Introduction to Applied Behavior Analysis

[Music] hi and welcome those Children's Mercy autism training series I'm Christina look Holly one of the licensed psychologists at Children's Mercy Kansas

Citian today I'll be talking to you about applied behavior analysis I want you to remember throughout these presentations that every child is unique and every situation is different this is

an informational presentation and not meant to replace tailored guidance for your child and family examples provided here may not be appropriate for your child and family but serve as a guiding

point for your accessing of ABA services and the views expressed here are not necessarily those of Children's Mercy or UMKC if your child was diagnosed with

autism you've likely at least heard of ABA before this presentation will provide an overview of ABA discuss common components of this intervention

teach you how to identify strong ABA programs and use video based instruction to illustrate how ABA interventions can be effective in teaching children with

autism I would like to suggest a structure for today's presentation that will provide you with a more rich and interactive experience I encourage all

those watching to pause when you see this pink play symbol and to navigate on a separate screen to the websites listed

on my slides and watch the videos provided on each slide after pausing my presentation you can return and we will talk through the key points of those

videos you can also find the links to the websites in the accompanying document section of the Children's Mercy autism web site let's get started the

first video I'd like you to watch is a brief introductory video about applied behavior analysis found at the interacting with autism website at the link you see below again you can find

these links on our website in the accompanying documents section so please take a moment to pause and watch the video for me you after watching this video I'd like to

discuss some of the nuances of ABA they're so subtly demonstrated in this video the first thing I'd like to point out is that ABA for young children often

involves teaching a wide range of skills such as communication interaction social skills through structured play and this is a key element for intervention in

children this young all of the implementers actions are purposeful and if they're really good at what they do you might not notice this intricate dance that they're doing during the

intervention another critical component of ABA is that children learn through consequences so what happens after they do a behavior and they learn that their

actions cause reactions by those around them these reactions may be in line or not with what they want and so they learn that their actions cause a

predictable sequence of events this is vital for a child with autism as it helps them to organize their world and make sense of what might otherwise seem

like purposeless or random behavior from others in the video the implementer mentions planned ignoring as just ignoring this is often one of the

hardest skills for parents to do because it involves not looking at touching or talking to your child immediately following a problem behavior and that's

really difficult to do again in this video they talk about visuals and schedules and they briefly mention these tools as a way to structure ABA based

intervention it helps to aid with transitions between tasks and also helps the child with autism to anticipate what's coming next and finally I hope when you watch these

videos you see that there's hope there's hope and intervention and there's hope for the progress that your child can make when you're doing evidence-based

strategies so let's talk about what ABA is ABA or applied behavior analysis is the structured approach for understanding and modifying behavior in

the context of an environment behavior is anything that a person does that can be observed by another person so talking walking chewing gum those are

all behaviors within an environment which is the physical and social events that might change or be changed by one's

behavior so for example being at school in their classroom or at home we'll talk about some antecedent based strategies later that were discussed in the video

but these are essentially changing the environment to increase or decrease the likelihood of the behavior happening again the environment is important to consider because as we know behavior

depends on the context so for example if you go to a fancy restaurant you may be less likely to pick up your food with your fingers or put your elbows on the table similarly your child may

demonstrate problem behaviors at home that their teacher swears they've never seen before and so it's important to consider these context when you're

planning a BA based interventions a BA is a systematic and intensive skill building program meaning that it's data-driven and it's all intentional

it's delivered at a high frequency and intensity of services and the goal is both to increase behaviors you want to see or adaptive skills and then decrease

any maladaptive or negative behaviors we don't want to see it's tailored to your child's specific strengths weaknesses and areas for growth and it focuses on

behaviors of social significance and these are behaviors that might cause harm or interfere with their daily

functioning ABA therapies collect data for target skills and behavior they're highly data driven interventions are

directed by data which then informs the use of positive strategies that are used to change behavior the vast majority of ABPA programs also include a parent

