Newsletter
Volume 30 | 2007 | Number 3
Home-Based ABA Programming for Young Children with Autism
By Dr. David Celiberti, President of Association for Science in Autism Treatment
A significant number of young children diagnosed with autism receive ABA programming in their homes, particularly prior to the age of 3. Many children, ages 3-5, receive at least some programming at home. There are a number of children who continue to receive home-based programming even after entering public school. This paper will address a few issues surrounding ABA programming in the home; however, other important topics such as training of staff and parents, environment set up, material utilization, characteristics of quality providers, and transition planning, as well as a review of the available research, are beyond the scope of this short paper. As many readers are aware, a subset of the behavior analytic research involves home-based intervention (e. g., Anderson, Avery, DiPietro, Edwards, & Christian, 1987; Birnbrauer, & Leach, 1993; Green, Brennan, & Fein, 2002; Lovaas, 1987; Luiselli, Cannon, Ellis, & Sisson, 2000; Smith, Groen, & Wynn, 2000; Weiss, 1999). Moreover, additional studies describing center-based intervention delivery have incorporated some component of home-based intervention. Further research is needed to examine various levels of intensity, duration, and other treatment parameters and systematically compare outcomes between home-based and center-based models controlling for particular variables that may confound the results.
Potential Role of Parents
Parents of children with autism, particularly in this past decade, have proven to be incredible advocates and bring to the table a level of sophistication that is unprecedented. A number of newly created, center-based ABA programs have been founded or co-founded by parents. Parents can inform the initial and ongoing selection of potential reinforcers and treatment targets and play an active role in the acquisition of language, social, self help, leisure, and community skills. Parents clearly possess familiarity with their children’s behavior across settings. Parents can actually enhance outcomes by employing methods consistently, exposing the child to novel stimuli, using time-delay procedures, incidental teaching, and least-to-most prompting hierarchies when warranted.
Parents involved in home-based programming may benefit from: 1) developing a working understanding of behavioral terminology (visit www.asatonline.org and www.pppsig.org for helpful resources); 2) communicating concerns carefully, efficiently, and discussing problems as soon as they arise; 3) sharing information on their culture and family dynamics when warranted; 4) requiring data-driven decision making from all providers; and 5) being forthright about obstacles that impede consistency and carry over, as well as participation in alternative treatments.
Sibling Considerations
It is critically important for teams to consider both the impact of home programming on siblings and potential roles that siblings may serve. Siblings may represent widely available, easily accessible, and highly motivated resources for the professional providing home-based ABA and can serve as excellent models of age-appropriate play, social, and communication skills for the child with autism. Common challenges related to home-based ABA may include: 1) Siblings may become resentful of the child with autism due to level of attention (and reinforcement) from providers in the home; 2) Siblings may be concerned and/or upset by witnessing maladaptive behaviors, particularly those that are escape motivated; 3) The need for structure and minimal distraction may pose some restrictions on the siblings’ play date opportunities or where or how they may be allowed to play within their homes; and 4) Children with autism may exhibit behaviors that either extinguish or in some instance punish the initiations of siblings.
Intervention as Early as Possible
The National Research Council recommends that children enter into intervention programs as soon as an autism spectrum diagnosis is seriously being considered (National Research Council, 2001). Without appropriate intervention, there can be a compounding of communication and social deficits over time and maladaptive behaviors can become easily entrenched and treatment resistant. Multiple benefits exist with effective early intervention which can include better long term prognosis, broader range of vocational possibilities, better quality of life for child and family, and reduced financial expenditures and allocation of special education resources (e.g., Jacobson, Mulick, & Green, 1998).
Commitment to Empirically Validated Treatments
As mentioned earlier, parents are exposed to a dizzying array of treatment options (e.g., Celiberti, Buchanan, Bleecker, Kreiss, and Rosenfeld, 2004). Additionally, the media bombards the public with treatments that lack empirical support. Multidisciplinary, independent reviews of research on the array of autism treatments using an evidence-based approach have been conducted by a few states' task forces and have acknowledged the very strong scientific basis to ABA (e.g., New York State Department of Health, Maine’s MADSEC). Furthermore, it is important to note the emergence of research demonstrating that eclectic approaches do not fare as well as more intensive, pure ABA approaches (Eikeseth, Smith, Jahr, & Eldevik, 2002; Howard, Sparkman, Cohen, Green, & Stanislaw, 2005).
Staffing
There is considerable variability in the size and composition of teams that provide home-based ABA. In some cases, individual instructors are provided, trained, and supervised by an agency. In other cases, parents are responsible for recruiting, interviewing, and managing their child’s instructors. Much of this is a function of funding sources and service delivery models that differ from state to state, as well as within a state.
Certain caveats should be considered with respect to the number of instructional agents. Children who receive the bulk of their intervention from only one or two providers may struggle with generalization across instructors. The sudden departure of an instructor can be disruptive and may provoke a regression in skills. On the other hand, teams that are too large may be extraordinarily difficult to manage clinically or administratively. With too many instructors, there is less opportunity to develop proficiency given fewer numbers of hours of contact and more potential for inconsistencies across instructors.
