Inclusion Criteria
Parent education and home-based behaviour
analytic intervention: an examination of parents’
perceptions of outcome
KAROLA DILLENBURGER 1
School of Social Work, Queen’s University of Belfast, Northern Ireland
MICKEY KEENAN
School of Psychology, University of Ulster at Coleraine, Northern Ireland
STEPHEN GALLAGHER
Parents’ Education as Autism Therapists, Northern Ireland
MARTIN MCELHINNEY
School of Social Work, Queen’s University of Belfast, Northern Ireland
There is convincing evidence that applied behaviour analysis (ABA) offers a
highly effective form of intervention for children with autistic spectrum disorder
(ASD). There is less evidence, however, about how parents perceive and
evaluate ABA programmes. In this paper an examination of parents’
perceptions of outcome is reported. Twenty-two questionnaires were completed
by two groups of parents. The first group had just completed an introductory
1Address for correspondence: Dr K. Dillenburger, School of Social Work, Queen’s University of Belfast, 7
Lennoxvale, Belfast BT9 5BY, Northern Ireland. E-mail: kdillenburger@bigfoot.com or
Dr M. Keenan, School of Psychology, University of Ulster at Coleraine, Cromore Road, Coleraine BT52 1SA,
Northern Ireland. E-mail: M.Keenan@ulster.ac.uk
Journal of Intellectual & Developmental Disability,
Vol. 29, No. 2, pp. 119–130, June 2004
ISSN 1366-8250 print/ISSN 1469-9532 online/04/020119-12 # 2004 Australasian Society for the Study of Intellectual Disability Inc.
DOI: 10.1080/13668250410001709476
course in ABA and were in the early stages of implementing ABA programmes
with their children. The second group had been involved in ABA education for
more than 2 years. Overall, both groups of parents reported a positive impact of
ABA on the lives of their children, their family life, and themselves. The long-
term group reported that they had achieved complex goals with their children,
whilst the short-term group reported an immediate positive impact on child and
family functioning and parental self-esteem. Conclusions are drawn in the
context of evidence-based practice.
Introduction
In common with many of the other natural sciences, behaviour analysis has a
conceptual, an experimental, and an applied strand (Baer, 1997; Chiesa, 1994). In this
paper we concentrate on the applied strand of behaviour analysis, that is, applied
behaviour analysis (ABA). ABA is defined as the use of knowledge gained within the
science of behaviour analysis for the improvement of behaviours that are socially
important (Baer, Wolf & Risley, 1968). It is used in many areas such as community
development, social work, nursing, industry, education, and medicine. For over 30 years
ABA has been employed successfully with children with autism spectrum disorder (ASD)
(Matson, Benavidez, Compton, Paclawskyj & Baglio, 1996). It is the aim of this paper to
add to the existing knowledge by exploring the views of parents who have been trained in
the use of ABA with their own children.
While the exact neurological differences between children with ASD and their typically
developing peers remain unclear, the diagnosis generally relies on observations of
differences in behaviour. Children are diagnosed with ASD if they engage in specific
behavioural excesses (e.g., ‘‘stimming’’, temper tantrums, stereotypic, emotionless play)
and particular behavioural deficits (e.g., lack of language, social interaction, social
initiation, and interactive play) (cf. DSM-IV, 1994). In behaviour analysis the term
‘‘behaviour’’ has a wide definition. Anything a person does is regarded as behaviour; this
includes publicly observable behaviours as well as ‘‘private’’ behaviours, such as feeling
and thinking (Reese, with Howard & Reese, 1978). This holistic perspective on being a
person means that the term ASD is viewed as a summary label for publicly observable
behaviour patterns as well as private responses (Holth, 2001).
ABA for children with ASD
The best-known applications of behaviour analytic knowledge for children with ASD are
discrete trial methods that were initially developed by Lovaas (1987). However, ABA
involves a wide range of other strategies, including Picture Exchange Communication
System (PECS), precision teaching, shaping and chaining of new behaviours, general-
isation and maintenance training to name but a few. It is not the aim of this paper to
describe in detail what is involved in a comprehensive ABA programme. Interested
readers are referred to the available literature (e.g., Keenan, Kerr & Dillenburger, 2000;
Maurice, 1993; Maurice, Green & Luce, 1996; Richman, 2001).