training component and parent training or parent participation in an intervention is key and the goal of all ABA interventions is to generalize the skills learned to all settings in people's

because if your child can do this behavior with an implementer that's great but wouldn't we like them to do it with their teacher with you with their peers one of the goals of ABA is to

decrease the frequency of maladaptive behaviors that may occur on a continuum from an annoying habit like nail biting to injury or destruction such as aggressive behavior or self-interest

behavior it's often important to target the most impairing behaviors first as they may interfere with acquisition of other skills for example if your child

runs away from you in public that's much more important in addressing than hand flapping for example with that said it's sometimes necessary to build momentum in

intervention by targeting smaller goals and having some success early on to feel like you can keep going you also work on

increasing the frequency of adaptive behaviors in ABA so you might teach your child pre academic skills so learning how to learn attending complying with

non-preferred directions self-help skills so if you have an older team you might be working on promoting good hygiene with ABA which all teams could

benefit from regardless of autism social skills communication imitation and play skills are some of their examples ABA principles have been packaged into a

variety of programs for children with autism and they're known by all of these other names it's important to remember that they're all guided by the same

behavioral principles and draw from the same evidence base one of the most commonly researched interventions for

young children and toddlers with autism is SDM or the early start Denver model I'd encourage you to pause and take a moment to navigate to this website and

watch the video on ES diem because it'll walk you through what early intervention ABA services would look like with a toddler welcome back let's highlight a few key

points from that video in ESD M the child and parent worked together to create imaginative play that also encourages communication providers and

parents respond positively and enthusiastically to all communicative in temps this is key especially for children with limited language we want

to highly reinforce any attempts to communicate whether it's verbal or otherwise the providers in this model offer place suggestions to help children

scaffold their play this is necessary because many children with autism don't instinctually know how to play appropriately so if you can provide them with some support around imaginative

play or ways to engage with others they're more likely to be successful in this skill the providers and parents in this intervention also use the child's

interests to guide play so for example in the video one of the children was really interested in farm animals and couldn't yet speak but had farm animal

sounds and so they began by starting with imaginative play on a farm because it incorporated their interests allowed them to use the verbal skills they already had and allowed them to be

successful before moving on and finally enthusiasm is key it may sometimes be embarrassing or out of your comfort zone to be as excited as you are in these

interventions but that's really a key component of any intervention working is being effectively enthusiastic as well as in your communication now that we

know a little bit about what ABA is let's talk about what ABA is not ABA is not traditional psychotherapy or play therapy your child doesn't meet with a

provider like myself once a week or once a month and just engage in in random play instead it or and again it's not a

one-size-fits-all approach so what works for one in child in ABA may not work for another which is why they take so much data and use assessment to drive intervention

individual therapy again is not ABA and it doesn't fix the problem ABA believes that you can modify behaviors and you can adjust

behaviors but that that's always occurring on a continuum and that your flexibly matching the child's needs at the time and ABA is not only used for children with autism it's used for

children with other neurodevelopmental conditions like the Down syndrome and intellectual disability

why ABA ABA is the number one recommended treatment for autism because it's a best practice treatment it's empirically supported which means that there are over there's over 40

years of strong research and over 600 published articles on the efficacy of this intervention and we all have limited time and resources and part of

the reason this is recommended is because we know it works and if you have this limited pool of resources let's invest in things we know work it's targeted it's targeted to your child's

specific needs and so it's most likely to produce meaningful gains for your child and family and it's data driven so ABA doesn't rely on guessing where your

child is it's constantly assessing and creating targeted goals based on those assessments there's a strong evidence base for ABA therapy as I mentioned and

