Although consumers have many options when it comes to ASD interventions, one of the most researched evidence-based practice is applied behavior analysis (ABA).

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Effects of Applied Behavior Analysis on individuals with Autism ABSTRACT : Autism spectrum disorder impacts individuals through a wide range of physical, verbal and social behaviors. Presented with these challenges, individuals with ASD and their caregivers frequently seek out evidence-based practices to help with developing new skills and reduce inappropriate behaviors while promoting independence. Although consumers have many options when it comes to ASD interventions, one of the most researched evidence-based practice is applied behavior analysis (ABA). ABA is the professional use of behavior science principles based on the work of B.F. Skinner, J. B. Watson and others to teach and reinforce the acquisition of socially significant adaptive behaviors. The ultimate goal of ABA is that learners will be able to generalize functional skills and live independent lives to best of their abilities. In an effort to educate consumers of therapies for ASD, this paper provides a brief history of behavior analysis, an explanation of what constitutes evidence-based practice and focuses on describing a few of the most readily available ABA therapies that are recognized as evidence Œbased practices for the effects they have in the treatment of ASD. Key Words: Applied Behavior Analysis, Antecedent Behavior Consequence, Autism Spectrum Disorder Lisa McNiven, MPA in consultation with Patrick Blevins, MA, BCBA May 20th , 2016

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Table of Contents Introduction ––––––––––––––––––––––––––––––. 2 Description of Autism Spectrum Disorder..––––––––––––––––2 Description of Applied Behavior Analysis (ABA)––––––––––––3 What are Evidence-Based Interventions?. ––––––––––––––5 Evidence-Based ABA Interventions. . 6 Antecedent Interventions –––..––––––––––––––––––––..10 Prompting ––––––––.––––––––––––––––11 Environmental Modification.––––––––––––––––..11 Time Delay (TD) –––––––––––––––––––––– 11 Task Analysis and Chaining–––––––––––––––––11 Visual Schedules (VS).–––––––––––––––––––..11 Behavior Interventions ––––––.––––––––––––––––––.12 Differential Reinforcement––––––––––––––––––12 Discrete Trail Training (DDT)– ––––––––––––––– ..12 Extinction (EXT).. ––––––––––––––––––––– –12 Functional Communication Training (FCT) –––––––––12 Other Common Evidenced-Based ABA Practices–––––––––––––.13 Pivotal Response Training (PRT) ––––––––––––– .13 Visual Supports (VS)–..–––––––––––––––––––13 Self-Management (SM).–––––––––––––––––––.13 Evidence of ABA Effectiveness––––––––––––––––––––––13 Limitations of Research–––––––––––––––––––––––––.15 Conclusion–––––––––––––––––––––––––––––––.16 References–––––––––––––––––––––––––––––..19 1

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Introduction The purpose of this paper is to identify the most current effects of applied behavior analysis on the process of teaching new skills as well as reducing problem behaviors that may be exhibited by individuals with autism spectrum disorder. A quick internet search results in over sixteen million resources related to applied behavior analysis and the positive effects this science has on the treatment of ASD (Smith, 2013). Applied behavior analysis is a science that is practiced by credentialed professionals who follow fithe process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improve ment in behaviorfl (Baer, Wolf and Risley, 1968). Based on this methodology, ABA is a discipline that includes many different specific strategies. Description of Autism Spectrum Disorder In 1942, child psychiatrist Leo Kanner wrote a paper describing eleven children who demonstrated no apparent affect and who seemed drawn into a shell and lived within themselves. He chose to describe these individuals as having autism which means fiselffl in Greek (Matson and Neal 2009). Kanner™s paper opened a door to providing supports, services and treatment for individuals with autism. As defined by the Individuals with Disabilities Education Act (IDEA, 2004), Autism is a developmental disability that significantly affects verbal and nonverbal social interactions and may include issues with executive processing and stereotypic/repetitive behaviors. Newly defined in 2013 by the American Psychiatric Association (DSM -5), Autism spectrum disorder incorporates the following diagnoses into one: autism, autistic disorder, Asperger™s, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified) (Herold et al. 2012). ASD may be evident before the age of three (Educator Guidelines, 2009). According to the CDC, within the last decade, the incidence of autism have increased from 4 to 5 children per 10,000 to 6-7 children per 1000 (Rice, 2007). 1 in 68 children are currently being diagnosed with ASD. There is no definitive consensus within the professional community (CDC, 2015) to explain the increasing incidence of individuals diagnosed with ASD but the re is naturally a skyrocketing interest in providing evidence-based educational supports and services. One of the most researched sciences that produces effective evidence -based interventions for the treatment of ASD is applied behavior analysis. 2

