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Scientific Support for Applied Behavior Analysis
Over the past 40 years an extensive body of literature has documented the successful use of ABA-based procedures to reduce problem behavior and increase appropriate skills for individuals with intellectual disabilities (ID), autism, and related disorders. The literature consists of numerous controlled studies employing single-case experimental designs, consecutive controlled case-series studies, controlled group studies, and some randomized controlled trials.
Types of Research Designs
A number of different research designs are used to evaluate treatments and answer other questions about treatment procedures. Each type of design has its own scientific and practical strengths and limitations, and each is ideally suited to answer particular types of questions are discussed further here.
Findings from Controlled Studies Employing Single-Case Experimental Designs
Small-n Controlled Studies.
Over a thousand studies reporting on ABA-based assessment and treatment techniques have been published since the 1960’s. As noted above, these controlled studies have strong internal validity as they use experimental designs that permits one to conclude that the intervention was responsible for the change in behavior. Studies on topics relevant to the use of ABA with persons with intellectual and developmental disabilities are most frequently published in journals such as: Behavioral Interventions, Journal of Applied Behavior Analysis, Journal of Autism and Developmental Disorders, Journal of Intellectual Disability Research, Research in Developmental Disabilities, Research in Autism Spectrum Disorders. Topics of these studies include communication training, social skills training, behavioral assessment and treatment of problem behavior (self-injury, aggression), educational instruction, early intensive behavioral intervention, etc. For further information, the reader is referred to these journals or to an on-line search engine (i.e., PsychINFO, Google Scholar).
Consecutive Case Series Studies.
As noted above, consecutive controlled case-series studies describe a series of cases where single-case experimental designs were used with all individuals encountered (regardless of whether the treatment was effective or not).
Functional Analysis of Problem Behavior.
As noted above, focused ABA interventions for problem behavior are designed for each individual based on an understanding what antecedents that may “trigger” problem behavior, and what consequences that may reinforce it. Functional behavioral assessment can be performed using a range of procedures, including interviews, questionnaires, direct observation in the individuals natural setting, and the use of structured conditions where environments are simulated in the clinic setting (termed “analog” conditions). This latter type of procedure, functional analysis, is the most rigorous type of functional behavioral assessment. It involves the use of analog conditions designed to test hypotheses while behavior is precisely recorded, typically using computerized data collection. In most cases, the results can reveal why problem behavior occurs and persists – and thus provides a foundation for focused interventions targeting these behaviors.
Literature reviews by Hanley, Iwata, and McCord (2003) and Beavers, Iwata, & Lerman (2013) collectively identified 435 peer-reviewed articles where functional analysis of problem behavior was reported. Studies listed below represent large-scale consecutive controlled case series studies involving functional analysis. These studies demonstrate that functional analysis is highly effective in identifying the controlling variables for problem behavior.
Iwata, Pace, Dorsey, Zarcone, Vollmer, Smith et al., 1994
Assessment: Functional analysis across a variety of settings (inpatient, residential)
Participants: 154 cases
Results: Conclusive results in over 90% of cases
Mueller, Nkosi, & Hine, 2011
Assessment: Functional analysis in school settings
Participants: 69 cases
Results: Conclusive results in over 90% of cases
Hagopian, Rooker, Jessel, & Deleon, 2013
Assessment procedure: functional analysis of severe problem behavior
Participants: 176 cases with severe problem behavior
Results: Conclusive results in over 90% of cases
ABA-Based Focused Treatment for Problem Behavior.
As noted in section 1.2.1 above, studies employing rigorous single-case experimental designs describing ABA focused interventions for problem behavior have been reported for four decades. The following large-scale consecutive controlled case series studies provide further support for the effectiveness of these interventions. Findings from these studies parallel findings from reviews and meta-analysis of small-n studies.
Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998
Treatment: Functional communication training for treatment of problem behavior
Participants: 19 inpatient cases with IDD
Results: 80% or greater reduction in problem behavior in 90% of cases
Asmus, Ringdahl, Sellers, Call, Andelman, & Wacker, 2004
Treatment: Function-based treatment for severe problem behavior
Participants: 138 inpatient cases with IDD
Results: 90% or greater reduction in problem behavior in over 83% of cases
Kurtz, Fodstad, Huete, & Hagopian, 2013
Treatment: Functional-based treatment delivered by care providers (mostly parents) for severe problem behavior
Participants: 42 outpatient cases with IDD
Results: 80% or greater reduction in problem behavior in 95% of cases
Rooker, Jessel, & Kurtz, 2013
Treatment: Functional communication training for treatment of severe problem behavior
Participants: 50 inpatient and outpatient cases with IDD
Results: 80% or greater reduction in problem behavior in 86% of cases
Broadly speaking, review papers summarize the published literature on a specific topic (i.e., diagnosis, type of assessment or treatment procedure). The reader is referred to recent reviews on comprehensive and focused ABA-based interventions for problems associated with Autism:
|Dawson & Bruner, 2011||Early Intensive Behavioral Intervention (EIBI) for ASD|
|Lang et al., 2010||Treatment of anxiety in ASD|
|Reichow & Volkmar, 2010||Social skills training for ASD|
|Myers & Johnson, 2007||Management of ASD|
|Anderson et al., 2012||Elopement in ASD|
|Doehring et al., 2013||Severe problem behavior in ASD|
Recent reviews on ABA-based procedures for persons with intellectual and developmental disabilities (IDD):
|Brosnan & Healy, 2011||Treatment of aggression in IDD|
|Lang et al., 2009||Treatment of elopement in IDD|
|Lillenfield, 2005||Psychiatric disorders in IDD|
|Sturmey, 2002||Psychiatric disorders in IDD|
|Kahng et al., 2002||Treatment of self-injurious behavior|
|Hanley et al., 2003||Functional analysis of problem behavior|
|Tiger et al., 2008||Functional communication training for problem behavior|
Review articles indicating that treatments for autism and intellectual disability derived from ABA-based procedures are empirically supported treatments also have been published in non-behavioral journals. For example, the journal Current Opinion in Psychiatry is a journal designed to assist clinicians and researchers by synthesizing the psychiatric literature. An article which reviewed the assessment and treatment of individuals with intellectual disabilities and psychiatric disorders concluded that: "Interventions based on applied behavior analysis have the strongest empirical basis, although there is some evidence that other therapies have promise" (Sturmey, 2002, p. 489). Also, in the journal Pediatrics, the official journal of the American Academy of Pediatrics (AAP), an article offering guidelines on scientifically supported treatments for childhood psychiatric disorders concluded: "The most efficacious psychosocial treatment for autism is applied behavior analysis" (Lilienfeld, 2005, p. 762). The AAP issued a Clinical Report in Pediatrics regarding the management of children with autism, and where the authors noted: “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.” (Myers, & Johnson, 2007, p. 1164). In the Archives of Pediatric and Adolescent Medicine, Barbaresi et al. (2006) concluded, “ABA should be viewed as the optimal, comprehensive treatment approach in young children with ASD.”