Extensive research over 30 years shows that early intensive behavioural intervention
can lead to significant gains in cognitive, social, emotional, and motor functioning that
can be generalised to other situations and maintained in the long term (McEachin, Smith
& Lovaas, 1993). A review of over 500 studies shows that ABA consistently offers
120 Dillenburger, Keenan, Gallagher & McElhinney
positive outcomes in terms of educating children with ASD and enhancing life skills
(Matson et al., 1996). Even in cases of less intensive parent-managed behavioural
intervention, it was found that children were able to live in less restrictive environments
than if they had not received behavioural interventions (Bibby, Eikeseth, Martin,
Mudford & Reeves, 2002). The level of ABA training and expertise of professionals
varies considerably, and ranges from having some training and experience with so-called
‘‘Lovaas’ methods’’ in the 1970s (Jordan, 2001) to rigorous internationally recognised
qualifications, such as those offered by the Certification Board for Behavior Analysis.
ABA treatment and parent education
The quality of ABA training is a crucial factor in the determination of treatment
outcome. Exact data relating to quality of training are generally unavailable (Bibby et al.,
2002) with the exception of one study which found that parent-employed therapists who
had received short-term training were less effective than college trained therapists (Smith,
Buch & Gamby, 2000). More research has concentrated on the quality of parent training
in general (Callias, 1994; O’Reilly & Dillenburger, 1997).
The approach to ABA training for parents differs between programmes (Keenan et al.,
2000; Richman, 2001). Some training programmes teach parents the use of distinctive
treatment procedures (Boyd & Corley, 2001) while others start by educating parents
about general behavioural principles (Keenan, 2001; Keenan & Dillenburger, 2000). The
former approach has been criticised as a ‘‘cookbook approach to practice’’ (Bronson &
Thyer, 2001, p. 193), likened to giving ‘‘recipes’’ for treatment, a ‘‘one fits all’’ approach.
The latter approach offers detailed knowledge of the broad spectrum of behavioural
principles so that parents are empowered to adapt interventions to the individual, ever-
changing needs of their own child (Webster-Stratton & Herbert, 1994). In the present
study the latter approach was used; in other words, parents were educated in general
principles of ABA to enable them to design individually tailored treatment programmes
for their children.
Parent training in ABA
Education in general principles of ABA begins by giving the parents a basic
understanding of the philosophy of the science on which ABA is based, namely,
behaviourism (Chiesa, 1994; Keenan & Dillenburger, 2000). Behaviourism encourages
the scientist to go to the root of traditional assumptions and beliefs by exposing the
futility of mind/body dualism inherent in much of contemporary psychology (Chiesa,
1994). This philosophy of science informs parents so they can recognise the tautology
inherent in the term ‘‘autism’’ and avoid the category mistakes (Holth, 2001). From this
basis parents are then taught some of the basic principles of behaviour and how these are
applied to children with autism (Maurice et al., 1996).
In the present study an introductory course in ABA that ran one evening per fortnight
in a local university for an 18-week period was designed for the parents. The topics
covered were: the philosophy of applied behaviour analysis, reinforcement, extinction,
increasing adaptive behaviours and decreasing maladaptive behaviours, shaping and
chaining new behaviours, stimulus discrimination training, observation and data
collection, designing and implementing an intervention, and a session dedicated to
revision. Parents read assigned chapters from a textbook (Grant & Evans, 1994) in
ABA programme evaluation 121
preparation for each session and were given a multiple-choice questionnaire at the end of
each session. The parents then carried out the applied practice of the theoretical skills
learned through the course at home as frequently as possible throughout the day. An
ABA professional visited each family on a weekly basis for approximately 2 hours to
supervise and adjust individualised programmes together with the parents.