I want to discuss briefly some of it with you ABA based strategies are the most effective and only evidence-based treatment for autism the caveat again is

that ABA has been packaged in other formats so you may hear about a strong evidence base for another ABA based treatment to be most effective children

need 25 hours or more of treatment between the ages of 2 & 5 which can feel very overwhelming or can feel like a missed opportunity for parents of children over the age of five

however the takeaway is the research shows that every little bit helps and the intervention at any age can be effective so even one hour per week of

professional support just training parents to implement strategies in the home can result in can't functional improvements so don't fret if your child's above the age of

five or if you're not able to attain 25 hours or more of service early gains from ABA treatment translate into millions of dollars been saving across

the lifespan including less restrictive educational placement it's more functional independence and adulthood and better functional outcomes we know

that ABA is highly effective in improving IQ or cognitive functioning adaptive skills and social functioning in children with autism spectrum disorder the findings are even more

robust when delivered early in development so again before that age of five and 50% of children with autism and mild intellectual disability who

received early intensive ABA services attained normal IQs and are educated in regular classrooms with minimal

assistance ABA let's talk a little bit more about what it looks like it's a broad approach that can be applied to

very young children to teenagers and it's specific to your child's needs so based on their strengths what you would like for them and functional outcomes

you hope to see it's often delivered in two to four hour sessions or chunks that include planned breaks and what might seem like play at time it's delivered at

a frequency of up to 40 hours per week although it often varies in intensity from 25 to 40 and that can also include

some time in your home some time on weekends and in the community it involves parents and caregivers parents and caregivers are key team members on

an ABA teen because they will have to implement those interventions when the providers are not in the home ABA candlelit be delivered in a home-based

setting in a center or in a school if you'd like to watch a quick video clip on school-based ABA you can navigate to the link on the slides to look at what a

pre school based program might look like and then finally ABA can be delivered in a group or an individual format a wide range of skills can be targeted

with ABA interventions and ABA programs will be picked based on your interest in what you would like to see for your child so they might work on motor skills such

as walking or handwriting they might work on functional skills like potty training or tooth brushing or completing elaborate hygiene routines you might work on communication so if your child

younger it might be expressive and receptive language or it might be that your child has a lot of language but they don't use it functionally to communicate with others so you work on

pragmatic language skills you can also work on homework completion if you have a child that's particularly resistant to

homework and pro-social skills again these are just a small list of skills that can be targeted in ABA multi-step behaviors so if for example you would

like your child to be more independent in their morning routine you can teach the steps of completing their morning routine getting out of bed changing out of their pajamas brushing their teeth

brushing their hair washing their face and coming downstairs eating new foods so how many of the kids that we work with ought that have autism eat only

beige foods and so ABA can be used to expand that food repertoire matching answering questions compliance decreasing aggression and increasing

waiting so regardless of the state you live in if they extend coverage for ABA treatment it must be provided or overseen by a board certified behavior

analyst and this can be a b c ba which is a master's degree or a b c ba d which it's a doctoral degree these professionals undergo years of schooling

1500 hours of field work and must successfully pass a licensing exam in order to be considered a b c ba and there's typically a team of experienced

providers that work under this BC BA in order to help your child meet their ABA goals and program implementers are the ones that come into your home on

a daily basis or come into the school and run the programs they often have a bachelor's degree or equivalent and are

trained in this intervention so now that we know what ABA is I want you to be able to evaluate whether or not the ABA program your child is getting is a

strong ABA program there are some components I think that are important to consider first the program has to be supervised and designed by a b c ba if it's not

it's not true a ba ii training for all team members is really important particularly training that is related to your your child's specific needs so if they have a medical condition or

aggressive behavior it's really important that the implementers are trained in interventions for those things that programming starts with a comprehensive skills assessment so there

should be a formal assessment period in which your child is evaluated for to essentially establish their baseline of

skills that functional programming creates clear and measurable goals that are of significance to you and your family that data is collected at every

visit throughout the visits and often times providers will share these data graphs with you the tasks are generalized because it's great if your child can do it in session but if they

can't do it the other or 30 hours of the week it's not that helpful that providers and team members elicit feedback from family members frequently

and that team mum team meetings with families are held on regular intervals or at regular intervals so let's talk about meeting a goal the ABA way first