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Description of Applied Behavior Analysis (ABA) As described by the national science and advocacy organization Autism Speaks, applied behavior analysis is based on the science of learning and behavior, and utilizes general filawsfl pertaining to how behavior works and how learning takes place in an enviro nment. Furthermore the Autism Speaks publication: Applied Behavior Analysis: A Parent™s guide, (2012) stated fiABA therapy applies these laws to behavioral treatments in a way that helps to increase useful or desired behavior. ABA applies these laws to help reduce behaviors that may interfere with learning or behaviors that may be harmful. ABA is used to increase language, communication skills, improve attention, focus, social skills, memory and academics as well as to decrease problem behaviors.fl Many consumers are surprised to hear that ABA is based on a psychological science that is over 100 years old. The modern field of applied behavior analysis traces its beginning to 1968 with the publication of the first copy of the Journal of Applied behavior Analys is and specifically the article fiSome Current dimensions of Applied Behavior Analysisfl by Baer, Wolf, and Risley (1968). This paper briefly describes the seven principles that guide all evidence – based applied behavior analysis practices. These core guideli nes include: applied, behavioral, analytic, technological, conceptually systematic, effective, and generalized outcomes. Seven dimensions of Applied Behavior Analysis Applied The work conducted must have social significance Behavioral Precise and reliable measurement of behavior should be attainable Analytic It must be shown that the treatment led to behavior change, and not something else, such as chance Technological Procedures used should be clearly described and identified Conceptually syst ematic Procedures should be described in terms of their principles Effective Procedures should improve the behaviors being addressed to a practical degree Generalized Positive changes should extend over time, environments, and behaviors Source: T. Meadows 2011 3

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The first princ iple described by Baer, Wolf, and Risley (1968) that guides the practice of applied behavior analysis is that interventions are applied to solve real life, socially significant issues and promote independence for the consumer. The second principle is that interventions are based on observable behavior . Within ABA, behavior is considered to be anything that humans do. This idea includes thoughts, feelings and , of course , actions. Applied behavior analysis is concerned about the specific observable behavior that is highlighted for change and behavior that can be measured by an observer through evidence. Careful measurement is arguably the ma in focus of behavior analysis and the reason why ABA interventions involve taking large amounts of data. The next principle of evidence -based behavior analysis is the idea that interventions are analytic . This very scientific sounding word means that the professional who uses an ABA intervention can prove through experimentation that what they say is causing a change in behavior is actually doing so. In other words, that there is enough evidence that a pa rticular ABA based intervention works and that change in behavior happened as a direct result of the intervention and not something else. Another core guideline of the science of ABA is that it is technological. This does not mean that those who practice A BA interventions always use computers or IPads but rather that interventions are designed in such a way that any other ABA professional can repeat it and get the same or nearly the same results. Conceptually systematic is the idea that to make an intervention meet the criteria of ABA it must be based on the psychology of behaviorism. The final two guidelines for the practice of ABA include that interventions are effective and can be generalized . Of course, consumers of treatments for ASD want these interventions to work but ABA requires observable evidence that there has been a socially significant change in behavior before an intervention can be called a success. Generality is the idea that although skills may be successfully taught to an individual with ASD in one setting (such as washing their hands in their home or saying fihifl to a friend), an intervention is only truly successful when the same individual can use the skill in many different settings or with many different social interactions (such as washing their hands at school and a restaurant, and saying fihifl to many friends and relatives.). This is the ultimate goal of all evidence-based ABA interventions for individuals with ASD. Applied behavior analysis has many specific treatment effects and can be implemented to increase language, functional communication skills, improve attention, social skills, memory and well as specific academic skills as well as to decrease problem behaviors (Autism Treatment Network , 2012). ABA interventions are not limited to individuals with Autism spectrum disorders. fiABA has become recognized as the treatment of choice for behavior problems associated with mental retardation ( intellectual disab ility ), brain injury, and other disordersfl (Axlerod, McElrath and Wine, 2012). ABA services are flexible 4