Parental perception of outcome
To date there exists only one parental satisfaction survey of early intensive behavioural
intervention for young children with autism in a community setting (Boyd & Corley,
2001). In Boyd and Corley’s study tutors and supervisors in California were trained in
autism and ‘‘discrete trial’’ training; in other words, they were trained in one specific 1:1
treatment procedure (often referred to as Lovaas therapy) rather than in the full range of
applications of ABA. Weekly review meetings then were held with parents, tutors, and
supervisors. Boyd and Corley reviewed 22 cases (mean length of treatment: 23 months;
mean age of child: 41 months). Two children were in home programmes; the remainder
received discrete trial training in schools. Boyd and Corley found that although all
children had made progress they did not achieve ‘‘recovery’’ (Lovaas, 1987). Parents were
generally satisfied or very satisfied with the implementation of their child’s programme
and outcome.
The study reported here differs in a number of respects. First, parent training did not
concentrate on one particular method of intervention. Instead parents were educated in
general principles of ABA that enabled them to tailor individual training programmes
according to the changing needs of their own children using the full range of strategies
developed within ABA. Second, it includes older children. Third, all children were on
home programmes; and fourth, the effect of treatment duration was assessed.
Methodology
Sample
A total population of 50 families were actively engaged in home-based ABA programmes
in Northern Ireland at the time of the study. All of these families were invited to
participate (see procedure). A total of 22 families took part in the study. The length of
time they had been involved in ABA training was used to differentiate between two
equivalent groups of families. The long-term group (LTG) (n~12) had been involved in
ABA programmes for an average of 35.5 months (range 18–72 months); the short-term
group (STG) (n~10) had been involved in ABA programmes for an average of 6.1
months (range 2–12 months). Although the age range of children in both groups was
virtually the same (3–12/13 years) more of the older children were in the LTG
(mean~125 months) than in the STG (mean~52 months). The mean age of children at
the start of ABA was 91 months for the LTG and 46 months for the STG.
Parents in the LTG were slightly older (mean age 41 years, range 31–52) than those in
the STG (mean age 36.6 years, range 32–43). The groups were equivalent with regard to
employment status (8 LTG parents vs. 5 STG parents in employment, the remainder
unemployed) and with regard to socio-economic status. The reasons parents were not
employed were similar between the two groups and were mainly related to caring for a
child with autism.
In regard to gender of parents and children the groups were equivalent (LTG: 5
122 Dillenburger, Keenan, Gallagher & McElhinney
fathers, 7 mothers, 10 boys, and 2 girls; STG: 3 fathers, 7 mothers, 9 boys, and 1 girl).
All families were two-parent families except for one father-led one-parent family in the
LTG. All families had other children. In the LTG the average number of other children
was 3 (range 1–4) and mean age of other children was 11 years (range 7–19). In the STG
the average number of other children was 2.5 (range 1–3) and mean age of other children
was 7.1 years (range 1–19). Both groups had one family in which the siblings of the child
with autism did not live in the same household. In both cases the father had custody of
the child with ASD while the mother had custody of the other siblings. Generally, all
parents reported good relationships with their children, although one mother (LTG)
stated that she had a strained relationship with her other child ‘‘because of the autistic son’’.
Procedure
ABA evaluation questionnaires were designed and circulated to the families. The
questionnaires evaluated the validity of ABA, including significance of goals of
the intervention, appropriateness of the intervention strategies, and importance of the
outcomes (Kazdin, 1977; Wolf, 1978). Questionnaires were sent by post to all 25 LTG
families who were in receipt of ABA at the time. Twelve of these families returned
questionnaires by post in a pre-paid addressed envelope, constituting a return rate of 48%.
Twenty-five STG families were in receipt of ABA education at the time of the study.
The questionnaires were distributed at the end of the final ABA training session. Ten
of the STG parents completed the questionnaire in the training room and returned
it anonymously to a table for collection, constituting a return rate of 40%. While the
return rate for postal questionnaires (LTG) is average, the relatively low return rate of
collected questionnaires (STG) can be explained by the fact that parents who had just
finished a training session were eager to get home to their children rather than fill in
questionnaires.
