effectiveness of [structured] ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology, and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior, as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups."
The same journal published in 2020, "Most evidence-based treatment models are based on principles of ABA... ABA interventions vary from highly structured adult-directed approaches (eg, discrete trial training or instruction, verbal behavior applications, and others) to interventions in natural environments that may be child led and implemented in the context of play activities or daily routines and activities and are altered on the basis of the child’s skill development (eg, pivotal response training, reciprocal imitation training, and others). To determine what intervention is most appropriate, the behavioral clinician works with the family and child to determine which skills to target for development and maintenance and what goals are appropriate... A comprehensive ABA approach for younger children, also known as early intensive behavioral intervention, is supported by a few randomized controlled trials (RCTs) and a substantial single-subject literature... Children younger than 12 years receiving more hours per week of ABA were found to be more likely to achieve the individualized goals identified in their programs. In retrospective studies, more intense ABA therapy was associated with achieving optimal developmental outcomes."
While Lovaas went on to establish The Lovaas Institute—an organization in Los Angeles, California that he headed since its foundation in 1993 until his death, most of his graduate students have become quite flourished professionals in the field (many of whom formed their own practices).
Some graduate students of Lovaas' in the 1970s included Drs. Laura Schreibman and Robert Koegel. Together, they pioneered Pivotal Response Treatment (PRT) with Koegel's wife, Lynn, a speech pathologist and educational psychologist. The Koegels' also co-founded the Koegel Autism Center at the University of California, Santa Barbara (UC Santa Barbara, or UCSB) while Schreibman directs the Autism Intervention Program at the University of California, San Diego (UCSD).
Drs. Tristram Smith and Doreen Granpeesheh were Lovaas' senior supervisors in the late 1980s. Smith even co-authored the 1993 follow-up study alongside Lovaas and colleague Dr. John McEachin, who went on to co-found the Autism Partnership with another graduate student, Dr. Ron Leaf, and their main office is located in Seal Beach, California.
In 1990, Granpeesheh founded and currently runs the Center for Autism and Related Disorders (CARD), Inc., the nation's most enormous agency providing EBI services for children with ASD, which is headquartered in Los Angeles, California.
Shortly before becoming a big-name scientist in the field of ABA at the University of Rochester Medical Center (URMC), Smith designed the first replicated study—and only randomized control trial—on structured EIBI in 2000, which he conducted with Drs. Annette Groen and Jacquie Wynn, who were Lovaas' clinic supervisors during the time of the 1987 study, and Wynn now directs the Center for Autism Spectrum Disorders at Nationwide Children's Hospital in Columbus, Ohio. The study's experimental group was, however, limited to 25 hours per week instead of the original 40 hours implemented in the 1987 study, and only 27% striving were in mainstream classrooms.
Another randomized study on structured EIBI was published by Sallows and Graupner (2005)—which, similar to the 2000 study, it at least managed to randomly assignthe participants, but contrasted drastically, as this study's experimental group consisted of 35 hours per week. Although 48% of the experimental group were striving in mainstream classrooms, with most of the other children progressing in their IQ, speech, and daily living skills, literature reviews indicated that not all the participants in the study received DTT; some received other less intensive forms of ABA, such as PRT, which means it did not stay true to the treatment fidelity (Rogers & Vismara, 2008; Smith & Iadarola, 2015), but what the study did show is that when the form of ABA implemented was tailored to the child's learning style, the numbers were as high as the 1987 study.
A year later in 2006, among Lovaas' other leading graduate students from UCLA, the late Tristram Smith along with his colleagues at the University of Rochester Medical Center conducted the third replicated study—though not randomized, but employed for 35 to 40 hours per week—which only showed that 29% were the rapid learners and best outcome children; for the remaining 90%, the IQ—not the spoken language—scores were as high as the 1987 study (Cohen, Amerine-Dickens, & Smith, 2006).