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and are not limited to one format or age group. They may be used by highly trained professionals in various environments including classrooms, homes, community centers, group homes, and employment settings among others. Although practice of ABA is a specifically trained science, practitioners regularly enlist and train parents and caregivers to actively participate in interventions. With specific training, parents and caregivers frequently help with collecting data or even administer interventions directly. With fifty years of research behind it, and comprehensive training protocols for practitioners, the science of ABA is widely recognized as an effective evid ence-based practice by the Centers for Med icare and Medicaid Services (CMS), the National Autism Center (NAC), and the National Professional Development center on ASD (NPDC) for the treatment of individuals with ASD. What are Evidence -Based Intervention s? There are many different types of interventions that are based on the principles of applied behavior analysis which use the concept of understanding and modifying behavior in the context of the environment. In order to determine which approach or intervention is considered evidence -based it is important to define exactly what evidence-based means. The Ohio Employment First, Evidence -based Practices for Transition Youth (2015) defined evidence-based practice to be: fiInstructional methods and strategies proven through research to be effectivefl. fiUse in a variety of settings, such as classrooms, work sites, community environments, social settings, etc.fl fiUseful to teach a variety of skills, such as those associated with employment, daily living, communication, academics, job-routines and tasks, independence, and workplace behavior.fl Additional criteria for what constitutes evidence-based interventions is described by the University of North Carolina, Autism Evidence-Based Practice Review Group (Wong et al., 2014) and are consistent with the criteria described by the National Professional Developmental Center on Autism Spectrum Disorder (NPDC), and the National Autism Center (NAC): fiAt least two high quality experimental or quasi-experimental group design articles.fl 5

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interventions that are considered as having ABA modality. There is no single intervention that is effective for every individual diagnosed with ASD. Each intervention is fundame ntally based on the needs of an individual consumer, their caregivers, and the ir family. Evidence-based interventions are mandated by law in educational settings (IDEA 2004), however, the interventions identified here have been shown to be effective in many settings, including schools, homes, and the community at large. This paper f ocuses on describing the following common evidenced-based ABA practices: antecedent interventions (including: prompting, and environmental antecedent modifications, and time delay), behavior interventions (including: visual schedules, differential reinforc ement, discrete trial training, extinction, and task analysis) as well as pivotal response training, functional communication and self -management. In addition, this report briefly describes the following core practices of ABA: Stimulus Control (Sds), Positive Reinforcement (R+), the three term contingency (Antecedent, Behavior, and Consequence), and Functional Behavior Assessment (FBA). Comprehensive ABA interventions focus on teaching (reinforcing) individuals to react to stimuli in an environment in a w ay that has functional, productive meaning for the individual and society (Schoen, 2003). The environment refers to everything observable through the senses that is present in given place and time. A stimulus is something particular that is present in the environment that causes a reaction in the senses (Kearney, 2015). Stimulus control refers to a change in the environment that consistently produces specific behavior. In other words, it is the signal to a learner that a particular behavior should be performed at a given place and time. This concept is crucial to ABA interventions and learning in general. For example, stimulus control is the idea that a student is taught to raise their hand . The student does this only in the presence of a teacher and is rei nforced socially for doing so. The student will not be reinforced for raising their hand in environments and situations where there is no instructor (i.e. no opportunity to be called on by an adult) nor will they be reinforced for talking before raising th eir hand (blurting out answers, shouting, etc.). When the learner can consistently identify that they should raise their hand to get a teacher™s attention (to ask for help, or answer a question) hand raising is said to be under stimulus control. The concept of positive reinforcement is also at the core of all ABA practices. As described by the NPDC: fiReinforcement is a foundational practice that is used with other evidence -based practices. Reinforcement describes the relationship between learner behavior and a consequence that follows the behavior. This relationship is reinforcing only if the consequence increases the likelihood the learner will perform the skill or behavior in the futurefl (AFIRM, 2015). Positive reinforcement of correct responses is what the practitioner (or teacher, or parent) does to fiteachfl. Behavior or filearningfl happens when correct responses are reinforced and incorrect responses are not. For example, a student who consistently tantrums and refuses to complete an acceptable task may be taught the replacement behavior of asking for a break. 7