Ethical considerations
Written, informed consent was obtained from parents prior to the study. A letter was
given to the parents explaining the purpose of the study and assuring them that their
participation was voluntary and that non-participation would in no way affect the
services they received. The letter outlined that their response to the questionnaire was
confidential and would be used for research purposes only.
Results
Did the intervention make a difference?
Table 1 shows that ABA was perceived to have made a difference to a number of
mutually agreed goals, such as independence, quality of life, skills development and
maintenance, and interaction in virtually all of the children’s lives. Only one LTG
parent, who had stated that ABA made a great difference in the other categories, did not
know if ABA had made a difference in the ‘‘quality of life’’ category for her 10-year-old
child with a severe disability. One STG parent (who had received ABA education for less
than 2 months) reported that ABA had made a difference already in all the categories,
apart from her 3-year-old child’s independence. There were no statistically significant
differences between LTG and STG parents’ perceptions.
ABA programme evaluation 123
Effectiveness of the intervention strategies
Table 2 shows that overall the ABA strategies which had been jointly agreed with the
parents were effective and had an important impact on the life of all the children. The
overall perception of most parents was that ABA was very effective. Only two LTG
parents (who had scored high levels of effectiveness in the other categories) found ABA
not to have been effective in self-help; one of these parents also did not think ABA had
been effective with social skills. One of these was the parent of a 10-year-old boy with
profound autism.
Two STG parents did not know if ABA had been effective in terms of self-help; one of
these parents was also unsure about the effect on social skills. These were all parents who
had commenced ABA education only 3–8 months earlier; one of these parents added the
word ‘‘yet’’ to her answer, indicating her expectation that ABA would be effective in this
area in the longer term. Only one LTG parent did not know if ABA had been effective in
Table 1
Number of parental responses regarding difference that ABA made to a range of child behaviour categories
Behaviour category
Response alternatives
Great difference
Some difference
Little difference
No difference
Don’t know
Not applicable
LTG STG LTG STG LTG STG LTG STG LTG STG LTG STG
Independence 3 5 8 4 0 1 Quality of life 7 8 2 2 1 0 1 0 Skills development 8 8 3 2 Skills maintenance 6 6 5 4 Interaction 6 7 5 3
One LTG parent did not complete these items.
Table 2
Number of parental responses regarding perceived effectiveness of ABA in a range of child behaviour categories
Behaviour category
Response alternatives
Very effective Effective
Not effective
Don’t know
Not applicable
LTG STG LTG STG LTG STG LTG STG LTG STG
Self-help skills 6 4 3 4 2 0 1 2 Social skills 9 4 5 1 0 0 1 Problem behaviour 9 5 3 5 Obsessive behaviour 8 4 4 3 0 3 Gross motor skills 9 6 3 3 0 1 Fine motor skills 9 6 3 4 Communication 9 7 3 3 Concentration 10 9 2 1
124 Dillenburger, Keenan, Gallagher & McElhinney
terms of self-help skills. There was a tendency for LTG parents to evaluate ABA
effectiveness somewhat better than STG parents.
Importance of the outcomes in relation to family life
In response to the question ‘‘What impact has ABA had on your family life?’’ parents in
both LTG and STG considered that ABA had a positive effect on family life, although
one parent drew attention to the amount of work and finance necessary for an intensive
ABA programme (Table 3).
Importance of the outcomes in relation to parents
In response to the questions ‘‘What impact has ABA had on you/how you feel about
yourself?’’ all parents felt that ABA had positively impacted on them and how they feel
about themselves (Table 4).
Importance of the outcomes in relation to the child
In response to the question ‘‘What impact has ABA had on the life of your child?’’ all
parents responded that ABA had had a very positive impact on their child’s life
(Table 5).