you'd start with that comprehensive assessment then you would identify goals goals need to be specific and measurable so an example of an ABA goal might be

that your child performs a certain skill in 80% of trials with two different people so that sounds very specific but that's the way that ABA goals are written so that they can be generalized

and that we real you have an understanding that your child is mastering the skills they determine the function of the behavior which we'll talk about in a second so

the reason a behavior happens will set the tone for what interventions we use will identify reinforcers that are of

importance to your child intervene with a strategy to address the function of the behavior modify the goals as your child's behaviors change but also

looking for mastery of previous skills so working in those old skills and then generalizing to other settings and people the functions of a behavior there

are five basic functions of behavior that we can intervene on the first is escaper avoidance so escape is to get out of something the child does not like

but is already doing whereas avoid is to completely avoid having to do something they have not yet started it might be to gain attention to parent provider or

peer attention remember that attention does not necessarily mean positive attention it just means that somebody is talking to looking at or touching them

this can include scolding or reprimanding to obtain a tangible item so to get something they want I hid my

peer because I want the toy they have it might be reinforced by sensory properties for example sometimes putting items in your mouth or eating in annable

objects is reinforced by the sensory sensation that you get or a behavior may be done to communicate with others I'm hitting you because I don't like that

oftentimes if we can increase functional communication we can decrease maladaptive behaviors let's briefly talk about some terms including reinforcement

and punishment I think these terms are used incorrectly a lot and so it's important to really understand what they mean in ABA terms reinforcement is something that happens immediately after

behavior that makes it happen more often it doesn't have to do with valence so positive or negative it has to do with whether or not the behave occurs more frequently the next time or

after that where as punishment is anything that happens after a behavior that makes that behavior happen less often and then when we think about

positive and negative I want you to think about it in terms of addition and subtraction versus good or bad so if you're having a positive reinforcement

it means you're adding a stimulus in order to increase the likelihood of a behavior so a child gets a reward for doing a behavior that you want you're

adding something positive and that makes that behavior happen more frequently whereas negative reinforcement is where you're removing something in order to make something happen more frequently so

you your child does well at school and you decide you don't have to do your Torstein because you got straight A's on that test or on your grades punishment

so a positive punishment might be adding a grounding because your child came home late and missed curfew negative punishment would be removing a stimulus

in order to make a behavior happen less frequently so maybe we're moving a privilege or access to something because they didn't do something they were supposed to do with the goal of

decreasing the frequency of that behavior another set of terminology might hear about in ABA is the ABCs and sometimes DS of behavior we'll talk

about each of these in depth but a stands for antecedent B console our behavior C consequence and D deficits and skills antecedents are events that

come before or trigger the problem behavior so for example which parent tells the child to clean up their toys they begin to scream and throw a fit the antecedent is the parent telling the

child to do something an electronic device runs out of batteries and the child throws it down the hallway the antecedent is something running out of batteries or a sibling taunts a child so

the child demonstrates the behavior of hitting another child consequences are in events that happen immediately after a problem behavior

so what is even if unintentionally increasing or maintaining this problem behavior one classic example parent says no to candy in the checkout line the

child cries parent gives the child because there the candy because they're embarrassed and to keep them quiet child throws an object and parent scolds them

so addition of parental attention makes it happen more frequently if you'd like to track the ABCs of a behavior you can

fill out an ABC chart just like this that might have the date the time the ABCs and then you can hypothesize the potential function of the behavior you

can find a printable copy of this ABC chart on our website if you want to print it out and track some behaviors at home let's work through an example so

for George George has some behaviors including aggression and verbal outbursts so on October 24th at 9:00 in the morning he is asked to pick up this

toys which is the antecedent the behavior is he screams and cries the consequence or what happens immediately after as the teacher talks to George

about appropriate behavior while he is still playing with the toys the function might be he's avoiding cleaning up another example

