**4. ABA-based interventions for children with autism**

Behavioural interventions were first used to support individuals with mental illness or intellectual disabilities in state care in the late nineteenth century. For example, Fuller showed that physical movement (e.g., movement of the right arm) could be introduced to a previously totally non-responsive patient by contingent use of a positive reinforcer (e.g., sweetened milk) [19].

The functional analysis procedures originally detailed by Iwata and colleagues form the basis of good ABA practice and have been adopted widely and successfully to address many dif-

The term 'autism' has been attributed to the Austrian-American psychiatrist Kanner in the early 1940s, although individual cases had been described well before that time. While Kanner's work was written in English and has been recognised widely, his predecessor, the Swiss psychiatrist Bleuler, who coined the term 'autism', and his contemporary, the Austrian paediatrician Asperger, both writing in German, were virtually ignored. Asperger was eventually recognised when his writings were translated into English posthumously. Subsequently, the body of research grew until the diagnostic classification was formalised for the first time in 1980 in the Diagnostic and Statistical Manual of Mental Disorders (DSM-

The diagnostic category changed over time, from 'Pervasive Developmental Disorders' that including autistic disorder, Rhett's disorder, childhood disintegrative disorder, Asperger's disorder, and pervasive developmental disorder – not otherwise specified (PDD-NOS) in the DSM-IV-TR [12] to the single category 'Autism Spectrum Disorders (ASD)' in the DSM-5 [13]. The diagnosis of ASD is based on two symptom domains, i.e., impaired social/communication and restricted, repetitive behaviours, and three levels of support needs. Autism was recognised as a heterogeneous condition with many presentations, i.e., each person with autism

The exact causes of autism are unknown and are likely to concern genetic vulnerabilities coupled with environmental risk factors. It is likely that there are a variety of aetiologies that

Rising rates of autism are associated with increased costs to society and quality-of-life for individuals and their families. Autism prevalence rates in children in the USA have risen from 1 per 110 (0.90%) to 1:50 [15] and even higher prevalence rates have been reported in South Korea (2.64%) [16] and the United Kingdom (3.5%) [17]. The individual lifetime support cost for someone with autism is estimated between USA\$1.4 and USA\$2.4 million (UK£0.9-UK£1.5 million) depending on the level of support needs. Assuming a prevalence of 60% co-occurring intellectual disability, 'the total annual costs are £3.4 billion (USA \$5 billion) per year in the United Kingdom and \$66 billion per year in the United States' [18]. Effective interventions can

do much to ameliorate the situation for individuals with autism and their families.

Behavioural interventions were first used to support individuals with mental illness or intellectual disabilities in state care in the late nineteenth century. For example, Fuller showed that

**4. ABA-based interventions for children with autism**

ferent behaviours, including core indicators of autism.

III) [11].

12 Behavior Analysis

affected in different ways.

lead to a variety of 'autisms' [14].

**3. Autism: Aetiology, diagnosis and prevalence**

Fester [20] and Oppenheim [21] were among the first to utilise behavioural principles to teach new skills to individuals with autism; however, it was not until Lovaas utilised intensive behavioural interventions, mainly Discrete Trial Training (DTT) with young children with autism, that ABA-based procedures became popularised [22]. A follow-up report of the Lovaas et al. study evidenced the long-term maintenance of the gains that had been achieved with the children [23]. For many not familiar with the science of applied behaviour analysis, Lovaas' name became synonymous with ABA interventions for autism. However, Lovaas' studies have often been misinterpreted as an evaluation of a complete intervention system with little or no recognition of its basis in applied behaviour analysis. This kind of misinformation has led to the erroneous perception that Lovaas Therapy, Lovaas Programme, or Discrete Trial Training (DTT), are the same as the scientific discipline of ABA.

Many ABA-based interventions for children on the autism spectrum are conducted in the home, with parents as active partners [24]. Maurice [25], mother of two children with severe autism, was one of the first to recount how home-based intensive behavioural intervention resulted in her children's ability to be included in mainstream schools without additional supports.