However, four non-randomized comparison studies (Eikeseth et al, 2002, 2007; Howard et al, 2005; Waters et al, 2018) did reveal that children who received structured EIBI outperformed those undergoing non- ABA-based 'eclectic treatments,' including—but not limited to—traditional speech therapy (Myers & Johnson, 2007; Waters et al, 2018).
Another crucial detail: A recent 2018 Cochrane literature review (Brignell et al., 2018)—one of the largest, most reliable research databases—indicated that because of the heterology of ASD, we now have a wide range of different learning styles. They noted a recent study conducted by Paul et al. (2013) at the Yale Child Study Center, which revealed that young children on the autism spectrum with receptive language delays only acquire speech from DTT whereas those with expressive language delays learn faster from PRT—or the naturalistic, play-based form of ABA.
So, it is clear that the reason each current randomized comparison study on 25 hours per week of PRT had shown to be more effective in fostering speech than those who obtained the same hours per week of DTT is because most diagnosed have expressive—instead of receptive—language delays. Despite this, 30 to 40 hours per week of DTT is needed for the children with receptive language delays, and who are otherwise still distracted from their natural environment.
Since Lovaas' therapy is such an expensive treatment and there have only been three studies that used random assignment, a number of states—to the exclusion of Vermont, Connecticut, Wisconsin, and possibly others—view the research design limitations on EIBI as though it were a drug treatment (see Keenan & Dillenburger, 2011), and therefore, refuse to fund the necessary hours or treatment all together.
To add, many families—who cannot afford to pay the rather high costs of $60-$70 thousand annually—still have to win lawsuits against their school districts through the Individuals with Disabillities Education Act (IDEA), and even though the Federal Department of Education currently provides up to 40 hours per week of EIBI, many states do not cover either the treatment or necessary hours, where families are expected to pay for an attorney. Because of this, some are now relying on their health insurance plans, such as Medicaid, to obtain such services.
With regards to fully recovery from autism, such outcome occurs in approximately 25% of individuals (see Helt et al., 2008). Studies also reveal this 'optimal outcome' to occur among children who received 40 hours per week of EIBI as opposed to other modalities (see Dawson et al., 2012; Orinstein et al., 2014).
While some children do fully recover from the autism spectrum after a varying length of time—which is evident among individuals who were diagnosed at an early age by many well-trained clinicians before they no longer met any criteria for the disability (but continue to often have co-morbid attention issues and/or anxiety), it is crucial for parents to focus more on their child's learning potential.
Since there is no guarantee of fully overcoming ASD *(see note below), most individuals will continue to have the disability but gain new skills as they grow older—with some becoming quite flourished as adults (take Drs. Temple Grandin and Stephen Shore, as well as the young college student Jake Barnett, for example).
Nevertheless, it should be noted that some parents look at—and become involved in—treatment modalities outside of the ABA realm which lack scientific evidence and can be inefficacious as well as potentially fatal because of it (see Sinha, Silove, & Williams, 2006). The staff from these organizations often try to sell you their books and free parent testimonial videos and make false claims about their success rates and even guarantee 'miraculous cures' (i.e., see Williams & Wishart, 2003; Association for Science in Autism Treatment, 2010; Mruzek, 2012; Moran, 2014).
This is why parents—especially when they find themselves being emotionally vulnerable—should be cautious of such interventions and have their children involved in therapies that are vigorously studied and empirically validated. To date, high-quality ABA-based procedures are the only set of interventions with such reputation and evidence.
*Errorless Learning is a form of Discrete Trial Training (DTT) in which prompts and prompt-fading are used to prevent errors from occurring.
*Mand Training is a Verbal Behavior (VB) training procedure based on the verbal operant mand, or having the child request for something. It serves as the basis for such naturalistic ABA-based teaching procedure as Pivotal Response Treatment (PRT, sometimes branded as Incidental Teaching or Natural Environment Training).
*The term "fully overcome" (or sometimes "cure" or "recovery")—as written here—is used to describe the individuals who fully overcame the social communication and learning challenges without any changes occurring their physiology. For more information, see the Fein et al. (2013) study from the University of Connecticut.
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