Table 3
Examples of parents’ statements regarding the impact of ABA on family life
Categories Examples from LTG parents Examples from STG parents
Before ABA treatment
Autism equals disruption, loss of a bedroom, wife having to leave work, cannot book holidays ...
General effect on family life
Made it easier. Time with other children has been reduced although they understand this.Immense impact. Entirely positive. Great impact.We are now approaching
normal family life. Life is a bit calmer. We have a level of reasoning. More manageable.
Effect on family cohesion
We have a level of reasoning. ABA has improved family life immensely. We have a direction now.Entirely positive. Gives us hope.Brought the family tighter
to help child. Brought the family together to help child.Great impact, more normal
family life.
Work load Made it more manageable. A lot of time and energy used up on implementing ABA programmes.
Structure More structured than before. It has put a strain on it to organise sessions.It has helped give a focus.
Able to deal with difficult situation.
Finance Financially very stressful.
Freedom Made us able to go on more outings.
It has raised expectations of relations.
ABA programme evaluation 125
Discussion
In this paper we reported an examination of parents’ perceptions of the outcome of
home-based ABA programmes. It was found that parents considered ABA to have high
effectiveness in facilitating development of their children. In particular they expressed
that ABA outcomes were important and had made a substantial difference for the family
as a whole and raised the general level of parents’ confidence and empowerment. In
the context of other similar programme evaluations the findings reported here are
noteworthy for a number of reasons.
Prior to the introduction of ABA, only one other treatment approach (Treatment and
Table 4
Examples of parents’ statements regarding the impact of ABA on themselves
Categories Examples from LTG parents Examples from STG parents
General impact Entirely positive. ABA works and that impresses me.I now feel like a normal person. I feel it is brilliant.
Communication A good impact through improved communications.
Confidence Made me more confident and relaxed. Given me confidence to help my child.I feel capable of helping my son. Gives me a sense of control in my child’s life.
It has made me feel confident.
Feel more focused. Confident as a mother.
I feel more in control. I feel as if I have done something constructive in helping my child.
Determination to change things.A sense of control over situations.
Coping More able to cope with situations at home.
Encouragement of X.
It has helped me in everyday situations and can cope better. Enables me to cope with life and not lost as I felt when my son was first diagnosed.
I am more hopeful. I feel I am actually doing something to help my child.
Gives me a greater understanding of my son and how to work properly with his needs.
Given me hope for the future. Has given me the hope that I can improve my daughter’s life without being dependent on professionals and their opinion.
Worry/stress Made me worry less and enjoy my child more.
It makes me realise what can be achieved but I sometimes feel inadequate to the task.Given hope and reduced stress levels. It has to some extent increased stress but as we become more familiar with the concepts, stress levels are decreasing slowly!
Given me some hope.
Self-esteem/ empowerment
Initially one feels rather inadequate in terms of what we had been doing to help X with his autism. However, undertaking ABA has been a definite step forward and constantly increases self-esteem.
It gives me skills.
Makes me feel more empowered.
It has given me the ability to help him.
126 Dillenburger, Keenan, Gallagher & McElhinney
Education of Autistic and Communications Handicapped Children, or TEACCH)
(Schopler, Mesibov, DeVillis & Short, 1981) had been available in Northern Ireland.
Sines’ (2001) evaluation of TEACCH showed that parents were generally satisfied with
the service they received for their child, although they were not convinced of the
effectiveness of TEACCH in achieving the goals that they were expecting. Data
presented here show that, when offered an alternative, parents reported very substantial
levels of satisfaction with the significance of goals of ABA intervention, the
appropriateness of ABA intervention strategies, and the social importance of ABA
outcomes for the child, the parents, and the family as a whole.
When compared with Boyd and Corley’s (2001) parental evaluation of ABA
programmes in California, findings reported here confirm a high level of parental
satisfaction with ABA. The subtle downward shift in terms of parental satisfaction
with treatment outcome noted by Boyd and Corley was not detected in this study. As
Table 5
Examples of parent’s statements regarding the impact of ABA on life of child
Categories Examples from LTG parents Examples from STG parents
General demeanour
Has controlled his outbursts and made him a happy child.