Support groups and social media have played a key role in parental advocacy becoming a grass roots movement for rising autism awareness, demanding ABA-based interventions [26], and attaining relevant autism legislation. In the United States of America, Federal Government and States legislation in almost all states have dramatically improved the funding for behavioural interventions by requiring insurance carriers to provide coverage of ABA-based services. Individual State initiatives have also added to the endorsement, e.g., the State of Maine convened a task force to evaluate the educational interventions for autism as a means of determining appropriate State policy in the area. The task force, citing some of the key features of ABA, such as the use of observable goals, reliable data collection, and programme evaluation based on data evidence, declared behavioural interventions substantiated as effective. Similarly, the New York State Department of Health gave the highest rating to behavioural-based interventions [27]; the Kennedy Krieger Institute of Maryland [28] and Autism Speaks [29] are among many other agencies that promote the use of ABA-based interventions for the people with autism.

A non-exhaustive list of ABA-based interventions with empirical support as efficacious for use with individuals with autism spectrum disorders are briefly described below. For further detail on these and other behavioural methods shown to be effective for children and adults with autism, see the cited research.

ASD is a diagnosis of behaviour deficits in social-communication skills and behaviour excesses in restricted, repetitive behaviours [13]. These behaviours can challenge or disruptive other activities [30, 31], consistently across age groups [32, 33] and over time [33]. ABA-based interventions to support individuals who experience these challenges include functional behaviour assessment (FBA) and behaviour intervention plans (BIP) [34, 35]. Positive Behaviour Support (PBS) is probably the most widely used behaviour analytic, evidence-based intervention package use to support these individuals [36, 37].

Functional communication training (FCT) is an effective method of addressing communication problems [38]. FCT uses shaping procedures to build appropriate communication repertoires, thus reducing the need for non-functional communication efforts [39]. Similarly, picture exchange communication systems (PECS) can improve functional communication in people with autism [40] by using pictorial strategies in an augmentative communication system [41]. Pivotal response training (PRT) is a verbal response prompting methodology for teaching communication to students with autism [42]. Taken together these naturalistic behavioural approaches to the acquisition of verbal and/or vocal communication skills provide powerful interventions for individuals with autism [43].

provided by autism charities, rather than good quality scientific peer-reviewed journals. Evidently, misinformation about ABA on the internet abounds and this can lead to parents being dissuaded from scientifically validated interventions usually to the detriment of their child [52]. Even if they find accurate information about ABA-based interventions and want to utilise these in support of their child's skills development, implementing home and school programmes requires significant resources. In most of Europe there is no state funding and parents have to pay for ABA-based services themselves, or fight for a little bit of state funding

Applied Behaviour Analysis and Autism: Science, Profession, and Practice

http://dx.doi.org/10.5772/intechopen.75823

15

In the USA, nearly all States declared ABA-based autism interventions empirically validated and mandate Health Insurances to cover the cost [29]. Yet, although they are not permitted to do so, Health Insurers still try to avoid providing cover by considering autism as a pre-existing condition, a mental illness, or a long-term disability, rather than a neurological disorder. Others try to avoid cover by viewing ABA as 'experimental' or purely educational, rather than medically necessary or pointing to perceived disagreement in the literature, rather than welcoming the large body of evidence supporting ABA-based interventions for autism. At the same time, insurers are right to expect that services they cover are managed by an appropriately qualified professional. Board Certified Behaviour Analysts (BCBA) manage home-based

The Behaviour Analyst Certification Board (BACB) [54] verifies behaviour analytic training at Universities and sets the standards and examinations for Board Certified Behaviour Analysts (BCBA) internationally. Thus, it offers a certain level of consumer protection against those who claim to offer applied behaviour analytic interventions without adequate training. In addition, a number of States in the USA have introduced licensure for Board Certified Behaviour Analysts (BCBA) to improve practice standards and ensure insurance coverage.