George is asked to go to the resource room he begins to scream and cry and throw a book the paraprofessional tells him no and helps to get the materials

cleaned up this might involve the function of avoiding a transition finally a peer takes a toy George hits them the pier is removed from the area and

George's the function of this behavior might be to express distress or obtain a tangible item

so again reinforcers something presented after a behavior that increases the likelihood of that behavior happening again a punishment is a Punisher is

something presented after a behavior that reduces the frequency of that behavior in the future and then an alternative behavior is a more acceptable talk behavior that

serves the same function as a problem behavior so for an example an alternative behavior instead of eating pieces of carpet or your diaper you

might teach a child to chew on at YouTube so that they get the sensory sensation that they're looking for and they don't eat the inappropriate item so

let's work through a few of these if the goal is to stop a tantrum and we think the function is to get parental attention I throw this tantrum because every time I do mom or dad turns bright

red they talk to me they get really close and interactions get interesting the modification might be parent says nothing stands up and leaves the room

which is really really hard to do if the goal is to teach the child to ask for a break to reduce aggression and the function is thought to be to escape a

task we might teach the child to use a break card which is a symbol essentially that they keep out on their desk that they can use at any time to get an immediate break and teach tolerance for

non-preferred tasks in small increments so they only have to work for 10 seconds at a time and then 30 seconds at a time in a minute time so here are some

examples of alternative behaviors you might teach for common presenting concerns if your child elopes or wanders away from you you might teach them the skills of staying with the parent

provide frequent weight reinforcement for walking with a parent down a hallway and sticking next to them if your child's having accidents in their underwear you might have to teach the

skill of toilet training they may not yet know how to do that if your child's throwing toys because that's how they play with toys as many children with autism do you might have to teach them

what toys are appropriate to throw like shooting balls into a basketball hoop or stack toys instead sleeping in your parents bed which is a hard problem to

deal with you might reward time spent in their own bed alone or interrupting by screaming you might teach a child to touch the parents are

to request their attention versus just screaming stock through some community resources so now that we know what ABA

is and why it is so recommended how do you go about it obtaining it one way is you might check with your local chapter of Autism Speaks and visit the Family Services tab on

their website and search for ABA services offered in your state so you could navigate down and it'll look on a map about where there are services

offered in your area you can check your local chapter of the Autism Society of America to find state-by-state resources you can look for BC pas at BAC be calm

and it'll pull up a comprehensive list of all licensed professionals in your state talk to your educational team and families you know they're often going to

be able to provide you with the best guidance and information about people and providers they like and then finally check with your insurance you may have to call the mental mental health or

behavioral health carve-out line or number in order to decide whether or not ABA services are covered by your insurance insurance coverage for ABA so

if I'm recommending 25 or 40 hours of intervention it would be really nice if it was covered by insurance wouldn't it and so coverage for ABA varies by

insurance carrier in policy we do know that it is getting better covered than it has been in the past but there are still lots of barriers to achieving these services or obtaining

these services and then also within each insurance carrier the policies may also

differ so as of June 8 2017 46 states in the District of Columbia have laws that require insurance coverage of autism services including Kansas in Missouri

that said there have been barriers to implementation of these laws including limited providers signing up for

services or difficulty enacting the laws in practice one thing I'd love you for you to check out is the resource that autism

speaks their insurance page because it talks a lot about healthcare coverage of ABA services ABA coverage within health

insurance marketplaces self-funded employer toolkits and many other free resources that you can navigate to help you be a better advocate for your

child's needs this is an example of what the service locator looks like for the Autism Speaks website and it can

pinpoint your area and providers that are near you and then finally I'd really like you to spend some quality time with

these three resources I think these are three creditable and reputable resources that will provide you with really good in evidence-based research on autism and

ABA the first is interacting with autism which you've been watching videos through on this training Autism Speaks org and Autism Society they have a lot

of great free resources for families as well as for people working with children with autism thank you for your time today and please navigate to our website

to see a list of other trainings

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