Applied Behavior Analysis and Adults with Autism: Applications to Promote Competence and Quality of Life
Peter F. Gerhardt, Ed.D., Organization for Autism Research
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 two-five cases per 10,000 individuals (2.5 per 1,000) (DSM-IV, 1994); the figure most often cited today is approximately four-seven cases per 1,000 individuals with the higher estimate resulting in the one case per 150 individuals most recently identified by the Centers for Disease Control, 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 disorders (ASD) in general and, subsequently, of adolescent and young adult learners in particular 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 a 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 between 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- A pervasive and inaccurate belief that interventions based upon principles of applied behavior analysis (ABA) are no longer applicable to adolescent and adult learners.
Given even the challenges of this abbreviated list, it seems reasonable to argue that the potential of adults with ASD to become employed and engaged adults 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.
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, to 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 surprising 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 |
| 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 Sd |
| Providing reminders and reassurances | Prompting, shaping, and reinforcement |
So if the research exists, why are such potentially effective behavior analytic interventions not used 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 “since we don’t do DDT with adults we can’t be doing 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 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 five-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 trails 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. 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.
Now assume this same leaner is 16 years of age and instead of color discrimination, the instructional goal is independent purchasing of lunch at McDonalds. If the resources are available to provide direct community instruction just once every other week, it would take approximately 40 years for the same number of instructional opportunities to be presented as were necessary to acquire 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.
ABA and Quality of Life
Quality of life for persons with autism or other developmental disabilities is not a new concept to behavior analysis and should, in fact, be considered central to the socially valid application of behavioral interventions. Further, programming to promote a more positive quality of life is not contrary to active instruction and habilitative intervention (e.g. Bannerman, et al, 1990) and is perhaps best understood as complimentary to such instruction. As noted by Green, Gardner, & Reid, (1997) “ensuring that individuals experience enjoyment or happiness with certain aspects of their lives” (p. 217) should be a key concern for behavior analysts working with adults with complex learning and behavior challenges as increased measures of happiness if long term positive outcomes are to be realized.
Summary
As children with autism become adolescents with autism who become adults with autism, the instructional challenges become increasingly diverse and complex. And as behavior analysts we have an ethical obligation to our clients and their families to provide treatment and intervention that is research-based and, thereby, most likely to be effective in addressing these challenges. This can be accomplished in a number of ways including the use of a diverse cohort of behaviorally-based interventions (1) in a way that is congruent with the current research and (2) with sufficient response effort (i.e., instructional intensity) to result in significant and socially valid behavior change. Or, in real life terms, an improved quality of life.
References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington D.C.: Author.
Bannerman, D. J., Sheldon, J. B., Sherman, J. A., & Harchik, A. E. (1990). Balancing the right to habilitation with the right to personal liberties: The rights of persons with developmental disabilities to eat too many doughnuts and take a nap. Journal of Applied Behavior Analysis, 23, 79-89.
Ganz, M. L. (2007). The lifetime distribution of the incremental societal costs of autism. Archives of Pediatric and Adolescent Medicine, 161, 343-349.
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 outcome 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.
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 US special education. Pediatrics, 117, 1028-1037.
Sulzer-Azaroff, B., Mayer, R. G. (1991). Behavior Analysis for Lasting Change. Fort Worth, TX: Holt, Rinehart and Winston, Inc. Williams, K., Mellis, C., & Peat, J. K. (2005). Incidence and prevalence of autism. Advances in Speech and Language Pathology. 7, 31-40.