The BACB is an accredited credentialing body (i.e., the National Commission for Certifying Agencies) and, although the organisation is based in the USA, it has world-wide reach. In fact, the European Association of Behaviour Analysis (EABA) endorses the credentials and offers information about European course sequences through its website. In Ireland, the Division of Behaviour Analysis (DBA) of the Psychological Society of Ireland (PSI) endorse the BACB

The number of BACB verified University programmes across Europe is growing. A full list of courses is available on the BACB webpage. Behaviour analysts are not regulated within European Union laws. The Czech Republic is the only country in Europe to legally regulate

There are four levels of professional BACB registration or certification, each with course work and supervised practice requirements and examinations. The Registered Behaviour Technician (RBT) is a pre-degree level qualification, while the Board Certified assistant

the profession of behaviour analysts, based on BACB standards [56].

as well as clinic and school-based services in applied behaviour analysis.

through the tribunal system [53].

**5. Behaviour analyst certification**

credentials [55].

Precision teaching (PT), focusing on accuracy and speed, i.e., fluency, of behaviour [44, 45], is used very effectively across behavioural and academic curricula as generalisation and maintenance of skills improve with fluency [45]. Other widely used ABA-based procedures include Direct Instruction, using instructional pacing to maintain student motivation, and coral responding, using scripted sequences thus allowing for high frequency of individual responses in large groups to gain and maintain curriculum-based knowledge [46].

With regards to educational interventions for children diagnosed with autism in jurisdictions outside of the USA, the support for ABA-based intervention has not always materialised despite the fact that Research Autism (UK) disseminates research evidence in favour of ABAbased interventions. Noticeably, ABA-based methods of autism support and education have been absent in official reports and, consequently, governments across Europe still support an 'eclectic' approach, rather than demanding scientifically supported interventions [47].

One of the key problems with an eclectic approach to autism interventions is that there is no consistent theoretical framework for the different interventions experienced by the children and thus potentially conflicting messages are propagated, staff training is necessarily inconsistent and training content rather variable, and the interventions are not evidence-based. In fact, Eikeseth and colleagues [48] compared an intensive behavioural programme with an eclectic approach in which both groups received one-to-one instruction for 28 h per week over the course of 1 year. The behavioural treatment group showed significant gains in IQ (i.e., an average of 17 points), language, and adaptive behaviours while the eclectic group showed only an average 4-point gain in IQ. Similarly, Howard and her team [49] reported significant advantages for the behavioural intervention group in the areas of cognitive, non-verbal, and communication measures in comparison to eclectic groups. Clearly, the potential inclusion of unsubstantiated or even hazardous interventions in an eclectic approach is problematical (e.g., facilitated communication and auditory integration training are still used despite evidence of ineffectiveness or even significant harm).

The contradictory reports across different jurisdictions are likely to have adverse effects as teachers and school administrators question the evidence status of different methodologies. Consequently, behavioural interventions may be implemented with less than recommended intensity, low levels of staff training, not at all, or as a part of an eclectic approach. At times it seems that opponents thrive on or even profit from misrepresenting the science [50].

In the absence of coherent and evidence-based guidance, parents educate themselves [51], relying on word of mouth, anecdotes from other parents, celebrity endorsements, and information provided by autism charities, rather than good quality scientific peer-reviewed journals. Evidently, misinformation about ABA on the internet abounds and this can lead to parents being dissuaded from scientifically validated interventions usually to the detriment of their child [52].

Even if they find accurate information about ABA-based interventions and want to utilise these in support of their child's skills development, implementing home and school programmes requires significant resources. In most of Europe there is no state funding and parents have to pay for ABA-based services themselves, or fight for a little bit of state funding through the tribunal system [53].

In the USA, nearly all States declared ABA-based autism interventions empirically validated and mandate Health Insurances to cover the cost [29]. Yet, although they are not permitted to do so, Health Insurers still try to avoid providing cover by considering autism as a pre-existing condition, a mental illness, or a long-term disability, rather than a neurological disorder. Others try to avoid cover by viewing ABA as 'experimental' or purely educational, rather than medically necessary or pointing to perceived disagreement in the literature, rather than welcoming the large body of evidence supporting ABA-based interventions for autism. At the same time, insurers are right to expect that services they cover are managed by an appropriately qualified professional. Board Certified Behaviour Analysts (BCBA) manage home-based as well as clinic and school-based services in applied behaviour analysis.