Unfortunately, many parents must assume the arduous task of securing oversight for their child’s home-based ABA program. Many do this with little understanding of the necessary credentials and experiences to carry out this treatment approach effectively. The Behavior Analyst Certification Board credentials behavior analysts (see www.bacb.com). Although this credential can provide some safeguards for consumers, consumers must recognize that certification in behavior analysis does not mean that the provider possesses competence in the delivery of behavior analytic service to persons with autism or is able to oversee home-based programming. Fortunately, the Autism SIG has undertaken the complex, yet critical, task of providing consumers with some guidance regarding how to select a behavior analytic service provider. The current version of guidelines can be found on the ABA Website.
Related service providers, such as speech-language pathologists and occupational therapists, are actively involved in home-based ABA programming. Many of these providers are familiar with and supportive of ABA, whereas others are opposed to ABA and widely practice interventions that have not been scientifically validated. In the later instances, parents may be confused and troubled by the mixed messages that they would be receiving. Requiring all providers to generate objective methods to assess outcomes, to be guided by research published in peer-reviewed journals, and to engage in data-based decision making is essential. Ideally, the delivery of related services would incorporate the effective use of reinforcement, appropriate levels of structure and consistency as warranted, and a data collection system to measure progress.
Goal Selection Considerations
The National Research Council emphasizes the need to target engagement, flexibility, spontaneity, and independent organizational skills. It is critical that the core deficits of autism exhibited by an individual child with autism be adequately addressed. These may include, although not be limited to: communication difficulties, limited play skills, deficits in social relatedness, behavioral inflexibility, limited spontaneity, difficulty with relationship formation, and poorly developed “learning to learn” skills. The emphasis should be on skills that will maintain over time and will lead to the student’s success and “marketability” in future settings. Prerequisite and foundation skills should be emphasized as they may help the child with autism potentially learn from less-intensive teaching methods. With an eye toward the Least Restrictive Environment (LRE), home programs should consider the multiple struggles that diminish capacity to learn in larger groups. This is important in that larger group sizes typically afford fewer learning opportunities with less repetition and intensity. Therefore, skills that may promote greater success in larger group settings must also be targeted systematically.
Evaluation of Treatment Effects
As is the case with children receiving services in center-based programs, children with autism in home-based programs deserve prompt and effective assessment, analysis, and troubleshooting. Data should guide decision making and be translated into timely adjustments in programming. The full array of skill acquisition and behavioral-reduction efforts need to be evaluated through systematic review of data. Performance criteria and behaviors targeted for reduction should be objectively defined and these definitions must be made explicit. IOA data should be collected periodically to ensure consistency and treatment fidelity.
Supervisors/consultants should socialize and educate the home-based team about the importance and role of data. Members of the home-based team should be trained in data collection and their data collection efforts should be monitored. It is important that there be reasonable expectations about the amount of data collection and that existing barriers to reliable and valid data collection be addressed.
References
Anderson, S. R., Avery, D. L., DiPietro, E. K., Edwards, G. L., & Christian, W. P. (1987). Intensive home-based early intervention with autistic children.
Education and Treatment of Children, 10, 352-366. Birnbrauer, J. S., & Leach, D. J. (1993). The Murdoch Early Intervention Program after 2 years. Behaviour Change, 10(2), 63-74.
Celiberti, D., Buchanan, S., Bleecker, F., Kreiss, D., & Rosenfeld, D. (2004). The road less traveled: Charting a clear course for autism treatment. The Oracle, http://www.researchautism.org/uploads/roadless.pdf
Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral treatment at school for 4- to 7-year-old children with autism: A 1-year comparison controlled study. Behavior Modification, 26, 49-68.
Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G., & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic treatments for young children with autism. Research in Developmental Disabilities, 26(4), 359-383.
Jacobson, J. W. (2000). Early intensive intervention: Emergence of a consumer-driven service model. The Behavior Analyst, 23(2), 149-172.
Jacobson, J. W., Mulick, J. A., & Green, G. (1998). Cost-benefit estimates of early intensive behavioral interventions for young children with autism: General models and single state case. Behavioral Interventions, 13, 201-226.
Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.
Luiselli, J. K., Cannon, B. O., Ellis, J. T., & Sisson, R. W. (2000). Home-based behavioral interventions for young children with autism/pervasive developmental disorder: A preliminary evaluation of outcome in relation to child age and intensity of service delivery. Autism, 4, 426-438.
MADSEC Autism Taskforce. (1999). Executive summary. Portland, ME: Department of Education, State of Maine.
National Research Council (2001). Educating children with autism. Washington, DC: National Academy Press.
New York State Department of Health Early Intervention Program (1999). Clinical practice guideline quick reference guide: Autism/Pervasive developmental disorders-- Assessment and intervention for young children (Age 0-3 Years). Health Education Services, P.O. Box 7126, Albany, NY 12224 (1999 Publication No. 4216).
Smith, T., Groen, A. D., & Wynn, J. W. (2000). Randomized trial of intensive early intervention for children with pervasive developmental disorder. American Journal on Mental Retardation, 105, 269-285.
Weiss, M. (1999). Differential rates of skill acquisition and outcome of early behavioral intervention for autism. Behavioral Interventions, 14, 3-22.