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Asking for a break serves the same function as shouting and throwing an assignment on the floor (escaping the task) but in a manner that is socially acceptable. The student is then positiv ely reinforced for asking for a break appropriately using the mode of communication that works best with the current abilities of the student (e.g. verbally stating: fibreakfl, pointing to or retrieving a fibreakfl card or icon) and not reinforced for engaging in tantrums. There are many ways to go about teaching communication depending on the needs of the individual student but the contingency is usually the same processes and the skills can be shaped over time to be as effective as possible in all settings. ABA interventions incorporate what is referred to as the three term contingency, which is described as the ABC™s of behavior. When practitioners talk about the three term contingency they are referring to an environmental antecedent (A), an observable behavior (B), and an environmental change or consequence (C). An antecedent (A) refers to what is present or has occurred in the environment immediately before a behavior . (In our asking for a break example, a teacher gave the student a worksheet or wrote the problem on a board). Observable behavior (B) seems like an easy concept but it is one that is frequently confused and when inaccurately described weakens interventions. Remember that practitioners of applied behavior analysis are concerned with behavior that we can directly observe and measure. In our example the observable behavior of the student exhibited a tantrum as soon as the task was presented. The tantrum may have included shouting, throwing materials, etc. and this specific behavior is what is recorded exactly as it was observed. Finally, a consequence (C) refers to what happened in the environment immediately after the behavior. In our example, the teacher may have withdrawn the task completely or presented it again and the student™s behavior might have correspondingly ended or restarted depending on its function. It is important to note that within ABA terminology, consequence does not automatically refer to punishment. Source: Neitzel, 2010 8

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Many individuals with autism spectrum disorder exhibit challenging behaviors. A core component of ABA practices is to try and find the function of problem behavior (i.e. what someone wants to get or get out of) and develop an intervention based on that function. There are four generally accepted func tions of behavior described in ABA research: social attention, escape from a task or stimulus, access to a tangible, and automatic reinforcement (reinforcement that is not mediated by another person) (Carr and Durand, 1985). Practitioners of ABA frequently use a Functional B ehavior Assessment (FBA) to determine what an individual wants or wants to get out of. Conducting a FBA is a crucial step in the process of developing effective interventions replace the function of challenging behavior with appropriate alternatives. Th e focus of an FBA is to look at the contingencies maintaining a given behavior. Once the contingencies that maintain a behavior have been identified and function of a behavior has been assessed, specific evidence-based interventions can be utilized to teach and reinforce replacement behaviors that serve the same function as the problem behavior. These interventions may benefit Individuals with ASD in the following ways (ABA Resources: What is ABA, 2000): Increase behaviors (e.g. reinforc ement procedures increase on Œtask behavior, or social interactions). Teach new skills (e.g. systematic instruction and reinforcement procedures teach functional life skills, communication skills, or social skills). Maintain behaviors (e.g. teaching self-control and self-monitoring procedures to maintain and generalize job related social skills). Generalize or to transfer behavior from one situation or response to another (e.g. from completing assignments in the resource room to performing as well in the mainstream classroom). Restrict or narrow conditions under which interfering behaviors occur (e.g. modify). Reduce interfering behaviors (e.g. self-injury or stereotypy). Evidence-based ABA practices highlighted in this report were included based on their prominence in literature and are likely to be encountered by consumers seeking ABA . The following interventions have been subjected to peer review and were identified as being evidence -based by four main agencies including: National Professional Development Center (NPDC), Centers for Medicare and Medicaid Services (CMS), National Standards Project (NSP), and the Agency for Healthcare Research and Quality (AHRQ): 9

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1) Antecedent Interventions which include the following: a. Prompting b. Environmental Modification c. Task Analysis (TA) and Chaining d. Time Delay (TD) 2) Behavior Interventions which include the following: a. Differential Reinforcement b. Discrete Tria l Training (DTT) c. Extinction (EXT) d. Functional Communication Training (FCT) Also included in this report are the evidence-based practices of: e. Pivotal Response Training (PRT) f. Visual Supports (VS) g. Self-Management Antecedent Interventions According to Matson and Neal (2009) in their paper, Applied Behavior Analysis for Children with Autism Spectrum Disorders, antecedent intervention is used to shift from a focus on response -reinforcement relationships to approaches that focus on manipulating the antecedents relevant to target behavior. In ot her words, changes to the environment change behavior. Wong et al (2014) stated that an antecedent package is an intervention that includes a variety of modifications that are made to the environment/context in an attempt to change or shape a student™s beh avior. Types of modifications to the environment include the schedule, activities, access to additional instruction or materials, and can be used effectively to address social, communication, behavior, play, school – readiness, academic, motor, and adaptive skills. Intervention techniques include prompting, environmental modification, time delay and visual schedules. 10

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