Calming influence, responds well to commands.
Improved tasks and difficult issues.
There has been a very big change in X.
Completely back in control and can deal with problem behaviours.
Communication/ speech
He is less frustrated and easier to manage.
It has improved his communication hugely. He is more settled, more spontaneous, speech much better. The improvements have been dramatic. Her language and awareness have exceeded all expectations.
Academic skills I don’t believe my child would be at mainstream primary school and coping academically without ABA.
Exceptional results. He has had nothing else. Better concentration and vast improvements in writing, reading and many other areas. He is starting to write/read and is doing things I would never dream he could do.
Independence Improved. He has learned to be more independent and acquired some basic skills.
He is now toilet trained.
She has learnt skills she did not have!
Taught my son that we expect him to participate/cooperate/interact/communicate.
Relationships Not only has it helped my child but also the whole family quality of life has improved dramatically.
ABA has certainly helped modify X’s behaviours and has had a positive impact on family life in general. Large impact. Lots of family life changes. Excellent positive effect.
ABA programme evaluation 127
mentioned earlier in this paper, parent education did not concentrate on one particular
method of intervention (e.g., 1:1 discrete trial training); instead, parents were educated in
general principles of ABA and then became involved in the development of individually
tailored treatment plans that encompassed the full range of methods developed within
ABA. It is possible that this difference accounts for the high levels of satisfaction.
Indeed, through this kind of education in ABA it is likely that in general parental
interactions with the child change, and that this change affects the child on a 24-hours-a-
day/7-days-a-week basis. If this were found to be the case it would have implications for
an analysis of treatment intensity. The intensity of behavioural intervention has been
found to be important for treatment outcome (Lovaas, 1987). Is it possible that
educating parents in ABA achieves increased levels of treatment intensity? Future studies
should include direct assessment of parental programme implementation as well as a
component analysis of parent education to shed more light on this tentative conclusion.
Previous research had shown that the age of the child at the onset of treatment is an
important factor in treatment success (Fenske, Zalenski, Krantz & McClannahan, 1985).
Results reported here confirm Eikeseth, Jahr and Eldevik’s (1997) findings that, while
there may be an optimum age for starting behaviour analytic treatment (STG), late
treatment onset (LTG) still has high levels of validity from a parental point of view.
Further studies should be conducted with older children who receive home-based ABA
interventions based on parent education programmes in order to establish exactly what
variables are responsible for the achievement of treatment goals with these children.
Length of treatment is also usually viewed as a decisive factor with long-term
treatment achieving better results than short-term treatment (Smith, 1999). Results
reported here however, show that parents educated in ABA in the short term can achieve
significant changes. The present study was based on the premise that there was no time
limit on ABA intervention. Instead the approach was to work with the child as long as it
takes to achieve the desired outcomes.
To the authors’ knowledge the study reported here is the first examination of parents’
perceptions of the outcome of home-based ABA programmes. Usually more rigorous
objective scientific research methodologies are harnessed to measure the effect of ABA
on various indices associated with a child’s development (Keenan, 2003; Keenan et al.,
2000). Despite the wealth of quantitative research reported in the literature (e.g.,
Anderson, Avery, DiPietro, Edwards & Christian, 1987; Smith, 1996, 1999; Weiss, 1999),
it is argued by some that the jury is still out on whether ABA is as effective as it is
purported to be (Ives & Munro, 2002; Jordan, Jones & Murray, 1998; Task Force
Report, 2001). Although the present study did not include evaluative, continuous data
on behaviour changes in the child, the tentative findings reported here mean that there is
a strong indication that parents are satisfied with the outcomes achieved through basic
ABA training. This group of parents was satisfied and perceived ABA to be valid in
terms of significance of behavioural goals, appropriate in relation to intervention
strategies, and important as regards outcomes for the quality of life for the children, their
own confidence and feeling of empowerment, and the impact on family life as a whole.
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