Review papers finding support for ABA can be found in the following non-behavioral journals:
- Current Opinion in Psychiatry (Grey & Hastings, 2005; Sturmey, 2002)
- Scientific Review of Mental Health Practice (Herbert, Sharp, & Gaudiano, 2002)
- American Journal on Mental Retardation (Kahng, Iwata, & Lewin, 2002)
- Psychiatric Times (Erickson, Swiezy, Stigler, McDougle, & Posey, 2005)
- Archives of Pediatric and Adolescent Medicine (Barbaresi, Katusic, & Voigt, 2006)
- Child and Adolescent Psychiatric Clinics of North America (Doehring, Reichow, Palka, Phillips, & Hagopian, 2014
In general, meta-analysis involves quantitative re-analysis of data reported in published studies. This requires standardizing treatment outcomes by statistically calculating “effect sizes” obtained within each study, for the purpose of evaluating data obtained across a group of studies on a particular treatment.
Similarly, seven meta-analyses (Campbell, 2003; Didden, Duker, & Korzilius, 1997; Harvey, Boer, Meyer, & Evans, 2009; Heyvaert, Maes, Van den Noortgate, Kuppens, & Onghena, 2012, Lundervold & Bourland, 1988; Ma, 2009; Weisz, Weiss, Han, Granger, & Morton, 1995) that collectively analyzed hundreds of studies concluded that ABA-based procedures were more effective for reducing problem behavior displayed by individuals with ID (as well as typically-developing individuals) than were alternative treatments. The large body of literature reviewed in these studies provides empirical evidence indicating that focused ABA interventions effective at assessing and treating a variety of socially important behaviors engaged in by individuals with a variety of diagnoses.
Furthermore, several meta-analytic studies also have found comprehensive ABA-based approaches for educating children with autism result in favorable outcomes (Eldevik, Hastings,Hughes, Jahr, Eikeseth, & Cross, 2010; Makrygianni & Reed, 2010; Reichow, 2012; Reichow, Barton, Boyd, & Hume, 2012; Virues-Ortega, 2010). In a recent meta-analytic study involving 22 studies, Virues-Ortega (2010) concluded: “Results suggest that long-term, comprehensive ABA intervention leads to (positive) medium to large effects in terms of intellectual functioning, language development, and adaptive behavior of individuals with autism.” (p. 397).
Systematic Evaluative Reviews
Systematic approaches for formally evaluating a body research have been developed to determine if a particular intervention can be characterized as “empirically supported” or “established” based on the number, quality, and outcomes of published treatment studies. These efforts have been undertaken for the purpose of guiding clinical practice, influencing regulations and standards, providing priorities for funding (for both research and treatment), and guiding professional training (see Mesibov & Shea, 2011). For example, the American Psychological Association (Task Force Promoting Dissemination of Psychological Procedures, 1995) described a process to identify “empirically supported treatments.” Those interventions with the highest level of support are characterized as “well-established” (Chambless, et al, 1996). Evaluations of the most commonly used focused ABA-based interventions (functional communication training and noncontingent reinforcement) indicated that these interventions meet criteria as “well-established” empirically supported treatments (Carr, Severtson, & Lepper, 2009; Kurtz, Boelter, Jarmolowicz, Chin, & Hagopian, 2011). ABA-based treatments for pica (Hagopian, Rooker, & Rolider, 2011), and for treatment of phobic avoidance (Jennett & Hagopian, 2008) displayed by individuals with intellectual disabilities also have been characterized as “well-established.”
The National Standard Project of the National Autism Center developed a similar model to evaluate interventions for problems associated with autism (2009) – that evaluative method used the term “established” to describe interventions with the highest level of support. The National Autism Center’s report characterized antecedent treatments and behavioral treatments as “established” interventions for autism in particular. Using their evaluative method, the National Autism Center (2009) characterize comprehensive ABA-based interventions have been characterized as being “established” treatments for autism.
Wong and colleagues (2013), as part of the Autism Evidence-Based Practice Review Group, describe a process for the identification of clinical practices that have sufficient empirical support to be termed “evidence-based.” The group stated in regards to the strength of evidence of ABA “Twenty-seven practices met the criteria for being evidence-based (see table 7, page 20)….evidence-based practices consist of interventions that are fundamental applied behavior analysis techniques (e.g., reinforcement, extinction, prompting), assessment and analytic techniques that are the basis for intervention (e.g., functional behavior assessment, task analysis), and combinations of primarily behavioral practices…”